,:•:••/ A SYSTEM Of SURGERY; PATHOLOGICAL, DIAGNOSTIC, THERAPEUTIC AND OPERATIVE. BY SAMUEL D.^GROSS, M.D., PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; SURGEON TO THE PHILADELPHIA HOSPITAL; MEMBER OF THE IMPERIAL ROYAL MEDICAL SOCIETY OF VIENNA, ETC. ETC. ILLUSTRATED BY TWELVE HUNDRED AND TWENTY-SEVEN ENGRAVINGS. SECOND EDITION, MUCH ENLARGED AND CAREFULLY REVISED. IN TWO VOLUMES. VOL. I. PHILADELPHIA: BLANCHARD AND LEA. 1862. \M0 ______________) %G3j_________ Entered according to the Act of Congress, in the year 1859, by BLANCHARD AND LEA, n the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania. PHILADELPHIA '. COLLINS, PRINTER. TO THE NUMEROUS PUPILS WHO, DURING THE LAST QUARTER OF A CENTURY, HAVE ATTENDED HIS LECTURES, AND WHO ARE NOW SETTLED IN EVERY SECTION OF THE UNITED STATES IN THE HONORABLE PURSUIT OF THEIR PROFESSION, €\tU MttttUS, DESIGNED TO ILLUSTRATE ONE OF THE MOST IMPORTANT AND VALUABLE BRANCHES OF THE HEALING ART, ARE RESPECTFULLY AND AFFECTIONATELY INSCRIBED BY THEIR FRIEND, THE AUTHOR. PREFACE. In preparing for the press a new edition of this work, I have carefully revised every chapter, introduced a large amount of new matter, and added nearly three hundred illustrations, a portion of them expressly engraved for its pages. The subject of gunshot wounds, invested at this moment with such a fearful interest on this Continent, has received more than ordinary attention. Notwithstand- ing these additions, it will be seen that the volumes, in consequence of the employment of a smaller type, are somewhat less bulky than the original ones. The general arrangement of the work is the same as in the first edition; and the new matter will be found to be essen- tially of a practical nature. For the nattering manner in which the work has been received by the profession, and for the encomiums bestowed upon it by the periodical press, both at home and abroad, I feel under deep obliga- tions. Such testimony is the highest reward which an author can expect for his labors. A translation of the work into the Dutch lan- guage is now in progress at Nieuwediep, in Holland, and will appear at an early day. To Dr. Richard J. Dunglison I am indebted for important aid afforded me in correcting the press, and in preparing the new index and table of contents. S. D. GROSS. Jefferson Medical College, Philadelphia, January 1st, 1862. PREFACE TO THE FIRST EDITION. The object of this work is to furnish a systematic and compre- hensive treatise on the science and practice of surgery, considered in the broadest sense; one that shall serve the practitioner as a faithful and available guide in his daily routine of duty. It has been too much the custom of modern writers on this department of the heal- ing art to omit certain topics altogether, and to speak of others at undue length, evidently assuming that their readers could readily supply the deficiencies from other sources, or that what has been thus slighted is of no particular practical value. My aim has been to embrace the whole domain of surgery, and to allot to every subject its legitimate claim to notice in the great family of external diseases and accidents. How far this object has been accomplished, it is not for me to determine. It may safely be affirmed, however, that there is no topic, properly appertaining to surgery, that will not be found to be discussed, to a greater or less extent, in these volumes. If a larger space than is customary has been devoted to the consideration of inflammation and its results, or the great principles of surgery, it is because of the conviction, grounded upon long and close observa- tion, that there are no subjects so little understood by the general practitioner. Special attention has also been bestowed upon the dis- crimination of diseases; and an elaborate chapter has been introduced on general diagnosis. The work, although presented, as its title indicates, as a formal and systematic treatise, is founded upon the courses of lectures which it has devolved upon me to deliver during the last twenty years; first in the University of Louisville, for a long time the most flourishing medical school in the Southwest, and more recently in the Jefferson Medical College of this city, in which I had the honor, in 1828, to receive my degree. During all that period, I have been unceasingly devoted to the duties of an arduous practice, both private and public; to the study of the great masters of the art and science of medicine viii PREFACE TO THE FIRST EDITION. and surgery; and to the composition of various monographs having a direct bearing upon a number of the subjects discussed in these volumes. The work should, therefore, be regarded as embodying the results of a large personal, if not of a ripe, experience, of extensive reading, and much reflection; in a word, as exhibiting surgery as I myself understand it, and as I have, for so many years, conscientiously taught it. If, upon certain points of doctrine, I have been obliged to differ from colaborers of acknowledged authority and of the highest professional eminence, it is because I have found it impossible to do otherwise. As Luther said at the diet of Worms, "hier stehe ich, ich kann nicht anders," so I may declare that what I have here written, I have written under a solemn conviction of its truth, though certainly not without a strong sense of my fallibility and shortcomings. In the composition of a work so extensive as this, comprising so many and such diversified topics, no man, however great his oppor- tunities for observation, could possibly rely entirely upon his own resources; for there are certain diseases, and also certain accidents, so infrequent in their occurrence as hardly to come under notice even once in a long lifetime; and it is, therefore, only by availing himself of the recorded experience of the profession that an author can hope to be able to communicate full and satisfactory information respecting them. I have, accordingly, made free use, wherever this was deemed necessary, of the labors of my contemporaries, both among systematic writers and the contributors to the periodical press of this and other countries. To the excellent works of Erichsen, Miller, and Fergusson, so well known on this side of the Atlantic, I have frequently referred as embodying the latest resume* of the art and science of surgery among our British brethren: while I have not neglected to consult some of the more recent treatises in the French and German lan- guages, as well as numerous monographs. Of the engravings which adorn the volumes, nearly four hundred are original, the remainder having been borrowed from different writers, as Liston, Cooper, Fergusson, Marcet, Bennett, Miller, Cur- ling, Tamplin, Lawrence, W. Jones, Dalrymple, Pirrie, Erichsen, Druitt, Ashton, Toynbee, Barwell, and Mutter. To Mr. Gemrio-, the eminent cutler, I am indebted for numerous illustrations, many of them specially prepared for the work, of the latest and most approved styles of instruments. Mr. Kolbe, another excellent manufacturer, has also placed me under obligations for several similar favors. To Professor Wright, of Montreal, Dr. E. Williams, of Cincinnati, Dr. Lente, of New York, and Dr. Packard, Dr. James Darrach, and Dr. Walter F. Atlee, of this city, my acknowledgments are due for PREFACE TO THE FIRST EDITION. ix various favors received during the progress of the work. To Dr. Bozeman, of Alabama, a valued friend and former pupil, I am in- debted for a complete series of drawings illustrative of his peculiar mode of operating for the cure of vesico-vaginal fistule. The index, which will be found to be unusually elaborate, has been prepared, with great care, by my son, Dr. S. W. Gross. The mechanical execution of the work will, I doubt not, meet with general approval. The publishers have spared neither pains nor ex- pense to render it as perfect, in this respect, as possible. To Messrs. Baxter and Harley, engravers, and Mr. Collins, printer, my best thanks are due for the able manner in which they have executed their re- spective tasks. S. D. GROSS. July 8, 1859. CONTENTS OF YOL. I. PART FIRST. GENERAL SURGERY. Preliminary Observations. ..... CHAPTER I. IRRITATION, SYMPATHY, AND IDIOSYNCRASY CHAPTER II. CONGESTION. CHAPTER III. INFLAMMATION. Sect. I. General Considerations . 1. Causes of inflammation .... 2. Extension of inflammation 3. Varieties ot inflammation .... 4. Terminations or events of inflammation . II. Acute Inflammation . 1. Local symptoms . 2. Constitutional symptoms .... 3. Changes of the blood in inflammation 4. Intimate nature of inflammation . 5. Treatment of inflammation I. Constitutional treatment II. Local treatment .... III. Chronic Inflammation . CHAPTER IV. TERMINATIONS AND RESULTS OF INFLAMMATION. Sect. I. Delitescence and Resolution II. Deposition of Serum Xll CONTENTS OF VOL. I. Sect. III. Lymphization or Fibrinous Exudation 1. Uses of plastic matter 2. Injurious effects of plastic matter Treatment IV. Suppuration and Abscess Abscesses 1. Phlegmonous abscess 2. Diffuse abscess or purulent infiltration 3. Scrofulous abscess 4. Multiple abscess or pyemia 5. Hectic fever V. Hemorrhage VI. Mortification 1. Acute mortification 2. Chronic mortification VII. Hospital Gangrene VIII. Ulceration and Ulcers Ulcers 1. Acute ulcers 2. Chronic ulcers IX. Granulation X. Cicatrization . PAOE 125 130 132 133 134 14U 141 149 151 156 163 167 168 169 177 182 189 192 194 197 205 207 CHAPTER Y, TEXTURAL CHANGES. Sect. I. Softening ....... 210 II. Induration ....... 211 III. Transformations ....... 213 IV. Hypertrophy ....... 216 V. Atrophy ........ 218 VI. Contraction and Obliteration ..... 220 VII. Fistule ........ 221 CHAPTER VI. CONGENITAL MALFORMATIONS. 225 CHAPTER VII. TUMORS OR MORBID GROWTHS. Sect. I. General Observations II. Benign Tumors . 1. Hypertrophic tumors 2. Vascular tumors . 228 231 232 233 CONTENTS OF VOL. I. 3. Fatty tumors 4. Horny tumors 5. Fibrous tumors 6. Cartilaginous tumors 7. Osseous tumors 8. Calcareous tumors . 9. Neuromatous tumors 10. Encysted tumors 11. Hydatic tumors 12. Polypoid tumors 13. Myeloid tumors Excision of benign tumors II. Malignant Tumors 1. Scirrhus . 2. Encephaloid 3. Epithelioma 4. Colloid . 5. Melanosis . Treatment Scrofula and Tubercle Treatment CHAPTER VIII SCROFULA. CHAPTER IX. WOUNDS. Sect. I. General Considerations . 1. Mode of dressing wounds 2. Mode of healing of wounds II. Incised Wounds . III. Lacerated Wounds IV. Contused Wounds V. Punctured Wounds VI. Tooth Wounds . VII. Gunshot Wounds Question of amputation in wounds Secondary effects of wounds and contusions Maggots in wounds VIII. Poisoned Wounds 1. Wounds inflicted by poisonous insects 2. Wounds inflicted by venomous serpents 3. Wounds inflicted by rabid animals 4. Glanders, farcy, or equinia xiv CONTENTS OF VOL. I. 5. Wounds inoculated with a peculiar septic poison generated in dead animal bodies ...••• °°^ a. Dissection wounds ...••• •'"^ b. Malignant pustule ...••• 367 CHAPTER X. EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. Sect. I. Prostration, Collapse, or Shock .... II. Traumatic Delirium . 371 376 CHAPTER XI. SYPHILIS. Sect. I. General Considerations . 381 II. Primary Syphilis 383 1. Chancre .... 383 2. Bubo . 401 III. Secondary Syphilis 406 1. General considerations 406 2. Affections of the skin 409 3. Alopecia .... 413 4. Syphilitic abscesses 414 5. Cervical adenitis . 414 6. Affections of the mucous membranes 415 IV. Tertiary Syphilis 418 1. General considerations 418 2. Syphilis of the throat and mouth 420 3. Syphilis of the nose 421 4. Syphilis of the larynx 421 5. Syphilis of the eye 422 6. Syphilis of the ear 423 7. Syphilis of the skin 423 8. Syphilis of the osseous system . 425 9. Syphilitic orchitis 428 10. Condylomatous growths . 430 Treatment .... . 432 Syphilis in the infant . 440 Syphilization .... . 444 CHAPTER XII GENERAL DIAGNOSIS. Sect. I. Examination of the Patient Examination of the different organs . II. Mensuration .... III. Attitude of the Patient . 446 448 453 454 CONTENTS OF VOL. I. XV PAGE Sect. IV. External Characters ....... 455 V. Instrumental Explorations ...... 458 VI. Examination of the Discharges ..... 463 VII. Microscopical Examination ...... 465 CHAPTER XIII. MINOR SURGERY. Sect. I. Instruments II. Incisions ..... III. Avulsion, Enucleation, Ligation, and Crushing IV. Abstraction of Blood V. Transfusion of Blood VI. Vaccination VII. Counter-irritation VIII. Escharotics IX. Dressing . X. Bandaging CHAPTER XIV. OPERATIVE SURGERY. Qualifications of a surgeon Preparation of the patient Assistants Duty of a surgeon Position of the patient and surgeon Operation .... Accidents during the operation Dressings and after-treatment Dangers after operation CHAPTER XV. PLASTIC SURGERY . . . .524 CHAPTER XVI. SUBCUTANEOUS SURGERY . . .529 476 480 483 492 493 494 499 501 503 510 513 514 515 515 515 516 518 XVI CONTENTS OF VOL. I. CHAPTER XVII AMPUTATIONS IN GENERAL Sect. I. Introductory Considerations II. Circumstances Demanding Amputation III. Methods of Amputation . IV. Operation and after-treatment Synchronous Amputation V. Affections of the Stump . 1. Primary affections . 2. Secondary affections VI. Constitutional Effects of Amputations VII. Artificial Limbs . VIII. Mortality after Amputations CHAPTER XVIII. EXCISION OF THE BONES AND JOINTS. Instruments Position of the patient Incisions . Removal of the bone Dressing . CHAPTER XIX. ANAESTHETICS OR THE MEANS OF AVERTING PAIN. General considerations Chloroform Mode of administration Effects Inhalation of ether Amylene . Kerosoline Local anaesthesia . CONTENTS OF VOL. I. XV11 PART SECOND. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. CHAPTER I. DISEASES AND INJURIES OF THE SKIN AND CELLULO-ADIPOSE TISSUE. Sect. I. Erysipelas . . . . Treatment . PAGE 589 596 II. Furuncle or Boil 603 III. Anthrax or Carbuncle 605 IV. Gangrene and Bedsores . 608 V. Burns and Scalds 610 VI. Frost-bite and Chilblain . 618 VII. Morbid Growths . 1. Warts, or verrucous growths 2. Sebaceous tumors . 3. Molluscous tumors 4. Moles 5. Hypertrophy of the skin . 622 622 623 625 626 . 627 6. Elephantiasis or hypertrophy of th e skin < md cellular tissue 627 7. Keloid tumors . 631 8. Eiloid . 635 9. Lepoid . 635 10. Lupus . 636 11. Melanosis . . 639 12. Scirrhus . 639 VIII . Insects in the Skin and Cellular Tissue . 640 CHAPTER II. DISEASES AND INJURIES OF THE MUSCLES, TENDONS, BURSES, AND APONEUROSES. Sect. I. Muscles . II. Tendons . III. Synovial Burses IV. Aponeuroses VOL. I___2 642 647 651 655 xvm CONTENTS OF VOL. I. CHAPTER III. DISEASES OF THE LYMPHATIC VESSELS AND GANGLIONS. Sect. I. Lymphatic Vessels II. Lymphatic Ganglions CHAPTER IV. DISEASES AND INJURIES OF THE NERVES Sect. I. Wounds and Contusions II. Tetanus . III. Neuralgia IV. Paralytic Affections 1. Wasting palsy 2. Infantile palsy 3. Partial palsy CHAPTER V. DISEASES AND INJURIES OF THE ARTERIES. Sect. I. Wounds and Hemorrhage II. Subcutaneous Hemorrhage III. Collateral Circulation IV. Hemorrhagic Diathesis . V. Diseases of the Arteries . 1. Acute inflammation 2. Chronic affections . 3. Intra-parietal separation 4. Varicose enlargement VI. Aneurism 1. Locality, prevalence, age, sex, and 2. Varieties . 3. Symptoms . 4. Diagnosis . 5. Effects and termination 6. Spontaneous cure . Treatment a. Deligation of the artery at the cardiac side of the tumor 6. Deligation of the artery at the distal side of the tumor c. Instrumental compression .... d. Digital compression .... e. Forcible flexion ..... CONTENTS OF VOL. I. /. Galvano-puncture .... g. Injection ..... h. Manipulation .... i. Valsalva's treatment of internal aneurism k. General medical treatment False aneurism . . . . Sect. VII. Aneurism of Particular Arteries of the thoracic aorta of the innominate artery . of the common carotid artery of the external carotid of the ophthalmic artery . of the internal carotid of the vertebral artery of the subclavian of the axillary artery of the brachial artery and its branches of the common iliac artery of the internal iliac of the external iliac of the femoral artery of the popliteal artery of the arteries of the leg and foot . VIII. Operations on the Arteries Ligation of the innominate or brachio-cephalic of the common carotid of the external carotid and its branches of the vertebral artery of the subclavian artery of the axillary of the brachial of the radial and ulnar of the abdominal aorta of the common iliac of the internal iliac of the gluteal of the sciatic artery of the external iliac of the epigastric and circumflex arteries of the femoral of the deep femoral of the popliteal of the anterior tibial of the posterior tibial of the peroneal CHAPTER VI. INJURIES AND DISEASES OF THE VEINS. Sect. I. Wounds ....... II. Diseases of the Veins . CONTENTS OF VOL. I. 1. Acute phlebitis 2. Chronic affections Sect. III. Varix . IV. Introduction of Air PAOE 831 833 834 837 CHAPTER VII. AFFECTIONS OF THE CAPILLARIES. Sect. I. Arterial Tumors II. Venous Tumors 842 849 CHAPTER VIII. DISEASES AND INJURIES OF THE BONES AND THEIR APPENDAGES. Sect. I. Periostitis Acute periostitis Chronic periostitis Endosteitis or Osteomyelitis Osteitis . Suppuration and Abscess Caries or Ulceration Necrosis or Mortification II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. Softening Rachitis . Fragility . Atrophy . Hypertrophy Tumors . Innocent formations 1. Exostoses or bony tumors 2. Fibro-cartilaginous tumors 3. Aneurismal tumors 4. Hematoid tumors 5. Sero-cystic tumors 6. Hydatic tumors 7. Myeloid tumors . Malignant formations . Tubercular Disease Neuralgia Fractures 1. General considerations 2. Simple fractures 851 852 853 854 856 860 862 871 882 886 890 893 894 896 896 896 901 902 904 904 907 909 910 913 915 917 917 924 CONTENTS OF VOL. I. XXI 3. Complicated fractures 4. Incomplete fractures or bending of the bones 5. Diastasis or separation of the bones at their epiphyses 6. Ununited fractures 7. Vicious union of fractures 8. Diseases of the callus Sect. XVI. Fractures of Particular Bones 1. Head and trunk Fractures of the nasal bones . of the upper jaw of the malar bone . of the lower jaw of the hyoid bone . of the larynx of the clavicle of the scapula of the ribs . of the costal cartilages of the sternum of the vertebrse of the pelvic bones . 2. Superior extremity Fractures of the bones of the hand and fingers of the shafts of the radius and ulna of the ulna . of the radius of the humerus 3. Inferior extremity Fractures of the foot . of the tibia . of the fibula of both the tibia and fibula Complicated fractures of the leg Fractures of the patella of the femur 1. of the shaft 2. of the inferior extremity 3. of the superior extremity of the femur Intra-capsular fractures Extra-capsular fractures Impacted fractures of the neck of the femur Fractures of the great trochanter . LIST OF ILLUSTRATIONS TO YOL. I. 1. Reticulated arrangement of the corpuscles in inflammatory blood 2. Buffy and cupped blood .... 3. Natural ear of a rabbit .... 4. Inflamed ear of a rabbit .... 5. Extravasated blood in an inflamed serous membrane 6. Changes in the capillary circulation in inflammation 7. Plastic corpuscles and filaments in recent lymph exuded on the pleura 8. Recent lymph, forming false membrane 9 ~h ' J- Nuclei and cells developing themselves into fibres 11. Perfect fibrous tissue .... 12. Newly-formed vessels in plastic lymph 13. Vessels in false membrane of the pleura 14. Natural appearance of pus corpuscles and after the application of acetic acid 15. Abscess opening into the external carotid 16. Bistoury for opening abscesses 17. Acute mortification .... 18. Mortification, with an appearance of the sloughing process 19. Chronic gangrene .... 20. Chronic ulcer ..... 21. Granulating ulcer, beginning to cicatrize 22. Strapping of an indolent ulcer 23. Arrangement of bloodvessels in a granulation 24. Structure of a cicatrice of the skin . 25. Vascular tumor of the scalp 26. Fatty tumor ..... 27. Minute structure of a fatty tumor 28. Horny excrescence of the scalp 29. Section of a horn .... 30. Microscopical characters of a fibrous tumor . 31. Enchondromatous tumor 32. Minute structure of enchondroma 33. Section of a neuromatous tumor 34. Microscopic structure of a neuromatous tumor 35. Painful subcutaneous tubercle 36. Microscopic structure of the subcutaneous tubercle 37. Hydatids inclosed in a common cyst 38. Cysts of echinococci .... 39. Echinococci ..... XXIV LIST OF ILLUSTRATIONS TO VOL FIG. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. Serrefine ...... Small forceps for temporarily checking hemorrhage Cancer-cells in the earlier stages Cancer-cells further developed Cancer-cells in their fibrous stroma Stroma of scirrhus . Scirrhus cells Stroma of encephaloid Encephaloid cells Tuberoid form of encephaloid Epithelial cancer in a state of ulceration Cells of epithelioma Papilla from epithelioma Colloid tumor, external appearance Colloid tumor, internal structure Microscopic structure of a melanotic tumor Tubercle corpuscles . Tubercles in the mesenteric glands Interrupted suture . Silver needle for twisted suture Twisted suture, elliptical Twisted suture, figure of 8 . Pin pliers India rubber suture . Glover's suture Quilled suture Price's needle for wire suture Murray's needle Lister's needle I Invaginated bandage for longitudinal wounds Diagram representing effects of gunshot wounds > Gunshot probe Bullet forceps Tiemann's forceps Gemrig's forceps Gross's forceps Kolbe's bullet extractor European extractor . Head of rattlesnake . Poison fang, magnified Indurated chancre . Sloughing chancre . Acute phagedena Chronic phagedena . Syphilitic ulceration of the larynx Syphilitic rupia Syphilitic caries of the skull Syphilitic hypertrophy of the femur, internal structure Syphilitic hypertrophy of the femur, external characters Condylomata ..... LIST OF ILLUSTRATIONS TO VOL. FIG. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. Syphilitic temporary teeth Syphilitic permanent teeth Probe . . - Speculum Exploring needle Smith and Beck's large compound microscope Arrangement of microscope for transparent objects Scalpels Bistoury Sharp-pointed bistoury Probe-pointed bistoury I Forceps [ Scissors Museux's forceps Pronged instrument for pulling and holding tumor Forceps for uterine polyps Grooved director Trocar Needles Suture needle First position in holding scalpel Second position in holding scalpel Third position in holding scalpel Fourth position in holding scalpel Different forms of incisions Double .canula Ecraseur .... Scarificator .... Cupping apparatus . Cupping glass with India-rubber top Veins of arm Mode of holding the lancet in venesection Compress applied to the temporal artery after arteriotomy Gross's transfixing apparatus Corrigan's button cautery . Seton needle armed Eye probe as a substitute for the above XXVI LIST OF ILLUSTRATIONS TO VOL. I. FIQ. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. Porte-moxa ..... r Acupuncture needles Marshall's galvanic cautery Different forms of cauteries Dressing forceps . Bandage of Scultetus Mode of applying the bandage Appearance of the bandage after its application Gangrene from strangulation by unequal compression of a Tenotome ....•■ Circular amputation, illustrated in the leg Circular operation, shown in the thigh Corresponding stump .... Flap amputation, illustrated in the thigh . Corresponding stump .... Amputation by the rectangular flap (Teale's process) Appearance of parts when brought together in the same Tourniquet of Petit Tiemann's improved tourniquet Gross's arterial compressor Amputating knife Catlin Amputating saw Small amputating saw Bone nippers Detached sequester Neuromata of the stump, after amputation of the Appearance of bony stump after amputation Palmer's artificial leg Ordinary form of wooden leg Palmer's artificial arm Butcher's saw Hey's saw .... Narrow concave saw for division of bones Chain saw .... [ Cutting pliers Carbuncle in its forming stage Ulcerated carbuncle Cicatrice after a burn Sebaceous tumor of the scalp Cyst of a sebaceous tumor containing hair Elephantiasis of the foot and leg Keloid tumors Microscopical characters of keloid . Nodule of black cancer in the skin Globular hydatid Fibroid bodies of a ganglion Fibroid bodies of a synovial burse . LIST OF ILLUSTRATIONS TO VOL. I. XXV11 FIG. PAGE 196. Hypertrophied lymphatic glands ...... 660 197. Melanosis of a lymphatic gland ...... 663 198. Cretaceous degeneration of lymphatic glands . 663 199. Syringe for endermic application of morphia 680 200. Plan of wounded arteries 690 201. Contraction of a divided artery 691 202. Plan of natural hemostatics in a cut artery 691 203. Change in artery after ligation 692 204. Diagram of the collateral circulation 692 205. Spring artery forceps 694 206. Tenaculum ..... 694 207. Sliding forceps .... 695 208. Mode of isolating an artery 695 209. Effects of ligation on the inner coats 695 210. Exterior of an artery after ligation 696 211. Reef-knot ..... 696 212. Surgeon's knot .... 696 213. Tenaculum-needle, armed with ligature 697 214. Physick's artery forceps 697 215. Aneurism-needle, armed with ligature 698 216. Carotid of a dog forty-eight hours after deligation 699 217. Carotid of a dog ninety-six hours after deligation 699 218. Carotid of a dog twelfth day after deligation 699 219. Acupressure; the pin seen through the skin 702 220. Position of the artery and pin in acupressure 702 221. Tourniquet applied to the thigh 702 222. Field tourniquet; handkerchief and stick . 703 223. Field tourniquet; handkerchief and sword 703 224. Prussian field tourniquet 703 225. Compression of the fingers, arresting the circulation in the upper extremity 704 226. Compression of the fingers, arresting the circulation in the lower extremity 704 227. Plan of a graduated compress .... 705 228. Torsion-forceps .... 707 229. Partial absorption of the clot 709 230. Collateral circulation shown in the thigh . 713 231. Deposition of calcareous matter in an artery 720 232. Atheromatous deposits in the aorta 720 233. Minute appearances of atheromatous deposits 721 234. Dissecting aneurism . 722 235. Varicose enlargement of the arteries 723 236. 1 237. 238. }• Arrangement of arterial tunics in spontaneous aneurism . . 724 239. 240. J Sacculated aneurism ....... 729 241. Aneurism of aorta .... . 730 242. Sacciform aneurism of aorta ready to give way . 731 243. Tubular aneurism of aorta . . 733 244. Aneurism by dilatation . 734 245. Erosion of vertebrae from aneurism . 739 246. Aneurism obliterated by deposition and organization of fibrin . 740 247. Aneurism of descending aorta; burst . 742 LIST OF ILLUSTRATIONS TO VOL. I. FIG. 248. Illustration of Hunter's operation . 24y. Illustration of "Brasdor's operation . 250. Illustration of Wardrop's operation 251. Gibbons's alternating compressor 252. Carte's compressor . 253. Hoey's clamp 254. Carte's circular compressor 255. Pravaz's syringe for injection in aneurism 256. Varicose aneurism; external view . 257. Varicose aneurism; internal view . 258. Aneurismal varix 259. Aneurism of innominate, proving fatal by bursting into the trachea 260. Ligation of the common carotid 261. of the lingual artery 262. of the facial artery 263. of the occipital artery 264. of the temporal artery 265. of the subclavian artery . 266. of the axillary artery 267. of the brachial, radial, and ulnar arteries 268. Double brachial artery 269. Ligation of the common iliac 270. of the femoral 271. of the popliteal 272. of the anterior tibial 273. of the posterior tibial 274. Phlebitis .... 275. Varix of the leg 276. Structure of an arterial tumor or anastomotic aneurism 277. Ligation of an erectile tumor 278 ~l „_ ' > Erichsen's mode of ligating vascular tumors 279. i 280. Hypertrophy of the tibia from inflammation 281. Abscess in bone ..... 282. Large chronic abscess of the tibia . 283. Trephine ...... 284. Caries with softening of the cartilage 285. Caries of bone consequent upon tertiary syphilis . 286. Caries of the head of the humerus . 287. Caries of the tibia, showing an ulcer in the skin . 288, 289, 290. Bone-drill, gouge, and scraper 291. Structure of a granulation in a bone 292. Necrosis of the tibia .... 293. Necrosed tibia, the dead bone lying loose within the new 294. Cloacae in a necrosed tibia .... 295, 296, 297, 298, 299. Instruments for removal of dead bone 300. Madame Supiot ..... 301. Rickets ...... 302. Eccentric atrophy of bone .... 303. Atrophy of the cellular tissue of the thigh-bone . 304. Senile atrophy of thigh-bone, in its advanced stage 305. General hypertrophy of bone—internal structure . LIST OF ILLUSTRATIONS TO VOL I. XXIX FIG. PAGE 306. General hypertrophy of bone—external characters . . . . 895 307. Hypertrophy involving both the thickness and length of bone 895 308. Exostosis of the thigh-bone ..... 896 309. Remarkable form of exostosis of the thigh-bone 897 310. Ivory-like exostosis, showing its internal structure 898 311. Enchondroma 901 312. Enchondromatous tumor undergoing ossification 902 313. Enchondromatous tumor of the ribs 903 314. Anastomotic aneurism of bone 903 315. Cystic disease of the femur 905 316. Encephaloid disease of the femur . 910 317. Encephaloid disease of the thigh-bone 911 318. Colloid tumor of the sphenoid bone 911 319. Tubercular infiltration of bone 914 320. Tubercular excavation of the cuneiform bone 915 321. Oblique fracture of bones of forearm 919 322. Longitudinal and oblique fracture . 919 323. Appearance of the ends of the fragments . 920 324. Impacted fracture of the neck of femur 920 325. Encephaloid of the thigh, followed by fracture 922 326. Fracture of the lower end of the radius 927 327. Bisected fractured tibia, showing the formation of new bone 930 328. Union of fracture, showing the condition of the medullary canal . 931 329. Appearance of ends of fragments in ununited fracture 932 330. Fracture of the arm-bone of a chicken .... 932 331. Wire-rack for fractures of the lower extremity 937 332. Seutin's scissors . . . . . . 940 333. Arrangement of the starch bandage for fractures of the thigh 941 334. Dressing in compound fracture of the leg . 941 335. Fracture of the leg, complicated with wound and comminution of the bon i 943 336, 337. Incomplete fracture of the bones of the forearm 947 338. Diastasis of the femur, reunited ..... 951 339. False joint in ununited fracture 951 340. Absorption of the humerus . 353 341. Gimlet for piercing bone 954 342. Brainard's perforator 955 343. Smith's apparatus for ununited fracture 957 344. Vicious union of fractures . 958 345. Exuberant callus after fracture of the thigh . 960 346. Fracture of the lower jaw . 964 347. Gibson's jaw bandage 966 348. Barton's jaw bandage 966 349. Pasteboard compress . N . 966 350. Hamilton's apparatus 966 351. Fracture of the clavicle 969 352. Complete oblique fracture of the clavicle . 970 353, 354. Levis's apparatus for fractured clavicle . 972 355. Figure of 8 bandage for fractured clavicle . 973 356. Boyer's apparatus for fractured clavicle 973 357. Hunton's yoke-splint for fractured clavicle 973 358. Fracture of the acromion process 974 359. Fracture of the neck of the scapula 975 XXX LIST OF ILLUSTRATIONS TO VOL. I. FIG. 360. Fracture of the glenoid cavity .... 361. Fracture of the coracoid process .... 362. The ordinary situation of fracture of the body of the scapula 363, 364. Fractures of the ribs, showing direction of displacement 365. Fracture of the ribs—united by osseous matter 366. Fracture of the spinous process .... 367. Fracture of the vertebral arches .... 368. Fracture of the vertebrae . 369. Fracture of the odontoid process of the axis 370. Fracture of the acetabulum ..... 371. Fracture of the pubic and ischiatic bones . 372. Fracture of the shafts of the radius and ulna 373. Vicious union after fracture of the shaft of the radius 374. Fracture of the shaft of the ulna .... 375, 376. Fracture of the olecranon process 377. Fracture of the olecranon process, united by fibrous matter 378. Apparatus for the same ..... 379. Fracture of the coronoid process .... 380. Apparatus for the same ..... 381. Fracture of the shaft of the radius 382. Fracture of the head of the radius .... 383. Multiple fractures of the lower extremity of the radius 384. Fracture of the'lower extremity of the radius 385. Fracture of the lower end of the radius, complicated with luxation of the ulna ....... 386. Bond's splint—the part for the back of the forearm 387. The same, for the front of the forearm and hand . 388. Apparatus for fracture of the lower end of the radius 389, 390, 391. Dr. Swinburne's apparatus for fracture of the radius 392. Fracture of the inner condyle of the humerus 393. Fracture of the outer condyle of the humerus 394. Fracture of the inferior extremity of the humerus 395. Complicated fracture of the elbow .... 396. Fracture with detachment of the head of the humerus 397. Fracture of the anatomical neck of the humerus . 398. Fracture of the surgical neck of the humerus 399. Welch's shoulder splints ..... 400. Oblique fracture of the tibia . 401. Tin case for fracture of the tibia . 402. Welch's splints for fracture of the tibia 403. Bauer's wire splints for fracture of the tibia 404. Vertical fracture of the fibula . 405. Dupuytren's apparatus for fracture of the lower extremity of the fibula 406. Fracture of the tibia and fibula 407. Fracture of the extremity and malleolus of the tibia and the lower end of the fibula ...... 408. Appearances of the broken articulating surface of the tibia 409. Fracture of the lower end of the tibia and fibula . 410. Neill's fracture-box ..... 411. Extension in fractures of the leg by the gaiter 412. Extension in fractures of the leg by the handkerchief 413. Extension in fractures of the leg by adhesive strips LIST OF ILLUSTRATIONS TO VOL. I. XXXI FIG. PAGE 414. Swinburne's mode of treating fracture of the leg . . 1018 415. Salter's apparatus for suspending the leg . . 1018 416. Smith's double-inclined plane .... . 1019 417. Complicated fracture of the leg .... . 1019 418. Fracture box ...... . 1021 419. M'Intyre's screw splint for compound fracture of the leg . . 1021 420, 421. Fracture of the patella .... . 1021 422. Signs of the same ...... . 1022 423. Separation of the fragments in fracture of the patella . 1023 424. Hamilton's apparatus for the same .... . 1024 425, 426, 427. Fracture of the upper portion of the shaft of the femur . 1027 428. Fracture of the inferior fourth of the shaft of the femur . . 1028 429. Jenks's fracture-bed ..... . 1029 430. Physick's long splint ..... . 1031 431. Gross's fracture-box ..... . 1031 432. Gilbert's apparatus for compound fractures of the thigh-bone . 1032 433, 434. Hodge's mode of counter-extension in fracture of the femur 1032,1033 435. Smith's anterior splint ..... . 1033 436. Mode of application of the same .... . 1034 437. Buck's fracture apparatus ..... . 1034 438. Swinburne's treatment of fractured thigh, without splints . 1035 439. Double inclined plane of Sir Charles Bell . . 1037 440. M'Intyre's splint, simplified and improved by Liston . 1038 441. The same applied to the limb .... . 1038 442. Fracture of the external condyle of the thigh-bone . 1039 443. Comminuted vertical fracture of the condyles of the femur . 1040 444. Normal appearances of the head and neck of the thigh-bone . 1041 445. Changes in the head and neck of the thigh-bone from old age . 1041 446. Capsular ligament of the thigh-bone . 1042 447, 448, 449. Intra-capsular fracture of the neck of the thigh-bone 1043, 1044 450. Vertical fracture of the neck of the femur . . 1044 451. Senile atrophy of the neck of the femur ... . 1049 452. Atrophy which might be mistaken for united fracture . 1049 453. Fibro-ligamentous union of the neck of the thigh bone . 1049 454. Daniel's fracture-bed ...... . 1052 455, 456. Extra-capsular fracture of the neck of the thigh-bone . 1053 457. Impacted fracture of the neck of the femur . 1056 458. Impacted fracture through the trochanters . 1056 459. Fracture of the great trochanter .... . 1061 460. Sir Astley Cooper's mode of treating fractures of the great trochai iter . 1062 PART FIRST. GENERAL SURGERY. VOL. I.—3 A SYSTEM OF SURGERY. PRELIMINARY OBSERVATIONS. Uxder the division of General Surgery, I shall consider, at some length, the leading facts illustrative of the great principles of surgical diseases and injuries, and of the operations necessary for their relief, removal, or cure. Beginning with the subjects of irritation, sympathy, and congestion, as inti- mately concerned in the production and maintenance of many of the most common and interesting morbid phenomena, I shall pass successively in re- view all that relates, generally speaking, to inflammation and its effects, tex- tural changes, new formations, whether benign or malignant, wounds, and poisons; as all these affections are liable to occur in every organ, tissue, and region of the body. To this division of the work, also, naturally appertain the subjects of general diagnosis, surgical instruments, and other appliances; and, lastly, anaesthetics, or the means of averting pain during the perform- ance of surgical operations, and in the reduction of hernia, fractures, and dislocations. Such an arrangement is suggested not less by common sense than by sound experience; for it is just as necessary in surgery to pass from the known to the unknown, or from the more simple to the more complex portion of the various topics which fall within its province, as it is in the study of mathematics, or any other abstruse science. The above subjects being disposed of, we shall come to that of Special Surgery, embracing an account of the various surgical diseases, injuries, and malformations of particular organs, tissues, and regions of the body. The general principles or great doctrines of surgery being understood, a know- ledge of the various topics discussed in this part of the work will be a com- paratively easy task. 4 The word surgery is a corruption of chirurgery, derived from a Greek compound, literally signifying manual procedure. Hence, surgery was for a long time regarded merely as a kind of handicraft, fit to be exercised only by men of inferior attainment, ability, and skill. For many ages, in fact, the chirurgeon was nothing but the servant of the physician, without whose ad- vice and direction he was never permitted to perform any operation, however simple. He had no agency whatever in preparing the system for the ap- proaching ordeal, nor any hand in the after-treatment of the case. His task was completed when he had made his incisions, spilt a certain quantity of blood, and relieved the suffering organ from impending danger, by restoring it to its natural position, or ridding it of foreign substances. His occupa- tion was a mere mechanical one; and, although there can be no doubt that he often possessed great manual dexterity, yet it is obvious that his very edu- cation unfitted him for the exercise of the more lofty duties of his profession. The contrast between the surgery of former times and that of the present 36 PRELIMINARY OBSERVATIONS. day, forms one of the brightest pages in the history of human progress and human achievement. Redeemed and purified by the genius of modern dis- covery, it is no longer a handicraft, but a science and an art, reduced, if not to perfection, to principles as accurate as any that have been introduced into the study of the natural sciences in general, of which, in fact, it forms one of the most interesting and useful branches. Surgery, thus improved and perfected, can no longer be separated from medicine; any attempt to produce such a severance must prove abortive. They are, in point of fact, one and the same science, and therefore indivisi- ble. No surgeon can practise his profession with credit to himself, or bene- fit to his fellow-creatures, if he is not an enlightened physician, or deeply grounded in a knowledge of the great doctrines of disease. He may, it is true, be an excellent operator, a good mechanic; but unless he is an able pathologist and therapeutist, he is unworthy to be intrusted with the health and life of the humblest citizen. Surgery has occasionally been separated into two distinct branches, medi- cal and operative; the former treating, as the name implies, of the principles of the science, or of the nature of disease, and of its management by drugs; the latter, of the various manual, instrumental, and mechanical procedures con- sidered necessary for the cure of external affections, and the repair of muti- lated structures. Upon this plan have been constructed several very excel- lent modern works, as those of Liston, Miller, Fergusson, Sedillot, Blasius, Velpeau, Pancoast, and Smith; but it is questionable whether such a man- ner of treating the subject is altogether judicious, as it is certainly calculated to invest the operative part of surgery with a degree of importance that does not legitimately belong to it, and which may lead, especially on the part of the young practitioner, to erroneous conceptions of the true province and dignity of surgery, considered as a science and an art. A work on surgery, or, indeed, on any subject, without principles, may be compared to a vessel at sea without helm or rudder to guide it to its place of destination. If, therefore, there is anyone part of the present treatise upon the study of which I would insist more than upon that of any other, it is that which treats of the great principles of surgery, as comprised under the head of inflammation, wounds, morbid deposits, new growths, and morbid poisons. Let the stu- dent make himself fully acquainted with these details, and he can hardly fail to become an enlightened and judicious practitioner. Let him learn princi- ples, and he will be able to form a more just appreciation of what is merely operative. IRRITATION. 37 CHAPTER I. IRRITATION, SYMPATHY, AND IDIOSYNCRASY. It is perhaps impossible, in the present state of the science, to offer any satisfactory definition of irritation, or to assign to this expression its true pathological and practical import, without an intimate knowledge of sym- pathy, or of those various and mysterious relations, anatomical and functional, which exist among the different organs and tissues of the body, and which thus serve to bind them all up into one harmonious, uniform, and connected system. Irritation and sympathy are not only closely associated together, in all the great operations of the economy, but they so constantly run into each other, as to render it impossible always to draw a precise line of distinction between them, or to determine what part they respectively play in the pro- duction, propagation, and effect of disease. Much of what has been written upon these topics has necessarily been exceedingly obscure, depending not merely upon the intrinsic difficulties of the subject—great and perplexing as they certainly are—but upon the unphilosophical manner in which they have, for the most part, been discussed by surgeons, whose authority has not only never been disputed, but regarded with a blind devotion as surprising as it has generally been unaccountable. To arrive at any other conclusion from an attentive perusal of their writings, is impossible. Every page, nay, almost every paragraph, bears testimony to the fact that they have constantly con- founded together affections of a very different, and even of an opposite nature; that they have, in numberless instances, violated their own definitions of dis- ease ; and that they have attempted to establish systems of treatment based upon principles of the most erroneous and unfounded character. What is irritation ? Is it an entity, or a mere myth, a certain undefinable something, which no one can see, but which every one may recognize by its effects ? Perhaps the best definition we can give of it is, that it is a dis- ordered state of the nerves of the affected part, attended with more or less pain and functional disturbance, but not with inflammation, although it may lead to that result, if not timeously arrested ; in other words, irritation is a disease whose predominant symptom is nervous derangement. Viewed in this light, it may be considered as bearing the same relation to the nervous system that inflammation bears to the vascular; the one consists essentially in disordered sensation, the other in disordered circulation ; in the one there is pain, but it is the pain of perverted sensation, in the other there is pain also, but it is the pain of inflammation, as is evinced by the concomitant vascular injection, discoloration, and tumefaction, which are wanting in the former. The differences between irritation and inflammation have sometimes been defined by stating that the former terminates where the latter begins; just as congestion may be said not to be inflammation, but the prelude to that affec- tion. Both may be merged in the latter disease, and may, consequently, serve to augment and perpetuate it. Irritation maybe of limited extent, as when it is confined to one particular organ, or part of the body, and is then said to be local; on the other hand, it is sometimes widely diffused, manifesting itself at numerous points, and constituting what is termed general irritation, of which one of the most 38 IRRITATION AND SYMPATHY. familiar illustrations occurs in nervous shock, consequent upon severe injury. It is also divided into direct and indirect; in the former case, the irritation displays itself at the place of the morbific impression; in the latter, on the contrary, it occurs at a situation more or less remote, sympathy and reflex action being the agents of its transmission. An example of direct irritation is afforded in the intolerance of light which results from over-fatigue of the eye, and of the indirect, in the convulsions which supervene upon the presence of worms in the alimentary canal, the irritation being communicated here from the nerves of the bowels to the spinal cord, or the cerebrospinal axis, and from thence to the nerves of the voluntary muscles, the seat of the spas- modic action. Local irritation may manifest itself in a great variety of ways and circum- stances. It is generally excited by the contact of some extraneous substance, or agent, foreign to the part, and, therefore, a source of offence to it. Thus, a drop of alcohol, falling upon the eye, instantly produces pain, and injec- tion of the conjunctiva, with an abundant flow of tears; the organ resents the aggression, and the consequence is a marked perversion both of sensa- tion and circulation, which, the exciting cause ceasing to operate, soon passes off, the parts regaining their comfort and accustomed action; or, the cause continuing in play, violent and even destructive inflammation may succeed, the minor evil being merged into the major. A pinch of snuff will excite sneezing by the irritation which its presence induces in the pituitary mem- brane ; on the same principle, some emetics cause vomiting, some cathartics purging, and some diuretics an increased secretion of urine. When the hand is held near a hot stove, or rubbed with spirits of ammonia, the skin pre- sently shows signs of irritation ; its sensibility is perverted, it burns and stings, and becomes intensely red. All these, and numerous other analogous cases that might be easily adduced, if it were necessary, are examples of local irritation, or of perverted nervous action, accompanied by vascular determi- nation, but not by inflammation, although such an event is certain to occur, if the exciting cause of the irritation be not promptly removed. Indirect, or reflex irritation, like the direct, also displays itself in different ways, and not unfrequently in a manner not less singular than perplexing, defying all effort at explanation. The subject offers a wide field for contem- plation and study. Time and space will permit me to glance only at a few of the more prominent facts which naturally connect themselves with such a discussion. To do anything even like partial justice to the subject, it will be proper to consider it in relation to the principal organs of the body, a pro- cedure which will necessarily bring up the question of sympathy, as a know- ledge of the latter is indispensable to a correct appreciation of the former, and conversely. It would be out of place in a work of this kind to inquire into the nature of sympathy. All that we know respecting it is, that there exists, both in health and in disease, an intimate relationship between certain organs and tissues, the result either of a continuity of structure, similarity of tissue or of ties, of which anatomy and physiology have failed to point out the true character. In health, this action is carried on so imperceptibly as to escape attention ; but, whenever there is any serious disorder of the system it mani- fests itself at every point, serving at once, at least in many cases, to indicate the nature of the lesion, and the particular tissues, or set of textures which it implicates. It is not difficult to account for the sympathy that exists be- tween parts that are united together by continuity of structure, as, for instance the eye and nose, or the bladder and urethra; or by similarity of structure' as the fibrous membranes, whose diseases, as gout and rheumatism are some- times suddenly transferred from one to another; but, in other cases—and these constitute some of the most interesting and important exceptions__no BRAIN. 39 connection of any kind can be traced, and we are therefore left in doubt in respect to its real character. It is only, then, by studying these effects, as they exhibit themselves in different parts of the body, and under different circumstances, that our knowledge of them can be made practically available at the bedside. 1. Brain.—The brain, from its elevated position in the scale of organs, and its importance to health and life, is subject, in a remarkable degree, to the causes which develop and influence irritation. Connected, either directly or indirectly, with every other organ and tissue of the body, its functions are liable to be disturbed in every variety of way, and in every possible degree, from the most simple and almost imperceptible departure from the normal standard to the most complete and thorough perversion, amounting, at times, to total annihilation of sensation. Hence, it is not surprising that while the brain is itself a source of irritation to other parts, it should, in its turn, be more or less seriously affected by irritation having its seat in remote struc- tures operating upon it through sympathy, or reflex action. It is in this manner that are developed many of the most distressing diseases of the cere- brum and cerebellum, and, also, as a natural consequence, of the mind ; and, what is remarkable is, that some of the most disastrous lesions often have their origin in apparently the most trivial cerebral irritation, which, but for neglect or ignorance, might usually be relieved by the most simple treatment. The arachnitis of infancy generally begins in reflex irritation, which has its seat in the bowels, stomach, liver, skin, or gums, fretted, perhaps, by the pressure of an advancing tooth. Such cases are of constant occurrence in this country, during our hot summer months, and there are none which are more justly dreaded by the practitioner. The influence of this kind of irrita- tion is often forcibly exhibited in traumatic delirium, or that excited state of the brain consequent upon accidents and operations, especially in subjects of intemperate habits and of a nervous temperament; the brain appears to be in a state of the utmost tension from pent-up irritability, which nothing but the most liberal use of anodynes can generally control; all the symptoms are such as to preclude the idea of the existence of inflammation in the cerebral substance, nor is it by any means certain that there is always gastritis, although usually there is marked derangement of the stomach. In disorder of the uterus, the brain is often affected by reflex irritation, as is plainly evinced by the eccentric phenomena which so generally attend hysterical diseases. On the other hand, disease of the brain is often productive of serious irri- tation, or disease in other parts. Thus, after concussion of this organ, it is by no means uncommon, after the main symptoms of the accident have sub- sided, to meet with paralysis of one side of the face, occasional vomiting, constipation of the bowels, irritability of the bladder, or disease of the sphinc- ters, causing involuntary discharges of urine and feces. The sympathetic relations between the cerebellum and testes have always been a matter of observation, and afford a ready explanation of the occurrence of certain diseases, which, but for a knowledge of this fact, would be impos- sible. Military surgeons long ago noticed that wounds of the occiput, even when they do not involve the substance of this portion of the brain, are often followed, at variable periods after recovery, by atrophy of the testicles. In- juries of the cerebellum have been known to be succeeded within a short time after their infliction by the most violent sexual excitement. In a case of gun- shot wound, the particulars of which have been related to me by Dr. Donne, of Kentucky, this sexual irritation existed in a most remarkable degree. The man was twenty-five years of age, and the ball, discharged from a common rifle, penetrated the skull near the lambdoidal suture, whence it passed obliquely downwards and backwards, lodging, there was every reason to 40 IRRITATION AND SYMPATHY. believe, in the cerebellum. The reaction, which was very slow, was attended with excessive excitement of the genital organs. Intense priapism supervened on the fifth day, attended with the most extraordinary salacity, which formed the all-absorbing topic of his remarks during his semilucid intervals up to the time of his death, nine days after the receipt of the injury. Nocturnal pollutions and the habit of onanism, in their most degrading forms, are often excited and kept up by a diseased state of the brain operating prejudicially upon the testes and seminal vesicles. The effect may be produced simply by inflammation of the cerebral tissues, or by the pressure occasioned by some morbid growth, as a fibrous, scrofulous, or encephaloid tumor. 2. Spinal Cord.—The study of the sympathies and irritations of the spinal cord naturally follows that of the brain. Connected as this cord is, on the one hand, by the nerves which are detached from its substance, with the organs of Volition and of special sensation, and, on the other, by the anastomoses of these same nerves with those of the great trisplanchnic system, its sympathies and relations are as universal as they are close and intricate. Hence what- ever has a tendency to derange these consentaneous movements, must neces- sarily be a source of disease, often of a wide-spread, if not of an all-absorbing character. Concussion, for example, of the spinal cord, when not immediately followed by death, is generally productive of excessive prostration of the vital powers, hardly less extensive and fatal than that of the brain itself. Life often hangs literally for hours upon a mere thread ; the face is ghastly pale, the pulse weak and fluttering, the breathing hardly perceptible. In the milder forms, the mind is frequently disordered for days, the bladder is ex- cessively irritable, the bowels are costive, the eye sees objects confusedly, and the ear is incapable of accurately noting sound. There are many-diseases which may induce spinal irritation; I shall allude only to inflammation, ulceration, and displacement of the uterus, the practice of self-pollution, con- stipation of the bowels, and chronic gastric disorder. On the other hand, spinal irritation is capable of sending its baneful influence through every portion of the system, deranging the functions of every organ, and causing a train of phenomena frequently as distressing as they are enigmatical, or difficult of interpretation. Nervous headache, hemicrania, partial paralysis, imperfect sight, partial aphonia, embarrassed respiration, palpitation of the heart, gastric irritation, vitiated appetite, costiveness, and disorder of the menstrual secretion are often directly traceable to disease of the spinal cord and its envelops; and no practitioner can make much progress towards a cure in these affections without bearing in mind the sources whence they spring. The renal secretion is often greatly deranged by disease and injury of the spinal cord, and a very common effect of such lesions is a tendency to various deposits, especially the lithic and phosphatic. The bladder is also apt to suffer under such circumstances; becoming irritable, inflamed, and the seat of calculus, especially when the spinal cord has been severely concussed, wounded, or compressed. Many cases of neuralgia, gout, and rheumatism owe their origin, there is reason to believe, to disorder of the spinal cord or the spinal cord and brain. 3. Nerves.— The nerves, those agents which convey to and from the brain and spinal cord the impressions made upon the various organs of the body are themselves not unfrequently the seats of serious diseases and injuries' serving to modify and pervert their functions. A spiculum of bone, a ball' or the point of a needle, pressing upon a nerve, or partially imbedded in its substance, has often been productive of epilepsy, partial paralysis, loss of sensation, and other unpleasant symptoms, which promptly vanished upon the removal of the foreign body. l HEART—LUNGS. 41 4. Heart.—As the heart is sympathetically connected with every portion of the body, so there are few diseases which are not capable of exerting a prejudicial influence upon its action, exalting it at one time and depressing it at another. It may be irritated and fretted in a thousand different ways ; now by this thing and now by that; at one time by the solids, and at an- other by the blood, its natural and proper stimulus. Both the surgeon and physician daily witness examples of these disturbing agencies, and prepare to meet them by the judicious exercise of their clinical knowledge, often sadly tried by the perplexing and dangerous features of the case. There is no organ, the brain hardly excepted, whose action varies so much as that of the heart within the limits of health, and none which suffers more frequently and profoundly in disease and accident. The blood which, on the one hand, serves to animate and rouse it, and which, on the other, it is obliged at every moment to propel to every portion of the body, is itself one of the greatest sources of irritation to which it is so constantly exposed. At one time the cause of the irritation perhaps is plethora, at another anaemia; in one case it may be due to an undue proportion of saline matter, in another to the pre- sence of some extraneous substance. Among the more prolific sources of cardiac irritation are disorder of the digestive apparatus, mechanical obstruc- tion to the circulation, however induced, mental emotion, and derangement of the liver, uterus, and kidneys. In injuries, derangement of the sympathetic relations of the heart is of constant occurrence, exhibiting itself in various forms and degrees, from the slightest disorder of its functions to almost complete annihilation of its mus- cular powers. In shock, the pulsations of the heart are weak and fluttering; in compression of the brain, slow and laboring; in hemorrhage, thrilling and vibratory; in plethora, strong and full; in anaemia, quick, jerking, and ac- companied with a peculiar systolic murmur. Irritation of the heart is often aroused by compression of the cardiac nerves by various kinds of tumors, by aneurism of the great vessels, and by diseases resident in its own tissues, causing them to act in an irregular and imperfect manner. As the heart's action may be disordered by various diseased states of the body, so may this organ, in its turn, occasion derangement and irritation in other structures, leading not unfrequently to violent inflammations which no remedial measures, however judiciously applied, can always arrest and subdue. These disordered states form a wide field of study, which it would be out of place to pursue in a work of this kind. The intelligent reader will not fail to appreciate their pathological and practical import. 5. Lungs.—The action and reaction which are so incessantly going on be- tween the lungs and the rest of the system cannot fail to strike the most superficial observer. From the importance of their functions, and their ex- tensive sympathetic relations, these organs are subject to numerous and diver- sified changes, the influence of which, upon the general health, can only be duly estimated by a profound study of the subject. Whatever seriously affects the functions of the more important structures is sure, sooner or later, to ex- ert an unfavorable impression upon the lungs, disordering the respiratory movements, and untowardly interfering with the aeration of the blood, or the introduction of oxygen, and the elimination of carbonic acid. Hence, a per- fectly healthy state of these organs is a matter of paramount importance in the treatment of every case of injury and disease. Among the more common objects of attention, with this view, should be a pure state of the atmosphere, the use of wholesome food, and the correction and improvement of the secre- tions, without which our best directed efforts will often fail to avert irritation 42 IRRITATION AND SYMPATHY. and disease, or to combat them successfully when their development has been unavoidable. 6. Stomach.—The stomach, possessing a wide range of sympathy, is often the seat, not less than the cause, of severe irritation. Food and drink are the natural stimulants of this organ, and, rationally employed, seldom fail to prove wholesome. But when the laws of digestion are contravened by dietetic debauch and indiscretion; or, in other words, when the stomach is overloaded with indigestible articles, nausea and vomiting, with more or less cerebral and other disturbance, are the necessary and inevitable consequences. In children and delicate nervous females, such abuse often manifests its effects in the most violent convulsions, from the irritation it provokes in the cere- brospinal axis and the nerves which are distributed to the voluntary muscles. An overloaded stomach frequently brings on a severe attack of asthma, pal- pitation of the heart, indistinctness of vision, and distressing noises in the ears. Affections of the oesophagus often create excessive irritation of the sto- mach, manifesting itself in nausea and vomiting. Examples of this morbid sympathy occur in scirrhus of the oesophagus, as well as in ulceration and ordinary stricture of that tube. I have seen a foreign body, as a common cent, lodged in the oesophagus of a child, keep up nausea and vomiting until it was extracted. The irritation of the stomach, produced by tickling the fauces, is well known to every one. On the other hand, the oesophagus is liable to suffer very seriously from disease of other parts of the body. Thus, spasmodic stricture of this tube, sometimes of an exceedingly severe and intractable character, may be produced by disorder of the stomach, bowels, uterus, or spinal cord, which can only be relieved by addressing our remedies to the seat of the primary affection. 7. Bowels. — Disorder of the bowels is a prolific source of irritation, exhibiting itself in different viscera and tissues; for there are few organs whose sympathetic relations are of a more varied and extensive character. We have already alluded to the effects occasioned by the presence of worms in the alimentary canal; the retention of irritating matter often produces similar impressions upon the great nervous centres, followed, in many cases, especially in infants and delicate nervous persons, by violent convulsions, disease of the arachnoid membrane, and palpitation of the heart. Itching of the nose, and various affections of the lips, tongue, and fauces, are frequently directly chargeable to dyspepsia, constipation and other gastro-enteric de- rangement. What is called sick headache affords a familiar illustration of cerebral irritation dependent upon disorder of the stomach and bowels, or of these organs and of the liver. Costiveness never fails, when long continued, to oppress the brain, and produce a sense of general malaise. 8. Rectum.—There is an intimate sympathetic connection between the bladder and the rectum ; also between the urethra and the lower bowel. In dysentery, hemorrhoids and fissure of the anus, strangury and spasmodic retention of urine are by no means uncommon, and sometimes constitute a source of real suffering. The ligation of a pile not unfrequently compels the surgeon to use the catheter for drawing off the urine; and I have known the vesical irritation in such a case to continue for several days. The same affections not unfrequently produce spasmodic stricture of the urethra. 9. Teeth.—A very lively sympathy exists between the teeth and some of the other parts of the body; more intimate and extensive than would at first sight seem possible. Children, from the pressure of the teeth upon the gums are extremely liable, especially during our hot summer months, to vomiting' TEETH — LIVER — KIDNEYS. 43 diarrhoea, fever, and convulsions. Arachnitis occasionally supervenes upon difficult dentition ; and certain affections of the skin, as eczema and porrigo, are frequently directly traceable to its effects, and rendered obstinate, if not temporarily incurable, by its persistence. A heated and tumid state of the gums, with thirst and redness of the skin, should be promptly met by the free division of these structures; otherwise, what is originally a mere irritation of the brain, stomach, or bowels, may soon be transformed into a fatal inflam- mation. A decayed tooth, even when it does not itself ache, will often cause severe pain in the face, temple, neck, throat, or ear; generally, but by no means always, on the corresponding side, doubtless because all these parts are sup- plied by nerves derived from the same sources. When the ear is involved, the pain is propagated along the nervous cord of the tympanum, a filament of the second branch of the fifth pair of cerebral nerves. A carious tooth occasionally creates violent pain in a sound one, though at a distance from it; and the suffering ceases the moment the offending tooth is extracted. I have known a severe attack of pleurodynia kept up by a diseased tooth; the patient was bled and purged, but relief came only with the removal of the affected stump. Enlargement of the lymphatic ganglions of the neck, ulcers of the chin, epilepsy, hysteria, dyspepsia, and various other affections, some- times of a very obstinate and distressing character, may be produced by carious teeth. It is difficult to conceive how a diseased tooth could keep up an attack of rheumatism of the hip, and yet the possibility of such an occur- rence is established by some well-authenticated cases. Dysmenorrhoea has been cured by the extraction of several of the large grinders ; and writers refer to instances of intermittent fever which were relieved in a similar man- ner, after the fruitless employment, for several months, of bark, and other remedies. A decayed tooth has been known to produce neuralgia of the arm, which promptly vanished upon its removal. 10. Liver.—The sympathetic relations of the liver are at once numerous and diversified, and any disturbance in them is generally productive of irritation in a number of the more important organs, especially the stomach, bowels, brain, heart, and lungs. The skin also frequently suffers in consequence of hepatic derangement, and, conversely, the liver from disorder of the cutane- ous surface. Various medicines, as well as different kinds of food, are capa- ble of seriously disturbing the functions of this organ; and it is well known that its secretions are often materially disordered by the direct influence of anxiety or strong mental emotion. An attack of jaundice is sometimes in- stantaneously produced by severe fright. The timid duellist and the affrighted soldier often suffer from this kind of irritation. Hepatic abscesses not un- frequently follow upon injury of the skull and brain ; and, on the other hand, disease of the liver occasionally provokes serious cerebral irritation. Dys- pnoea, palpitation of the heart, nausea, flatulence, and vomiting, are common effects of disease of this viscus. Pain in the top of the right shoulder has long been recognized by physicians as a symptom of hepatitis. Violent shock is occasionally followed by total suppression of bile; and the passage of a gallstone always causes intense gastric irritation. 11. Kidneys.—The kidneys have important sympathetic relations with different parts of the body, manifesting themselves in various forms of irrita- tion, some of which are easily explicable, while others are involved in impene- trable obscurity. Thus, it is easy to understand why a renal calculus should excite pain in the urethra, and a desire to urinate, simply by remembering that there is here a direct continuity of structure, the mucous membrane of the kidney being prolonged as far as the head of, the penis; but it is very 44 IRRITATION AND SYMPATHY. difficult, if not impossible, to comprehend why a foreign body of this kind, as it descends along the ureter, should occasion retraction of the testicles, and excessive irritability of the stomach. Severe injuries, involving great shock of the system, are often followed by total suppression of urine; and, on the other hand, there are various affections in which this fluid is poured out in enormous quantity. 12. Bladder.—The bladder also is variously affected by disturbance of its sympathetic relations. After injuries, as compound fractures and severe operations, the organ is often incapable of contracting upon its contents, thus necessitating the employment of the catheter; its perceptive faculties are suspended, and a few days usually elapse before they are reinstated, so as to enable the patient to pass his water without assistance. Stone in the bladder causes pain and burning in the head of the penis, and retraction of the testi- cle. Sometimes the pain is felt in the knee, heel, and foot; and a curious case has been reported where it was seated in the arm. For a long time the professional attendants were unable to discover the cause of the suffering; but at length, the man complaining of vesical trouble, a sound was intro- duced, when he was found to have stone, the removal of which put at once a stop to the unpleasant symptom. A very common effect of stone in the bladder is spasm of the sphincter muscle of the anus, which is often so great as to interfere with the passage of the finger. The introduction of a bougie into the urethra occasionally induces swooning, followed by violent rigors and high fever; and cases occur, although they are not common, of severe pain being excited in the extremity of the coccyx by such an operation. In the female, a warty tumor at the orifice of the urethra will occasionally cause intense pain in the region of the bladder and kidney, with a frequent desire to urinate, and excessive scalding in passing water; in short, a train of phe- nomena closely resembling that produced by vesical calculus. 13. Uterus.—There is perhaps no class of sympathies of greater interest, in a pathological and practical point of view, than those which subsist be- tween the uterus and the general system. It was a knowledge of this cir- cumstance which induced Aristotle to say that the womb was an animal within an animal. The morning sickness of early pregnancy, the hysterical convul- sions, the depraved appetite, the rigors which usher in labor, and the contraction of the uterus when the cold hand is suddenly applied to the abdomen, are all examples of the mysterious relations by which this organ is bound to the rest of the body. Nowhere do these effects display themselves more strikingly than between the uterus and the mammary gland. Durin"- pregnancy, the breasts begin to sympathize at an early period, as is evinced by their tender and tumid condition : and the effect which the application of the child to these organs has, soon after delivery, in causing after-pains, is familiar to every one. A knowledge of this fact has induced obstetric prac- titioners to take advantage of this means as a remedy for inducing contraction of the uterus in case of tardy expulsion of the placenta, or tendency to hemorrhage of this organ. The derangement of the stomach which accom- panies prolapsus of the uterus, the pain and swelling of the mammary gland from menstrual irritation, the suppression of the lacteal secretion in puerperal fever, and the occurrence of carcinomatous disease of the breast at the decline of life, may be cited as additional illustrations of the intimate connection between the womb and the rest of the system. 14. Testicle.—An intimate sympathy exists between the testicle and the parotid gland. In mumps, or inflammation of the latter organ, it is by no means uncommon for the testicle, after the lapse of some days,' to take on TESTICLE — SKIN — EYES. 45 inflammation also, and generally to such an extent as to bear nearly the whole brunt of the disease. The translation of the morbid action is usually quite sudden, and the suffering of the testicle is often much greater than that of the parotid, being not only attended with severe pain and swelling, but occa- sionally terminating in complete atrophy of the seminiferous tubes. In what manner, or in accordance with what law of the animal economy, this occur- rence takes place, it is impossible to determine, as there is no similarity of texture between these parts, or any direct nervous connection. The parotid is supplied with filaments from the ascending cervical nerves, and with branches from the fifth cranial; the testicle, with filaments from the spermatic plexus, formed by the sympathetic. 15. Skin.—Remarkable sympathies exist between the skin and the mucous membrane of the alimentary canal, as well as between the cutaneous tissues and other parts of the body. Irritations, the result of a disturbance of these relationships, are of frequent occurrence, and serve to explain many morbid phenomena which, but for our knowledge of this circumstance, would be a complete mystery to us. The sympathy between the skin and mucous mem- branes is particularly close and intimate, arising from their great similarity of structure, it being well known that these tissues are convertible the one into the other, although there is no direct connection between them, except at the various mucous outlets; here, however, it is inseparable, and this is per- haps one reason, if not the principal, why disease of the one is so apt to cause disorder of the other. The fact that various substances taken into the stomach as food and medicine often produce the most singular cutaneous affections, within a short time after their introduction, is of daily occurrence. Every one's experience informs him of certain articles which he cannot use with impunity. There is no doubt that many diseases of the skin, generally of a very simple character, are often greatly aggravated and rendered obsti- nate, by inattention to the diet and neglect of the bowels and secretions; and it will be readily conceded that the practitioner who is aware of all this pos- sesses a great advantage in the cure of these maladies over one who is igno- rant of the circumstance, or wilfully disregards it. It is generally supposed that the skin suffers more frequently from disorder of the mucous membranes than the latter do from derangement of the former; but this is probably a mistake. It must not be forgotten that there is a marked difference in re- spect to the relative frequency of the affections of these two classes of struc- tures in different climates, and at different seasons of the year. In tropical regions the prejudical effects of a disordered state of the skin show themselves in a great variety of ways in the mucous membranes; especially those of the stomach and bowels, as in different forms of gastric irritation, diarrhoea, and dysentery. Erysipelas, carbuncle, and furuncle are generally supposed, and very correctly, to be essentially connected with disease of the chylopoietic viscera; indeed the more common varieties of these affections usually owe their origin to derangement of the stomach and bowels, and hence the prac- titioner rarely makes much progress towards a cure if he loses sight of this pathological relation. An unhealthy state of the skin often produces serious disease of the eye, brain, lungs, and liver, which is promptly relieved by attention to the cutaneous surface. Observation has shown that in bad cases of burns and scalds life is not unfrequently destroyed by ulceration of the duodenum, or the upper portion of the bowel, and yet it would puzzle the most profound physiologist to account for such an occurrence by a reference to any of the known laws of health and disease. 16. Eyes.—It is notorious that the eyes, like all symmetrical organs, have an important sympathy, not only with each other, but also with many other 46 IRRITATION AND SYMPATHY. portions of the body, which displays itself both in health and disease, and not unfrequently becomes a cause of irritation and inflammation. A familiar example of this internuncial action occurs in cataract. When one eye suffers from this disease, the other, at no distant period, is very apt to become affected also. Even in ordinary ophthalmia a similar liability to the exten- sion of the morbid action is exceedingly common. The sound eye either soon takes on inflammation, or, if it be so fortunate as to escape this disease, it is sure to become the seat of such an amount of morbid sensibility as to render it utterly unfit, for the time being, for the purposes of useful vision. A percussion cap, or other foreign body, lodged in one eye, has not unfre- quently been the cause of destructive inflammation in the other; and this disposition to the involvement of both organs, where one is originally ex- clusively affected, is nowhere more forcibly and painfully exhibited than in amaurosis. It is true it is not always easy, under these circumstances, to determine, in any given case, what share of the disease in the eye secondarily affected is due to the influence of consentaneous irritation, or to the operation of the same morbific agency which provoked the original malady; but it may reasonably be assumed, in the absence of positive information, that much, in the majority of instances, is the direct result of deranged sympathy. This liability of the eyes to participate in each other's diseases seems to be due to the intimate connection which exists between the optic nerves; and the same circumstance serves to explain the reason why the eyes are so frequently affected in organic disorders of the brain. The eyes and nose are intimately related with each other, first through the distribution of the ophthalmic branch of the fifth pair of nerves, and secondly through the pituitary membrane, which is prolonged upwards through the lachrymal passages to form the conjunctiva. Hence it is easy to see how catarrhal affections should induce pain and redness in this membrane as it is reflected over the eyes; how snuff should excite a flow of tears; and how sudden exposure of the eyes to a strong light should cause sneezing. The connections which the frontal, infra-orbitary, and other nerves form with the filaments of the ophthalmic ganglion enable us to explain the occurrence of amaurosis in consequence of blows, wounds, and neuralgia of the face, eye- brows, forehead, and temples. The eyes are connected with the abdominal viscera, particularly the stomach and bowels, through the medium of the branches of the sixth pair with the great sympathetic. The partial blindness, consequent upon gastro-enteric irritation, is readily accounted for in this way; and the same circumstance serves to explain the dilated state of the pupil which occasionally attends the presence of worms in the alimentary canal of children. It is probable that the pneumogastric nerves also play an important part in these sympathetic relations, otherwise it would be difficult to assign a reason for the excessive nausea and vomiting which now and then supervene upon injuries and ope- rations of the eye, as severe blows and the depression of the cataract. The eyes and teeth sometimes actively sympathize with each other, caries of the latter occasionally keeping up violent inflammation of the former, which promptly disappears upon the removal of the offending organ. I have several times seen the photophobia attendant upon strumous ophthalmia, speedily yield in this way, after the failure of numerous other remedies. 17. Ears.—A curious sympathy, noticed by all aural practitioners, exists between the ears and the respiratory apparatus, and also between the ears and the stomach. Thus, pruritus of the auditory tube sometimes provokes coughing and vomiting; and the former of these effects, it is well known, is not unfrequently caused simply by probing or sponging this passage in the removal of wax, or the extraction of a foreign body. Mr. AVilde in refer- EARS—AGE AND EFFECTS. 47 ring to this phenomenon, says that it is by no means unusual, although it cannot be produced in all cases. "I never witnessed it," he continues, "in children or very young persons; it is most common in males of about middle life, and is in nowise connected with any previous disease existing in the respiratory apparatus. In some persons the slightest touch of the floor of the external auditory passage, about midway between its external outlet and the inferior attachment of the membrana tympani, will bring on violent irri- tation and spasmodic action in the larynx. In this case also the patient will generally tell us, upon inquiry, that he does not experience pain; but the moment we touch this very sensitive spot he feels a tickling sensation in his throat, which immediately increases to the feeling one has when 'a bit is gone astray.' What the nervous connection is which induces this has not been fully determined, but the fact is worthy of note." Arnold has reported a case of chronic vomiting in a child, which long re- sisted a great variety of remedies; but which was promptly cured by the extraction of a bean from each ear, the foreign substances having been intro- duced during play. Mr. Toynbee states that he had had under his charge a patient who suffered under a cough which no treatment subdued, but which permanently disappeared upon the removal of a fragment of dead bone from the auditory canal. 18. Age and Effects.—All persons are liable to suffer from irritation; but there is, as might be supposed, great diversity in this respect, in different in- dividuals. Thus, it is well known that persons of a nervous, irritable tem- perament are more prone to be affected with it than such as are of a sanguine or leucophlegraatic disposition, owing no doubt to the fact that they possess a more highly-wrought nervous system. Women suffer more frequently than men, both from local and general irritation ; and some of the worst forms of reflex irritation that the practitioner meets with occur in hysterical females. Infants and children are extremely liable to the disease, the slightest cause often serving to light up the most distressing suffering. Loss of sleep, anx- iety, grief, hard study, intemperance, inordinate sexual indulgence, impover- ished diet, and the enervating effects of a hot climate, are all circumstances which powerfully predispose to the occurrence of irritation. The inhalation of the foul air of the dissecting-room is another well-known cause operating injuriously upon the system. If a young man who is nightly engaged, until a late hour, in the study of practical anatomy, pricks his finger, he will be much more likely to suffer severely than one from a similar wound who enters the dissecting-room only occasionally. In the one case the constitution is deteriorated by exposure, and is therefore incapable of resisting the effects of disease; in the other, on the contrary, it is healthy, and indisposed to take on morbid action. An irritable state of the system often sadly interferes with the reparative process. Thus, the healing of a wound is sometimes suddenly arrested by an unhealthy state of the system, manifesting itself in a general exaltation of the nervous sensibility, altogether incompatible with the development of healthy blastema. An aneurism of the aorta, attended with constitutional irritability, has been known to prevent the consolidation of a fracture of the femur. These, and other similar facts, are of deep practical interest, as they are suggestive of valuable therapeutic measures. Another very common effect of irritation, especially when extensive or seated in an important organ, is derangement of the secretions, not only of the parts more immediately affected, but of the rest of the system. Thus, irritation of the brain, however induced, is very certain to disorder the func- tions of the stomach, liver, and kidneys, as evinced by indigestion, a bilious 48 IRRITATION, SYMPATHY, AND IDIOSYNCRASY. appearance of the skin, and a high-colored and scanty state of the urine. The salivary glands, too, suffer, the month becoming dry and viscid; the head aches, the pulse is excited, and the extremities are cold. In concluding this rapid survey of irritation and sympathy, a few remarks may be offered on the subject of idiosyncrasy, as it closely connects itself with the discussion of these two topics. Idiosyncrasy literally signifies a peculiarity of constitution, or a state of the general system in which certain articles, whether taken as food, drink, or medicine, produce an effect altogether different from what they are accus- tomed to under ordinary circumstances. Thus, lobster and other varieties of shell-fish, although they may be used with perfect impunity by most per- sons, are extremely prone in some individuals to induce urticaria, vomiting, and purging. A young lady, a patient of mine, married, robust, and of a florid complexion, cannot eat eggs, no matter how prepared, without being seized, almost immediately after, with vomiting. Some persons are overpow- ered by a particular odor, or by the sight of blood. I know a lady who has not been able, for many years, to eat watermelon without being almost in- stantly seized with hoarseness and soreness of the throat and mouth, attended with a burning, pricking sensation, nausea, and colicky pains. The use of watermelon-seed tea invariably produces a similar effect. Another lady, for- merly a patient of mine, can never take an ordinary dose of laudanum without being copiously purged; opium affects her in a similar manner, but morphia does not. Laudanum, administered by the rectum, vomits freely and nau- seates for many hours. These articles, however, always afford relief to her suffering. I am acquainted with several persons, among others a physician, in whom the inhalation or smell of ipecacuanha invariably excites a violent attack of asthma, generally lasting for two or three days. In the case of the medical practitioner, the perception of the presence of this substance is so keen that, if he be in the third story of a house on the first floor of which an ordinary dose of the article is compounded, he is instantly seized with spasmodic cough and wheezing. A gentleman, for many years a patient of mine, cannot drink a cup of green tea without being promptly and copiously purged; it usually operates on the bowels in from fifteen to twenty minutes after it is taken, bringing away thin, watery evacuations, accompanied with more or less griping; black tea produces no such effect, which he has expe- rienced from the green from his earliest recollection. In two other cases, the use of green tea, even if taken only in small quantity, invariably acts as a powerful diuretic, causing an abundant secretion of urine, with a frequent desire to void it, for a number of hours. I remember the case of a patient, an habitual asthmatic, thirty-five years of age, a tradesman by occupation, who cannot enter a room where feathers are without instantly experiencing an aggravation of his pulmonary affection. To provoke this effect, it is not necessary that he should see or smell the feathers; it is only necessary that they shall be near him. Led blindfold into an apartment thus furnished, he will at once be conscious of their pre- sence, and be immediately compelled to retreat. Idiosyncrasy not unfrequently displays itself in the operation of various medicines, affording thus useful hints to the practitioner in the selection of his remedies. There are many persons who cannot take opium in any form without being kept awake by it for hours and even days, besides suffering greatly from nausea, excessive itching, delirium, and other distressing symp- toms. The most minute quantity of mercury will, in some persons, cause pro- fuse ptyalism, while in others the article may be given in large doses and for a long time without the slightest effect of this kind, the system being abso- lutely proof against the action of the medicine in any of its forms and modes TREATMENT. 49 of exhibition. Most individuals are freely purged by a drop of croton oil, and yet we occasionally meet with an instance in which hardly any operation upon the bowels is produced by twrenty times that quantity. The above instances, which might be multiplied to an almost indefinite extent from my own experience, will serve to illustrate a class of the most singular affections, whose influence in modifying, if not in inducing disease, is eminently worthy of the attention of the practitioner. TREATMENT OF IRRITATION. In the treatment of irritation there are several leading indications which claim special attention. The first is to remove the exciting cause; the second, to correct the secretions; and the third, to palliate the disease, both primary and consecutive. To remove the exciting cause of irritation is not always an easy task. In many cases, indeed, it is either wholly inappreciable, or can only be guessed at. The duty of the surgeon of course plainly is to get rid of it if he can ; the ball, the calculus, the splinter of wood, the dead piece of bone, and the carious tooth, are promptly extracted. Irritating ingesta are dislodged by emetics ; offending feces by purgatives ; worms by anthelmintics. The mor- tified toe is amputated ; the compressed gum lanced ; the suppurating felon freely laid open. Light is excluded from the inflamed eye ; noise from the suffering ear; cold from the shivering surface. In all such cases the indica- tion is plain, and in general easily fulfilled. But it is otherwise when the cause is occult. Here the disease must be met on general principles ; and the judicious practitioner will do well to look into the condition of his pa- tient's secretions, his bowels, and his diet, which are among the most common sources of the disease. The correction of the secretions is a matter of primary importance in every case of irritation, whether local or constitutional. The manner of doing this will necessarily depend upon the character of the suffering organ ; but no practitioner will fully discharge his duty if he neglect attention to this point. The viscera whose derangements are most liable to provoke reflex irritation are the stomach, bowels, liver, and uterus, and they should, therefore, always be objects of special consideration. Not unfrequently the cause of the trouble will be found to exist in irritation of the spine, or of some particular portion of the brain, demanding local depletion and counter-irritation, with perfect tranquillity of mind and body. Whatever the cause of the disturbance may be, it will be found that purgatives can rarely be dispensed with, while in not a few cases they constitute the chief anchor of our hopes. The diet, as a general rule, should be mild and uuirritant, the proportions of its nutritive principles varying with the exigencies of each particular case. The last indication is to cure the disease, or to palliate it if it be irremedi- able. To point out the methods of doing this in a class of affections of so protean a character as this, would be absurd. Every case must necessarily suggest its own treatment. In ordinary instances antiphlogistics, properly so called, may usually be dispensed with, and large draughts made upon the narcotic class of remedial agents, as their direct influence is to allay pain and spasm, and induce tranquillity of the system. The choice of the particular articles must be regulated by the circumstances of the case, and will often require no little judgment and experience for its successful exercise. vol. i—4 50 CONGESTION. CHAPTER II. CONGESTION. It is practically a matter of no little importance that the surgeon should be able to discriminate accurately between inflammation and congestion ; or, in other and more comprehensive terms, that he should possess clear and definite ideas respecting the more essential differences between these two morbid states; for upon their correct appreciation must often depend the result of his treatment. The subject, it must be confessed, is one of no ordi- nary difficulty, and a careful examination of what has been written upon it will serve to convince any unprejudiced mind that there are no two points in pathology concerning which there still prevails a greater amount of confu- sion ; for what one author considers as congestion, another with equal confi- dence calls inflammation, and conversely ; leaving thus the young and inex- perienced practitioner in painful doubt not only in respect to the nature of the disease, but, what is far worse, in regard to its proper mode of manage- ment. As the subject of inflammation will be fully discussed in the ensuing chapter, I shall limit myself here to a plain and simple exposition of some of the more important facts relative to congestion, preceded by an attempt to assign to this expression its legitimate import. Congestion signifies an accumulation of blood in a part, the result either of some mechanical obstruction, or of some vital defect in the circulation, interfering with the onward movement of the sanguineous fluid. The word is synonymous with hyperaemia, which Andral has proposed, without any just reason, as a substitute for it. It simply denotes the existence of an ab- normal quantity of blood in a part, without any of the ordinary phenomena and effects of inflammation, which, however, it generally accompanies, if indeed it does not form a necessary consequence of the increased quantity of blood sent into the suffering structures in that disease. Pathologists usually divide congestion into two varieties, denominated, respectively, the active and the passive. The first, as the name implies, is characterized by inordi- nate activity of the part, as is evinced by its scarlet complexion, its augmented temperature, and its functional disturbance; and soon leads, if allowed to progress, to various kinds of deposits, particularly the serous and plastic. Passive congestion, on the other hand, is distinguished by the dark color of the part, the enlarged and sluggish condition of the vessels, and the chronic march of the disease. Owing to these differences in the action and aspect of the affected structures, these two varieties of congestion are often denominated arterial and venous ; terms which are ill chosen, as they have a tendency to create erroneous impressions respecting the true nature of the two lesions, for it is impossible to conceive of any case of congestion, however slight or severe, in which the disease is exclusively confined to one set of vessels^ It will thus be perceived that active congestion is closely allied to inflam- mation, although it does not, properly speaking, constitute inflammation, except in the opinion of certain pathologists, who, as it seems to me, are not very felicitous in their attempts at separating the two affections from each other, although it is evident that they strive very hard to do so. They treat of congestion as a distinct entity, and yet they do not hesitate to ascribe to CONGESTION. 51 it phenomena and effects which belong exclusively to inflammation, and which congestion, considered in the proper sense of that term, is utterly incapable of producing. Whenever a part, however situated in relation to the amount of blood it contains, is the seat of morbid deposits, it has passed the stage of congestion, and gone over into that of inflammation. If this be not so, then it necessarily follows that active congestion and inflammation are essentially one and the same disease, and that, consequently, it is absurd to attempt to describe them separately. In all acute inflammations, whatever their cause or situation, active con- gestion is a necessary antecedent of the morbid action ; one of the first links in the chain of the malady. Hence it would not be improper to say that it is part and parcel of the inflammatory process, ushering in the disease, and continuing up to the very point of effusion ; or, in other words, ceasing only where effusion commences. But this is strictly true only to a certain extent; for there is in every case of inflammation a circle beyond the process of the morbid action, where the blood, playing about in eddies, has accumulated in large quantity, distending the capillaries, and destined soon to part with some of its constituents, if the disease be merged in the inflammation. A real fire is lighted up here : the part is hot, preternaturally red, and perhaps somewhat painful; nay, it may be, even a little tumid, from the dilated state of the vessels; the blood moves with unwonted force and velocity; the func- tional disturbance augments more and more ; and presently congestion ceasing, inflammation takes its place, and goes through its allotted course. Another sign of distinction is that, in active congestion, the capillaries, although greatly crowded with blood, are more easily emptied than in inflammation : during life by pressure, and after death by injecting matter. But active congestion is not always necessarily followed by inflammation, although prone to pass into that state if it continue even for a short time. The cause which induced it having been removed, the vessels cease to attract blood in undue quantity, and getting rid of what is redundant, speedily re- gain their normal caliber and function. A familiar illustration of this oc- currence is afforded by the conjunctiva, when, from any transient cause, a sudden and violent rush of blood takes place to the affected part; in an instant hundreds of vessels, previously invisible, become apparent, being crowded with red blood, so as to give the surface almost a scarlet hue. Now, if we analyze these phenomena, it will be found that they depend simply upon a dilated state of the vessels of the eye and the presence of an unusual quantity of blood, containing a large number of red globules, which, in the healthy state, are either withheld from these vessels, or which are propelled along them in such small numbers as not to permit their coloring matter to become visible through their delicate walls. Another familiar example of active congestion is furnished by what occurs in the hand when plunged into cold water, or exposed to a very low tem- perature. The skin soon becomes remarkably red from an unnatural afflux of blood, the parts are the seat of an unpleasant tingling sensation, and the capillaries, both arterial and venous, are exceedingly dilated; still, there is no inflammation, or any tendency to morbid deposit; the suffering structures are only irritated and preternaturally injected. Cautiously treated, the hand soon regains its natural condition ; the skin recovers its former hue and sensibility, the blood ceases to accumulate, and the vessels resume their normal caliber. But it is otherwise, when the case is improperly managed ; the congestion then will not only continue but it will steadily increase, and be soon merged in inflammation, or perverted action and effusion. Now what occurs in the external parts of the body, immediately under the eye of the observer, may be supposed to happen, under similar circumstances, in the internal organs. Thus, we know that when there is a sudden repul- 52 CONGESTION. sion of the cutaneous perspiration, the blood is extremely apt to collect in the lungs, causing active congestion of the pulmonary tissues, so often the precursor of pneumonia. Poison introduced into the stomach almost in- stantly induces active congestion of the mucous membrane of that organ, frequently followed, in a few hours, by the most intense and destructive inflammation. A ligature bound tightly around a limb affords a good illus- tration of the manner in which active congestion may be supposed to be induced in strangulation of the bowel in hernia and in intussusception. A distinction should be made between active congestion in a part, and a determination of blood to a part. The former is always the effect of some morbific influence ; the latter, on the contrary, may be the result simply of a natural cause. Thus, when the infant is applied to the breast there is an instantaneous determination of blood to the organ, so as to enable the vessels to furnish the necessary supply of milk ; during menstruation, there is a marked determination of blood to the uterus, probably accompanied with more or less active congestion. In blushing there is a rush of blood to the cheek; in erection, to the penis ; in anger, joy, and other emotions, to the brain. Excessive, sudden, and overwhelming determination of blood to the internal organs sometimes takes place during the cold stage of intermittent fever, especially in that variety of it to which Alibert and others have applied the term malignant. In the congestive fever, as it is termed, of the Southern States, death not unfrequently results within a few hours after the commence- ment of the attack, the system never reacting from the effects of the chill. Scarlet fever occasionally proves fatal in a similar manner; the surface is pale, or slightly livid, the extremities are deadly cold, and the internal organs are literally inundated with blood, determination and congestion co- existing in their worst forms. In passive congestion, the morbid action is distinguished by its peculiarly sluggish character ; the vessels are not only dilated, but frequently varicose, tortuous, elongated, and incapable of contracting upon their crowding con- tents ; the discoloration is dark, venous, or purple, the circulation is tardy and languid, and there is often marked evidence of morbid deposits, espe- cially of serum and lymph, occupying the cells of the areolar tissue. Various causes may give rise to passive congestion. The most common are the following : 1st, inflammation ; 2dly, mechanical obstruction ; 3dly, debility ; and 4thly, dependent position. 1st. Inflammation, in whatever form occurring, is almost always followed by a certain degree of passive congestion; the affected parts, exhausted by severe suffering, are reduced in strength and life-power; the vessels, dilated to their utmost capacity, and perhaps partially ruptured, are too feeble to contract upon their contents; the crippled structures are unusually vascular; and the slightest cause is generally sufficient to rekindle the disease. Indeed, as will be stated by and by, an organ that has been once severely inflamed is ever after extremely liable to become inflamed again; passive congestion often lasting for months and even years. 2dly. Mechanical obstruction is a prolific source of passive congestion. Examples occur almost without number, both in medical and surgical prac- tice. I shall allude only to a few, as they will be sufficient for my purpose. A good illustration of the effects of mechanical obstruction in producing passive congestion is seen in organic disease of the valves of the aorta iu> peding the passage of the blood through the lungs. Compelled to remain here habitually in undue quantity, the pulmonary vessels soon fall into a state of passive congestion, which thus acts as a predisposing cause not only of inflammation, to which individuals so affected are extremely prone, but also of pulmonary apoplexy. Obstruction of the larger veins, as the femoral and iliac, is always followed by passive congestion in the parts below. In vari- CONGESTION. 53 cose enlargement of the veins of the leg, attended with disease of their valves, the blood has great difficulty in finding its way to the heart, and the conse- quence is that the distal portion of the limb is always in a state of passive congestion, with a strong tendency to inflammation, and different deposits, especially the serous and plastic. Obstruction of the artery of the leg, by fibrinous concretions, is always followed by congestion and inflammation, if not gangrene of the foot. The structures in the neighborhood of morbid growths are generally habitually congested ; hence the profuse hemorrhage which so often attends their extirpation. Their vessels being compressed by the overlapping tumor, the passage of their contents is seriously interfered with, and hence they frequently undergo a remarkable dilatation, almost amounting to a real varicosity. 3dly. Debility of a part, however induced, is a frequent source of passive congestion. Examples of this form of the affection are seen in the retina and choroid coat of the eye from over-exertion of that organ; and in various parts of the body from loss of innervation, profuse hemorrhage, or other discharges, and from the natural wear and tear of the frame. If, under these circumstances, any particular organ is more feeble or exhausted than the rest, it can scarcely fail to become the seat of passive congestion, or congestion and inflammation. 4thly. That dependent position may give rise to passive congestion is a matter of daily observation. It is in this way that inflammation of the lungs is so often induced during the progress of lingering diseases and accidents, as typhoid fever, erysipelas, and compound fractures ; the disease usually beginning in the posterior portions of these organs, in the form of passive congestion, and proceeding gradually but steadily from bad to worse, until it proves fatal, a result so much the more to be dreaded on account of its insidious character. In the so-called bedsores, consequent upon long con- finement in one posture, during which the pressure of the body is concen- trated with peculiar force upon the sacrum, the iliac crest, and the great trochanter, similar effects are produced. There is, both in these and similar instances, in the first place a determination of blood to the most dependent portions of the body, then passive congestion, and, finally, as a natural con- sequence, inflammation; often followed, in the latter case, by mortification. Passive congestion, however induced, is a frequent cause of inflammation; often of a very destructive character, the more so, because the symptoms which attend it are so indistinct, if not so completely disguised, as to prevent the early recognition of their real import. It is for these reasons that the practitioner should constantly be on the alert whenever he has anything to do with diseases and injuries involving long confinement to one particular posture, and an unusual amount of expenditure of the vital forces. Inasmuch as congestion may be induced by such a variety of causes, it would be folly to attempt to lay down anything like a regular systematic plan of treatment; to do so, would be to encroach upon every department of pathology and practice, both medical and surgical, of which we have any knowledge. The judicious surgeon, knowing how likely the continuance of such a condition is to be followed by inflammation, or to aggravate inflam- mation when these two states coexist, will do all in his power to avert the evil, or to combat it when he finds that it has already taken place. The leading indication of cure, in every case of congestion, is to equalize the circulation; but to accomplish this object often demands great judgment and an amount of pathological and therapeutic knowledge such as comparatively few men possess. 54 INFLAMMATION. CHAPTER III. INFLAMMATION. SECT. I.—GENERAL CONSIDERATIONS. A thorough knowledge of inflammation is indispensable to every prac- titioner of surgery. It should form the principal subject of his studies dur- ing his pupilage, and the main object of his professional contemplation in after-life. When it is recollected that there is hardly any disease which comes within the province of this department of science that does not origi- nate in inflammation, or that is not more or less affected by it during its progress, the truth and force of these remarks will appear sufficiently obvious. The smallest pimple upon the nose is, in point of fact, as much an inflamma- tion as an erysipelas that covers the face and head. An ulcer of one of the mucous follicles of the mouth does not differ, in principle, from an ulcer of one of the glands of Peyer, which are the seat of so much disease and danger in typhoid fever. Many of the maladies, vaguely called nervous, are nothing but forms of inflammation, the nature and seat of which it is often difficult, if not impossible, to determine. Their predominant symptoms are of a nervous character, and hence the diseases which they accompany are usually con- sidered as nervous, while in reality the reverse is too frequently the case. All accidents, whatever may be their nature or degree, are necessarily followed, if the patient survive their immediate effects, by inflammation. The little wound made in venesection, the incision left in cupping, and the bite inflicted in leeching, would never heal without the aid of this process; the parts would remain open, and be the seat of incessant bleeding, or they would become festering and putrid sores. In a word, there would be no repara- tion after injuries of any kind, however simple, and operative surgery, instead of bearing healing on its wings, and being a blessing to our race, would be the merest cold-blooded butchery. Thus, it will be perceived that inflam- mation is capable of playing, as it were, a double game in the animal economy, being at one time a cause of death, and at another a source of life. It is for this reason that it is often designated by the terms healthy and unhealthy, according as the one or the other of these states predominates. Inflammation may be defined to be a perverted action of the capillary ves- sels of a part, attended with discoloration, pain, heat, svvelljng, and disordered function, with a tendency to effusion, deposits, or new products. In addition to these changes, there is also an altered condition of the blood and nervous fluid as an important element of the morbid process. In what inflammation essentially consists, it would be idle to inquire, since it would be just as im- possible to unravel its true nature as it would be to explain the intimate character of attraction, repulsion, gravitation, or cohesion. Hence, in study- ing its history, all that we can do is to examine its causes, symptoms, and effects, or, more properly speaking, to institute a rigid analysis of its ap- preciable phenomena. If we endeavor to step beyond this, we shall like our predecessors, lose ourselves in the mazes of conjecture and hypothesis those quicksands upon which so many of the noblest minds of the profession have in all ages since the origin of medicine and surgery, been wrecked and CAUSES OF INFLAMMATION. 55 stranded, as if to warn us of their folly and the impossibility of further pro- gress. 1. CAUSES OF INFLAMMATION. The causes of inflammation are almost as numerous as the circumstances which surround us. Whatever has a tendency to affect injuriously our mental or physical organization, whether directly or indirectly, is capable of inducing disease, or, at all events, of laying a foundation for it. The division of the causes of morbid action into predisposing and exciting has long been recog- nized by pathologists, and cannot be dispensed with at the present day. By predisposing causes are understood those which produce in the system, or in a particular part of the economy, certain changes, states, or conditions favor- able to the development of inflammation, without actually provoking it. They are usually tardy in their operation, and are either natural or acquired, ac- cording as they are inherent in the constitution of the individual or dependent upon accidental circumstances. The exciting causes, on the contrary, are such as are directly concerned in awakening the disease, or fanning it, as it were, into existence. It is not always, however, in the power of the practi- tioner to ascertain either the predisposing or exciting causes of the morbid action, and hence such cases, which are by no means unfrequent, are usually known as occult cases. The natural predisposing causes of disease have reference to peculiarities of constitution, and to a tainted state of the economy, in consequence of hereditary transmission. To the former class belong plethora, debility, and nervous susceptibility, which prepare the system for disease, by the changes which they produce both in the fluids and solids. Persons who have naturally an undue quantity of blood, as indicated by their ruddy complexion, and the extraordinary functional activity of their organs, are peculiarly prone to inflam- mation ; their bodies may be compared to a mass of tinder, which the slightest spark is capable of kindling into a devouring flame. Those, on the other hand, who are naturally feeble, are remarkably prone to local congestions, which, especially when they become habitual, are sure to lead to inflammation, often of a very unmanageable character, because it cannot be met by the ordinary remedies. Persons of nervous temperament are predisposed to maladies of the brain, spinal cord, and sympathetic nerves, as exhibited in derangement of the respiratory, digestive, and genito-urinary apparatus; maladies which are generally tardy in their progress, and which are often so obscurely marked as to be difficult of recognition. The fact that some diseases are transmissible from the parent to the offspring has long been known to practitioners. There are family diseases, just as there are family likenesses, manners, and peculiarities; and, what is remark- able, they are more liable to be communicated by the mother than the father, as if it were her special prerogative to impress her vices, as well as her virtues, upon her descendants. Another law is that some of these diseases may skip one generation to reappear in another, and that it is not necessary that the parents should be actually laboring under an attack of them at the period of the child's conception. The affections which may be transmitted in this way are gout and rheumatism, pulmonary phthisis, asthma, scrofula, carcinoma, and constitutional syphilis, together with several others which it is unneces- sary here to specify. It is in this wise apparently that God visits the sins of the parents to the third and fourth generation of their offspring. In what element of the economy the germ of the morbid action is locked up, neither reason nor experience has been able to determine : for a time it would seem to be latent in the blood, and then to explode, either suddenly or gradually, with zymotic violence. 56 INFLAMMATION. Among the acquired predisposing causes of inflammation are, the effects of previous disease, plethora, and debility, however induced. When an organ has once labored under inflammation, it is extremely apt to suffer from it again from the most trifling causes. The part, enfeebled by the attack, does not recover completely from its effects for a long time, if ever. Hence, influences which, in the natural state, would not disturb its physiological relations, are, under such circumstances, peculiarly prone to excite disease. A good illustration of this fact is afforded in the tonsillitis of children, in whom a reproduction of the malady is almost sure to be awakened upon the slightest exposure to cold. It is not necessary here to enlarge upon plethora and debility as predisposing causes of inflammation. If these states of the system are capable of preparing it for the development of disease when they are a natural result of the organization, it may readily be supposed that they would be much more likely to produce such an effect when they are acquired, in consequence of the mode of life of the individual, or of the influence of structural lesion. Age, sex, temperament, occupation, food, dress, exercise, climate, and season, are all so many predisposing causes of inflammation. Infancy is particularly obnoxious to enteritis, croup, and arachnitis; childhood, to affections of the skin, struma, parotitis, and tonsillitis; manhood, to pneu- monitis, carditis, and diseases of the genito-urinary organs; and the decline of life, to gout and rheumatism, asthma, arteritis, and the various forms of malignant maladies. The differences in regard to the liability of inflammation in the two sexes arises mainly from their anatomical peculiarities, and are much less common than is generally imagined. The function of parturition renders the female particularly liable to peritonitis, phlebitis, arachnitis, and carcinoma; while the male, from his occupation and mode of life, is more prone to cystitis, urethritis, gout, rheumatism, arteritis, hepatitis, pneumonitis, and pleuritis. Of the influence of temperament as a predisposing cause of disease, too little is known to enable us to speak with any degree of certainty. The san- guine temperament, being characterized by plethora with inordinate capillary activity, disposes to inflammation of the internal organs ; while the lymphatic is apt to be attended with affections of the skin, joints, serous membranes, stomach, bowels, and lymphatic ganglions. Occupation is a powerful predisposing cause of inflammation. Persons who work much in the open air, and who are much subjected to the influence of cold and wet, are extremely liable to suffer from pneumonia, arthritis, ton- sillitis, aud enteritis. A sedentary life leads to chronic disorder of the ali- mentary canal; and, if conjoined with constant mental exertion, is liable to be followed by diseases of the brain and arachnoid membrane. Excessive exercise of an organ, as of the larynx in singing and speaking, is always a predisposing cause of inflammation. The influence of food in disposing to inflammation is well known. The habitual use of stimulating articles of diet, especially when conjoined with a want of due exercise, is among the most powerful of the causes under notice. On the other hand, an impoverished diet, or a privation of nitrogenous food, by inducing a defective blood, leads to scurvy, chlorosis, typhoid fever scro- fula, and inflammation of the serous structures, terminating in dropsical effu- sions. Certain articles, as ergot, if employed for any length of time, or in any considerable quantity, dispose to arteritis and gangrene of the extremi- ties. The habitual indulgence in alcoholic drinks leads to gastro-enteritis hepatitis, and attacks of epidemic diseases, whenever such diseases are preva- lent. Dress may be an indirect cause of inflammation. It may keep the body too warm or too cold, or exert injurious compression; in either event local CAUSES OF INFLAMMATION. 57 congestion will be apt to be induced, which the slightest circumstances may fan into disease. A change of climate, whether from hot to cold, or cold to hot, powerfully predisposes to inflammation. Hence the period of acclimation is always pe- culiarly trying, and few persons escape without suffering. Season, too, exerts a predisposing influence. Thus, in summer, inflammation is most apt to assail the stomach and bowels; in winter, the lungs, pleura, joints, and throat. Mental excitement is a prolific source of inflammation. Fear, grief, anxiety, hard study, and loss of sleep, by deranging the secretions, and interfering with the digestive process, all dispose to this disease. In short, whatever has a tendency to interrupt, disorder, or arrest healthy action, is apt to exert a pernicious influence. This is often the only way in which we can account for the occurrence of erysipelas, carbuncle, rheumatism, cerebritis, scrofula, and carcinoma. The exciting causes of inflammation are extremely numerous, and of the most diversified nature; they act in two ways, either directly upon the parts, or indirectly through the system. Hence they are said to be local and constitutional; and the former are either of a chemical or mechanical cha- racter. Among the chemical causes are, first, high degrees of heat, as hot water and iron ; secondly, partial application of cold ; thirdly, caustic substances, as the alkalies and acids; fourthly, acrid vapors, hartshorn, and gases; fifthly, certain secretions, as urine and bile; sixthly, blisters, embrocations, and rubefacients; and lastly, various septic agents, as those of smallpox, syphilis, glanders, and malignant pustule. All these agents act directly upon the parts to which they are applied, either destroying them by their immediate effects, or combining with them in such a manner as to change completely their structure and function. Their operation is always rapid, and the resulting inflammation is usually marked by severe symptoms, both local and constitutional. The mechanical causes comprise, first, punctures, incisions, contusions, and lacerations ; secondly, fractures, and dislocations ; thirdly, sudden and forci- ble distensions, as from the accumulation of pus, serum, blood,*or gas; fourthly, compressTon, as by bandage, ligature, posture, or effused fluids; and, fifthly, the presence of foreign bodies, as a stone in the bladder, a bean in the air-passages, a bullet in the flesh, a tubercle in the lung, or a fibrinous concretion in the brain. The manner in which these various causes act in producing inflammation is too evident to require explanation. The constitutional causes of inflammation make their impression either di- rectly upon the part, or indirectly through some remote structure. Logically speaking, it would perhaps be more proper to say that they all act in the latter way, and not in any case immediately upon the part, as is usually as- serted they do. Thus, a morbific impression primarily made upon the respira- tory passages, as the inhalation of some noxious gas, or the contact of ma- laria, instead of causing disease in the lungs, or some of its constituents, often, if not generally, explodes upon some other organ, perhaps very dis- tantly, if at all, associated with the lungs by sympathy, or similarity of struc- ture and function. A septic poison, for example, as the virus of smallpox, introduced into the system, acts not merely upon the blood into which it has been conveyed by the absorbent vessels, but also, and mainly, upon the cuta- neous tissues, for which it has evidently a greater elective affinity than for any other part of the economy ; if it produces any action at all upon other structures, it is altogether of an indirect character. In the transmission of secondary syphilis from the parent to the offspring, the force of the disease is spent, in the first instance, upon the skin and mucous membrane of the 58 INFLAMMATION. throat and month ; there is no inflammation, so far as we are able to determine, in the cellular, fibrous, and serous tissues, or in the internal organs, properly so called. In tertiary syphilis the bones, periosteum, and cartilages are par- ticularly prone to suffer, although the disorder has a more general tendency, as there is more profound contamination of the system. Whatever doubt, however, there may still be respecting the mode of action of the above agents, there can be none about the operation of heat and cold, which are such prolific causes of inflammation. The influence of a tropical sun, acting upon an impressible nervous system, in producing hepatitis, is well known to the practitioners of our Southern States, and to those of Africa, Asia, and the West Indies. Gastritis and enteritis, in their worst forms, are often developed in the same manner. The effect of cold feet in producing tonsillitis, croup, pleurisy, pneumonia, enteritis, cystitis, and rheu- matism, is familiar to every one. In all these instances the primary impres- sion is made through the medium of the skin, by suppressing the perspiration, and throwing the onus of the functional disorder upon some internal and re- mote organ, between which and the cutaneous surface there is not the least direct connection. The blood itself is a frequent source of inflammation ; sometimes, because it is overloaded with earthy salts or other irritating materials, as the poison of erysipelas, carbuncle, and various eruptive diseases ; at other times, because of its impoverished condition, rendering it unfit as a supporter of life and nutrition. There is reason to believe that the latter cause lies at the founda- tion of many of those low and unhealthy forms of inflammation which so often eventuate in destructive ulceration of the mucous and cutaneous tissues, as well as of some of the worst forms of morbid deposits, as imperfectly vitalized lymph, albumen, and tubercle. Deficient secretion, especially of the liver, kidneys, and skin, is a frequent cause of disease, various substances being thus retained in the circulation, much to the detriment of the general economy, as well as of particular organs, perhaps already predisposed to morbid action. From the foregoing considerations it will be perceived that inflammation may ha traumatic or idiopathic; that is, produced by external injury or by con- stitutional causes, the latter of which are often wholly^ inappreciable by our senses. Inflammation is sometimes caused by sympathy. Thus, the eye occasionally suffers in consequence of disorder of the stomach, the brain of derangement of the intestines, the mamma of disease of the uterus, and the testicle of lesion of the urethra. A man who has for years habitually overtaxed his digestive powers, and in the meanwhile taken hardly any exercise, will be extremely apt, in time, to perish from carbuncle or erysipelas ; or, at all events, to have disease, in some form or other, of the skin, simply because these parts are intimately related to one another by similarity of structure and function. For the same reason disease of the skin is very liable to be followed by disorder of the alimentary canal. Finally, inflammation may be caused by metastasis. The event is character- ized by a transfer, for the most part gradual, but occasionally quite sudden, of irritation from the part originally affected to another, perhaps at a con- siderable distance from it, and in nowise related to it by structure or function. In inflammation of the parotid gland the testis is often involved in this way] but why it should be, neither our anatomical nor our physiological knowledge enables us to explain, as there is no traceable connection of any kind what- ever between them. In rheumatism of the joints the heart often suffers • and in erysipelas of the skin the morbid action frequently leaves one part of the surface and breaks out upon another. Such occurrences, which are sometimes greatly promoted by our local applications, should always be sedulously EXTENSION OF INFLAMMATION. 59 watched, as they are generally fraught with danger, especially wheu they show themselves in important internal structures. 2. EXTENSION OF INFLAMMATION. The manner in which inflammation spreads, or extends from one structure to another, is worthy of brief notice. This may happen in several ways, as by continuity of structure, through the agency of the vessels, by nervous sympathy, and probably also through the aid of the blood, which, as will be seen hereafter, is always more or less disordered in the more severe forms of the malady, however situated. All inflammations, whatever may be their character, are, in the first in- stance, of a local nature, that is, they begin in, and are confined to a particular tissue, spot, or point, from which, as from a common focus, the morbid action radiates in different directions, until it becomes, so to speak, general. To illustrate my meaning, let it be supposed that the malady commences in a particular part of the mucous coat of the small bowel, as, for example, in one of the glands of Peyer. After having remained here for a short time, it gradually spreads to the fibro-cellular lamella, then to the muscular fibres, and finally to the peritoneal investment, thus involving the whole in one mass of disease. In erysipelas the same law is observed. Here the morbid action, beginning at a little point of skin, gradually extends to the deeper structures, until, as in the case of a limb, it invades cellular substance, aponeurosis, muscle, vessels, nerves, periosteum, and occasionally even bone. A pneu- monia, in its progress, usually involves the pulmonary pleura and the bronchial mucous membrane. These instances will suffice to prove the position here assumed, which is the more important because it presents the characters of a general principle. The rapidity with which inflammation extends from one texture to another is too variable to admit of any precise statement; in some instances the time is very short, perhaps not exceeding a few hours, and such cases are, it may be remarked, generally very prone to be characterized by more than usual violence. It must not, however, be inferred from this statement that the morbid action always spreads from the point originally attacked ; for, although there is unquestionably a very strong tendency to this, yet there are numerous exceptions to it. In some cases this limitation is due to the nature of the disease itself; in others, it depends upon the deposit of plastic matter; while in a third series of cases it is owing to the structure of the overlying tissue, as, for example, in the periosteum, which often serves to protect the bone which it surrounds from the encroachment of disease of the soft parts. One of the most common modes in which inflammation propagates itself is by continuity of structure. The morbid action, once begun, finds it easy to pass along the tissues in which it originated, and hence it often spreads rapidly over a large extent of surface, similarity of structure and function favoring the process. By continuity of surface an erysipelas of the skin, perhaps not larger at its commencement than half a dime, spreads in a few hours over an entire limb, or even over the greater portion of the body. In the same manner inflammation is liable to be propagated along the mucous canals, as is exemplified in tonsillitis, croup, and other affections of the throat and air- passages, and in the various diseases of the stomach, bowels, and genito- urinary apparatus. In duodenitis the morbid action may readily extend along the choledoch and hepatic ducts to the liver ; and in gonorrhoea nothing is more common than for the disease to spread along the seminal passages to the epididymis and testis. In the second place, inflammation may propagate itself by contiguity of structure, as already indicated in one of the preceding paragraphs. A phleg- 60 INFLAMMATION. monous erysipelas of the skin has a tendency not merely to spread over the neighboring surface, in consequence of its similarity of structure and func- tion, but alio to extend in depth, thereby involving cellular tissue, aponeu- rosis, muscle, and, in short, every other texture within its reaclL The tissues mainly concerned in the enterprise are the vascular and connective, the pecu- liar structure of which renders them highly favorable for the propagation of the morbid action. An inflammation, beginning in the conjunctiva, often in its progress involves the entire eye, simply from the intimate manner in which its different tunics are superimposed upon each other. In the bowel and other mucous canals the same effect is frequently witnessed. In pneumonia, especially in the more violent forms, the disease is rarely confined to the pa- renchymatous substance, but is almost sure, in time, to spread to the pleura and bronchia. In orchitis, although the inflammation is primarily seated in the tubular structure of the epididymis and testicle, yet it is by no means un- common for it to extend to the albugineous coat, and occasionally even to the vaginal. An inflammation of the synovial membrane of a joint often extends, by virtue of the same law, to the articular cartilage and the head of the bone beneath, contiguity and intimate connection favoring here, as else- where, the propagation of morbid action. Thirdly, the extension may be effected through the agency of the veins and lymphatics. Of the former a good example is afforded by what occasionally happens in venesection, where, apparently from the use of a foul lancet, the inflammation is sometimes spread from the little wound in the vessel, at the bend of the arm, as high up as the right auricle of the heart; and of the lat- ter by what takes place in chancre, where the poison, taken up by the absorb- ent vessels of the penis, is carried by them to the glands of the groin, where it causes a hard and painful swelling, constituting what is termed a bubo. In dissection wounds the absorbent vessels always serve as vehicles for the trans- mission of the peculiar poison which gives to these lesions their character- istic features. For a short period after inoculation the poison is apparently latent, when its effects show themselves by one or more red lines extending up the limb as far as the axillary glands, whence, as from a common centre, its injurious consequences are radiated over the whole system. Of the extension of inflammation by nervous agency, or sympathy, a fami- liar example is afforded in parotitis. In this disease, which attacks chiefly young subjects, the inflammation often suddenly leaves the organ originally involved, and fastens itself upon the testicle, which is then compelled to bear the whole onus of the morbid action. Of the precise manner in which this transfer is effected we are ignorant. That it is not through any direct nerv- ous connection is sufficiently obvious, for everybody knows that no such con- nection exists; hence, as the only plausible explanation left us, we must con- clude that it is brought about by the operation of sympathy, although of the nature of this operation it is impossible, in the present state of the science, to form any just idea. A similar relationship exists between the mamma and uterus, the stomach and lungs, and between the stomach and brain, or, ra- ther, between the former organ and the arachnoid membrane. Finally, inflammation may be propagated by the blood. This fluid, as will afterward appear, undergoes various changes in this disease, of which the most important is an increase of- fibrin and colorless globules, with a strong tendency of these substances to adhere to the sides of the vessels as they are propelled along with the general circulating mass. The blood, thus altered in its properties, leads to obstruction of the capillaries in different parts of the body, thereby establishing foci of morbid action. It is not improbable that metastatic abscess, or what is now called pyemia, is generally produced in this way ; at all events, this is a more rational mode of accounting for that occurrence than the one which attributes it to the absorption of pus, or the VARIETIES OF INFLAMMATION. 61 admission of this fluid into the blood, through the agency of open-mouthed veins. 3. VARIETIES OF INFLAMMATION. With the exception, perhaps, of the epidermis, the hair, and nails, there is no part of the human economy which is not susceptible of inflammation and its consequences. The reason why these structures are usually consi- dered as incapable of this process is, that we are not able to demonstrate in them any bloodvessels, nerves, and lymphatics, which are the great and essen- tial elements of organization in the more thoroughly elaborated and complex tissues. Notwithstanding this, it is extremely difficult to unite in so sweep- ing a conclusion, when we reflect upon the fact, of which daily observation furnishes examples, that these external coverings undergo various lesions, of form, size, color, and consistence, which can only be explained on the as- sumption that they are the product of inflammation, modified by the nature of the affected parts. There are other structures, as the arachnoid mem- brane, the cornea, and some of the cartilages, in which it is impossible to detect vessels, and yet no one would doubt for a moment, on this account, that they are incapable of disease. We should, therefore, I think, not make any exception, as it respects the possibility of the occurrence of inflamma- tion, even in regard to the scarf-skin, the hair, and nails. The susceptibility of a part to inflammation may be stated to be, as a general rule, in direct proportion to the amount of its vascular and nervous endowments, the importance of its functions, and the nature of its exposure. Hence it is found to be most common in the skin, cellular tissue, the mucous and serous membranes, the joints, lungs, liver, kidneys, bladder, urethra, ovaries, and uterus. The only exceptions to this law are the brain and heart, which, notwithstanding their incessant labor, the excessive delicacy of their organization, and their universal sympathetic relations, are compara- tively rarely the subjects of inflammation. In the thyroid body, the salivary glands, the pancreas, the prostate, and the spleen, together with the voluntary muscles and their tendons, the nerves, vessels, fibrous membranes, and even the bones, the disease is also quite uncommon, although several of these structures are sufficiently prone to suffer from inflammation as it manifests itself in certain forms of syphilis, scrofula, and rheumatism. It is easy to know why the skin should be so frequently diseased when we reflect upon its vast extent, its wonderful vascularity and nervous endowments, its sympathy with the brain, lungs, stomach, and, in fact, almost every organ in the economy, and its constant exposure to all kinds of injurious impressions. For the same reason it is not difficult to account for the frequent occurrence of pneumonia, hepatitis, nephritis, and inflammation of some of the other viscera. The cellular tissue, although less highly organized than the skin, is yet a frequent subject of disease, growing out of the circumstance that it is the great connecting link by which the various tissues of the frame are cemented together, and also that it serves as a means of transmission of the vessels and nerves from one part to another. The functional activity alone of some of the organs affords a ready key to their liability to inflammation. Thus, the genital organs are almost exempt from disease until the age of puberty; but from that time on, when their slumbering season is over, and their fretful life begins, they are extremely prone to take on morbid action, both of a common and of a specific character. The progress of inflammation exhibits much diversity, being at one time rapid, at another slow; hence its distinction into acute and chronic. An acute attack is one which runs its course swiftly, and which is characterized by well-marked symptoms, as is seen, for example, in tonsillitis consequent • 62 INFLAMMATION. upon a severe cold, and where, in the space of a few days, the affected gland acquires a large bulk from vascular engorgement and interstitial deposits, attended with great local and constitutional disturbance. Force and rapidity of action are its distinguishing features. Chronic inflammation, on the con- trary, is marked by comparative slowness and feebleness of action ; the attendant phenomena are also less bold, although there is generally a decided tendency to effusion. It may be the sequela of au acute attack, or it may show itself as a primitive affection : that is, it may exist for a considerable period without being discovered, owing to the absence of the usual diagnostic signs. Once in this condition, it may last almost for an indefinite time, as is exemplified in certain cases of gleet, leucorrhoea, tonsillitis, osteitis, arthritis, otorrhoea, and ophthalmia. Inflammation may be healthy or unhealthy, according as it manifests a tend- ency to restoration, progress, or mischief. It would be wrong to regard inflammation always in the light of a disease, since it is the means which nature must necessarily employ whenever she wishes to repair the injury which has given rise to it. It is only when the process proceeds blindly, so to speak, that it is likely to be productive of harm by overpowering the part and system. An incised wound, occurring in a sound constitution, will, if properly managed, heal promptly by union by the first intention ; but if the reverse be the case, there will not only be no immediate union, but its edges will separate, and suppuration taking place, a long time may elapse before consolidation will be completed. In the one case, the action is 'said to be healthy, in the other unhealthy; and it will generally be found that the nature of the action is a true index of the condition of the part and system ; as the latter is, so will be the former. There are of course exceptions to this law, but they are infrequent and unimportant. There is a form of inflammation to which pathologists have applied the term irritable, but which in reality does not differ materially from unhealthy inflammation, just described. The best illustrations of it occur in strumous ophthalmia, in ulcers of the extremities, in rupia, and in chronic tonsillitis, bronchitis, dysentery, cystitis, urethritis, and orchitis. It seems to depend upon an exaltation of the natural sensibility of the affected structures, aggravated by an unsound state of the nervous system. Inflammation may be common or specific; common, when it proceeds from ordinary causes; specific, when it is produced by some peculiar poison, as the matter of gonorrhoea, syphilis, or smallpox. A more important distinction is, that certain inflammations are capable of appearing only in certain tissues. Thus, erysipelas is generally a disease of the skin ; in rare instances it affects the mucous membrane of the month and throat, and, perhaps, also the peri- toneum and pelvic veins, as in lying-in females; but it never fastens itself, as a primary affection, upon the muscles, aponeuroses, nerves, arteries, bones, cartilages, or internal viscera. Gout and rheumatism have a special fancy for the joints and fibro-serous textures; secondary syphilis, for the skin and fauces; tertiary syphilis, for the bones and periosteum ; scrofula, for the lymphatic ganglions; and carcinoma, for the glandular structures, as the mamma, uterus, and liver. Finally, inflammation may be latent. This expression is curious, and yet full of meaning; it simply implies that the morbid action does not reveal itself by the ordinary phenomena. Such an inflammation is always to be dreaded, because, being of a peculiarly insidious character, it is extremely apt to be overlooked. One of the best examples of this form of disease is afforded by the glands of Peyer in typhoid fever, the inflammation and ulceration of which constitute the anatomical lesions of that singular malady. Patients thus affected seldom complain of pain, or, indeed, of any other suffering directly referable to these bodies, even when the morbid action is so • ACUTE INFLAMMATION — LOCAL SYMPTOMS. 63 extensive as to lead to perforation of the bowel. Latent pneumonia is a sufficiently common disease, and abscesses of the spine and other parts of the body often make great progress before their true nature is even sus- pected. 4. TERMINATIONS OR EVENTS OF INFLAMMATION. Inflammation has various modes of termination ; upon strict inquiry, how- ever, it will be found that these amount only to two, and that all the rest are merely so many states, conditions, or events of the process. This distinction is real, not imaginary, and therefore of no little practical value. Philoso- phically speaking, there are but two terminations of the morbid action, the one being in health, the other in the death of the part. The former may oc- cur by delitescence and resolution ; the latter, by ulceration and gangrene. All deposits, whether serous, plastic, purulent, or sanguineous; aqd all changes of structure, whether in the form of softening, induration, contrac- tion, or thickening, are to be viewed simply as so many products, effects, or results of inflammation, without necessarily involving a suspension of the pro- cess itself. This indeed may still go on, sometimes even for an indefinite period, and thus produce additional changes, more serious, perhaps, in their consequences than those which attended the act in its earlier stages. In sup- puration, for example, the inflammation does not geuerally end the moment matter forms, or as soon as the pyogenic crisis has been fairly attained ; in- stead of this it proceeds in a modified state, accompanied by ulceration, or still further deposits. The same remarks are applicable to lymphization and even to the production of serum, the latter of which may be regarded as one of the processes employed by nature to deplete the inflamed tissues ; in this, however, she generally succeeds only by degrees, as is shown by the fact that the disease often continues for a considerable length of time after the drainage has commenced. Blood, either perfectly pure, or variously combined with the secretions of the affected surface, may be poured out quite freely, and yet the morbid action continue as actively as before, as we see exemplified in dysentery and other hemorrhagic forms of inflammation. Hence there is really no such thing as a termination of inflammation in effusion of serum, deposit of fibrin, or the formation of pus. These events occurring, the mor- bid action may still go on, being merely modified in its character by the in- fluence exerted upon it by the attendant secretion or the morbid product. The nomenclature of inflammation has been much simplified within the last quarter of a century. As it now stands it is based essentially upon the ana- tomy of the affected tissue, structure, or organ, the term itis being merely added to the name by which the part is generally known, as sclerotitis, cys- titis, laryngitis. Sometimes, however, the old expressions are retained, as quinsy for inflammation of the tonsils, ophthalmia for inflammation of the eye, and gonorrhoea for inflammation of the urethra. SECT. II.—ACUTE INFLAMMATION. The symptoms of inflammation naturally divide themselves into local and constitutional; or those furnished by the part and those afforded by the general system. 1. LOCAL SYMPTOMS. The most prominent external symptoms of inflammation have long been known to practitioners. They are tersely stated by Celsus to be " rubor, calor cum tumore et dolore." This writer flourished in the first century of 64 INFLAMMATION. Christianity, and was a contemporary of Virgil, Horace, and Ovid. His knowledge of inflammation, however, was extremely imperfect, and it was not until some time after the commencement of the present century that the sub- ject began to be studied in its relations with the different organs and tissues of the body. Bordeu, Carmichael Smith, and Bichat, by laying the founda- tion of general anatomy, paved the way to a more comprehensive acquaint- ance with the nature and seat of morbid action, and were thus instrumental in revealing an amount of light, the beneficial effects of which can even yet be hardly foreseen. They have shown us, what might, a priori, have been anticipated, that the phenomena enumerated by the Roman author, as cha- racteristic of inflammation, are liable to great and constant variations, ac- cording to the nature of the affected structure, and that the most violent morbid action may often be present, and yet nearly all of these phenomena be absent. Hence, at the present day, too much stress cannot be laid upon disordered function, inasmuch as this is frequently the only symptom that is at all appreciable, especially in inflammation of the internal organs. Modern research has shed important light upon the condition of the capillary vessels and their contents in inflammation, and has enabled us to explain much of what was before obscure and mysterious in regard to the more intimate na- ture of the process. 1. Discoloration.—The discoloration of an inflamed part varies from the slightest increase of the natural hue to the deepest purple, according to the character of the affected tissues and the intensity of the morbid action. It is always, other things being equal, most distinctly marked in those structures which are very vascular, while in such as have comparatively few vessels it is either entirely wanting, or present only in a faint degree. It is a prominent phenomenon in inflammation of the skin and mucous membranes, the cellular tissue, lungs, pleura, spleen, kidneys, and peritoneum ; structures which are distinguished by their great vascularity, and by the large amount of blood which they are capable of admitting in disease. On the other hand, there is but little discoloration in inflammation, however intense, of the tendons, car- tilages, bones, and fibrous envelops, the brain, nerves, heart, and voluntary muscles. In inflammation of the arachnoid membrane the only evidence of disease observable after death is effusion of serum or of serum and fibrin; all trace of vascularity is wanting, and yet the morbid action has been sufficient to destroy life. The discoloration of inflammation often acquires a high grade in a very short time, depending upon the activity of the circulation of the affected structures. In general, however, it proceeds rather slowly, keeping steady pace with the ingravescent action ; advancing from rose to red, from red to purple, or from purple to black, as when the part is about to fall into morti- fication. It is always most distinct at the focus of the inflammation, from which it gradually recedes until, in most cases, it is insensibly lost in the natural hue of the surrounding healthy structures. Occasionally, however, as in erysipelas of the skin, as well as in some affections of the mucous mem- branes, the line of demarcation is very abrupt, the diseased surface exhibiting a red and well defined circle. The discoloration varies not merely in degree, but also in its character thereby throwing, not unfrequently, important light upon the diagnosis of the case. Thus, it may be scarlet, as in the skin, throat, and bowels • lilac or bluish, as in the sclerotica and the fibrous envelops of the muscles • brick- colored, grayish, or brownish, as in iritis; yellowish, as in erysipelas, espe- cially when associated with derangement of the biliary secretion ; of a copper hue, as in the eruptions of secondary syphilis; purple, as in the edo-es of a scrofulous ulcer; livid, as in violent tonsillitis; and black, as in mortification. LOCAL SYMPTOMS. 65 These varieties of color, in these and other structures, are dependent, partly upon the organization of the affected tissues, partly upon the nature of the inflammation itself, and partly upon the amount, degree, or intensity of the morbid action. The discoloration varies in extent, from the smallest speck, perhaps not larger than a pin's head, to a surface occupying many inches, if not several feet in diameter, as in erysipelas, where the disease sometimes involves the greater portion of the body. When this is the case, the discoloration is said to be diffuse ; it is arborescent, when the vessels upon which it depends are spread out in dendritic lines ; punctiform, when it occurs in the form of little dots, or points, as in some of the inflammations of the serous and mucous membranes; linear, when it presents itself in a distinct streak, as in phlebitis and angeioleucitis; and maculiform, when it assumes the appearance of a blotch or ecchymosis. In the latter case, as well as in the punctiform variety of discoloration, the morbid hue is due to an actual extravasation of blood, consequent upon a rupture of some of the capillary vessels of the part. To be of value as a diagnostic sign of inflammation, the discoloration must be permanent, not transient; advancing and receding with the morbid action; disappearing under pressure, but reappearing the moment the pressure is taken off. The blush of shame vanishes in an instant, with the excitement that produced it; and the hectic flush upon the cheek of the consumptive merely denotes the existence of the fever which succeeds the afternoon's rigor; they are very different from the discoloration which marks the rise, progress, and termination of inflammation. Besides, the latter is usually associated with other symptoms, as heat, pain, swelling, and disordered function ; phe- nomena sufficiently distinctive, in every case, to prevent error of diagnosis. The immediate cause of the change of color in inflammation, is a preter- natural afflux of blood. It was formerly supposed that it depended upon the formation of new vessels, but the fallacy of this opinion was long ago dis- proved by minute injection and microscopical observation. It is now well known that there is a class of capillaries too delicate to admit a sufficiency of red blood to render them visible in the natural state, but which, the moment they become involved in irritation or inflammation, are distended to such a degree as to show themselves in every direction, hundreds and even thousands appearing, and that frequently in an instant, where hardly any could be dis- cerned before. We see this fact exemplified in the vessels of the conjunctiva, when a particle of foreign matter lodges upon the cornea ; and what occurs here may be supposed to take place, under similar circumstances, in other structures. It is only in reparative inflammation, or in the inflammation which is necessary to rebuild parts that have been lost or destroyed, that vessels are ever formed. The process is entirely incompatible with ordinary inflammation. 2. Pain.—Pain, like discoloration, is one of the most constant symptoms of inflammation, usually setting in early in the disease, going on steadily in- creasing until the morbid action has attained its maximum, and then gradually abating, as the disease recedes, until it is insensibly lost. The subject of pain presents several points of interest, which, as they have a practical importance, should be well understood by the surgeon. Pain varies in degree from the slightest change in the normal sensibility of the part, to the most excruciating agony, according to the nature of the affected structure, and the intensity of the morbid action. Doubtless idio- syncrasy also exerts an important influence, for it is well known that what causes pain in one individual occasions little, if any, in another. Most per- sons bear the application of a blister well, but I have seen some in whom the remedy, although retained only for a few hours, was productive of the most vol. I.—5 66 INFLAMMATION. exquisite torment. Such a result can only be explained on the assumption of an idiosyncrasy, or a difference in the nervous organization of our patients. The same remark is true in regard to the effects of injury. As a general rule, the pain is greatest at the focus of the inflammation ; it is usually fixed in its situation, but sometimes it darts about in different directions; is in- creased by pressure, motion, and posture; and rarely intermits, although it often remits, especially in the morning and the early part of the forenoon. Much diversity obtains in regard to the character of the pain, so much so, indeed, that we may often, from this circumstance alone, form a tolerably correct idea of the seat, and even of the nature, of the inflammation. Thus, in the pleura it is sharp and lancinating; in the cellular tissue, acute and throbbing, as is exemplified in boil and carbuncle; in the liver and lungs, obtuse and heavy; in the skin, prurient, itching, or burning; in the bones, dull and gnawing, as if insects were feeding upon the part; in the urethra, scalding or burning; in the conjunctiva, gritty and itching; in the teeth, throbbing, beating, or pulsatile. When inflammation is about to terminate in mortification, the pain generally becomes hot and burning. Pain is sometimes felt at a point more or less remote from the seat of the morbid action ; hence, it does not always serve to denote its existence. In coxalgia, the earliest and most prominent symptom usually is severe pain in the knee, and it has often happened, especially in the hands of the ignorant and inexperienced practitioner, that the latter has been leeched, cupped, and blistered, when all this care should have been bestowed upon the former. In inflammation of the bladder, ureters, and kidneys, a prominent symptom is uneasiness in the head of the penis; and in hepatitis, considerable suffering is often felt in the right shoulder. It is not always easy to explain these occurrences; but, in general, they are dependent either upon continuity of structure, as in the case of the urinary passages, or upon reflex action, as in coxalgia and hepatitis. It is worthy of note that the pain is generally much more severe when the inflammation is seated in the covering of an organ, than when it occupies its proper substance. A pleuritis is always attended with severe local dis- tress, whereas few persons ever experience any pain in pneumonitis. In in- flammation of the parenchymatous structure of the liver, great disorganiza- tion may take place, and yet the patient be entirely ignorant of the fact, as far as pain is concerned; but should the fibro-serous envelop of the organ be mainly implicated, violent suffering will be a prominent symptom. The same law holds good in inflammation even of the brain and its membranes. It is important that the practitioner should be aware of the distinction be- tween the pain of inflammation and the pain of spasm, since it must exert an important influence upon his therapeutic measures. It has been already seen that the former is gradual, not sudden in its attack; persistent, not in- termittent ; increased by motion, pressure, and posture; and, moreover, it is generally accompanied by more or less febrile disturbance, and other evidences of indisposition, plainly marking its character, to say nothing of the history of the attack, which usually furnishes important light in regard to the diagnosis of the individual case. In spasm, the pain comes on suddenly, and ° after having continued for a short time, intermits, or entirely disappears' only however, to return again, and pass through the same course; in a word it is paroxysmal, coming suddenly, and going suddenly ; relieved by pressure and nearly always attended with eructations and rumbling noises in the bowels, supposing the case to be one of colic; there is no fever—indeed generally no constitutional excitement of any kind—and there is also an absence of the other local symptoms of inflammation, as heat discoloration and intumescence. ' ' In neuralgia the pain is sharp and lancinating, often darting through the LOCAL SYMPTOMS. 67 parts with the rapidity of lightning, or like an electric shock: accompanied by a sense of soreness or aching, and generally aggravated by pressure. It is usually paroxysmal in its character, coming on perhaps once every day, lasting a few hours, and then going off gradually, or even suddenly, to re- appear about the same time the following day; it is, in fact, generally an intermittent disease, with a distinct interval of freedom from pain, resem- bling, in this respect, an ordinary intermittent fever, and having often, like it, a miasmatic origin. The pain, moreover, is not always fixed, but is at one time here, and at another there, generally in the course of a sentient nerve. Severe pain, especially in a nervous, irritable person, is always a formida- ble occurrence, as it exhausts and depresses the powers of life, and is sure, if not timeously combated, to occasion serious, if not fatal, mischief. The rule, therefore, is to arrest it promptly, and at all hazard, before the disease, of which it is a symptom, has made much progress. A sudden disappearance of pain, unless occasioned by the use of anodynes, is generally denotive of danger, as it implies a termination of the morbid action in the death of the affected structures. The occurrence should, at all events, excite suspicion, and lead to careful investigation. An individual, for example, has been the subject of strangulated hernia; the constriction has lasted for several days, and has been characterized by severe suffering, both local and general; suddenly the pain ceases, and the patient flatters himself that he will soon be well. The surgeon, however, comes to a widely different conclusion ; for the sunken features, the clammy skin, the feeble and flickering pulse, the incessant hiccough, and the trembling hand, but too plainly foreshadow the approach of death from mortification of the bowel. Pain is not always present, even although the inflammation may be ex- tremely violent. In typhoid fever, a disease attended with inflammation of the glands of Peyer, often terminating in extensive ulceration of these bodies, there is generally an entire absence of this symptom, from first to last, unless the case is followed by perforation of the bowel, and an escape of its con- tents into the peritoneal cavity. In pneumonia there is frequently no pain whatever; and the same thing is true in relation to inflammation of some of the other viscera. In scrofulous affections of the spine, particularly those forms of it known as Pott's disease and psoas abscess, pain, properly so called, is one of the rarest phenomena, especially in the earlier stages of their pro- gress. A painless inflammation is peculiarly dangerous, inasmuch as it is very liable to be overlooked by the professional attendant, particularly by one who is in the habit of placing undue confidence in the ordinary phenomena of the disease. Howr is pain produced ? It has been supposed that it is caused by a de- velopment of new nerves ; but that this is not so is sufficiently established by the fact that this symptom is often present, and that in a very severe degree, almost at the very commencement of the morbid action, and consequently long before it is possible for such an occurrence to take place. A more plau- sible opinion is that the suffering is occasioned by the compression of the nerves of the part by the dilated vessels and the effused fluids; but to render this theory complete it is necessary to go a step further, and to suppose that the various component structures of the nerves themselves are inflamed. It can hardly be imagined that these structures should escape this action even in the milder grades of inflammation, much less when the disease is fully established. Of the intimate nature of pain nothing is known. All that observation teaches is that it is a peculiar mental perception, dependent upon a healthy state of the brain, without which it is impossible for it to occur. The indi- vidual must possess the faculty of consciousness, or he cannot take cognizance 68 INFLAMMATION. of the mischief that disease produces in the different organs and tissues of the body. We have a convincing proof of this in what occurs in apoplexy and paralysis of the lower half of the body, in which the most violent inflam- mation may be set up, both in the internal viscera, and in the external struc- tures, and yet the patient be utterly insensible of its presence. The brain and nerves are crippled; hence the latter are unable to convey, and the for- mer unable to receive, painful impressions of any kind. Although pain is undoubtedly a great evil, yet it is extremely fortunate that it is so generally present in inflammation, since it serves to warn the pa- tient of his danger, and often imparts to the practitioner useful information respecting the nature and seat of the morbid action. How many persons formerly perished of typhoid fever, simply because there was no pain to guide the physician to the true lesions of the disease ? Doubtless this affection has existed from time immemorial, but it has only been within the last quarter of a century that we have known anything definite of its seat and character. Were pain one of its prominent symptoms, it would long ago have pointed the practitioner to the condition of the glands of Peyer. What is termed throbbing is a peculiar form of pain, generally denotive of the approach of suppuration. It is, however, sometimes felt at an early stage of the morbid action, especially when it involves the fibrous, fibro-serous, and osseous tissues. It is generally dependent, in the first instance, upon an unusually crowded state of the capillary vessels, impeding the onward flow of blood, and afterwards, when the disease is more fully developed, also upon the presence of inflammatory products. Posture exerts an important influ- ence upon its production, as is evinced in whitlow, odontalgia, and common furuncle. In the first of these affections the pain is increased a hundred fold, almost in an instant, when the hand is permitted to hang down by the side of the trunk; a decayed toOth that is free from pain in the day, while the patient is sitting up or walking about, will ache violently the moment the head touches the pillow at night; and a boil on the buttock, which will cause hardly any uneasiness when the body is recumbent, will throb violently when it is erect. These occurrences, which are easily explained by the in- creased determination of blood which the affected structures receive, under such circumstances, teach a valuable practical lesson in regard to the import- ance of position in the treatment of inflammation. 3. Swelling.—Swelling'is saldom entirely absent in inflammation of the external parts of the body, although it may be in that of certain internal structures, however violent or extensive the morbid action. Under the latter head may be enumerated, in particular, the fibrous and serous membranes, the tendons, cartilages, bones, vessels, and nerves, along with most of the different viscera. The mucous membranes also rarely suffer in this way; the principal points where swelling is liable to occur, as a result of inflammation, are the conjunctiva, glottis, tonsils, and vulva, for the reason that these parts are largely supplied with lax cellular tissue, which, wherever it exists, is so per- missive of infiltration of serous and other fluids. Hence it is that swelling is generally so conspicuous in inflammation of the subcutaneous and inter- muscular filamentous substance, especially in the extremities, and even some- times in the head, as is noticed in the more severe forms of erysipelas, where the scalp and face are occasionally puffed up to an enormous extent,'fright- fully disfiguring the features. The progress of the swelling varies; in general it is gradual, commencing early in the inflammation, and going on steadily increasing until the morbid action has attained its height; even then, however, it does not always stop, but often continues until the vessels have parted with their more fluid con- tents, which sometimes occurs only after the disease has begun to decline. LOCAL SYMPTOMS. 69 Occasionally, however, cases are met with where the swelling is most rapid and extensive, spreading, in a short time, over an entire limb, or even over the greater portion of the body. The best examples of this occurrence are witnessed in certain injuries, as compound fractures and dislocations, phleg- monous erysipelas, and the inflammation consequent upon snake-bite. The swelling varies in its character; thus it may be soft or hard, transient or protracted, beneficial or injurious. A soft swelling is usually denotive of serous effusion; a hard one, of a deposit of fibrin, or of the more solid ele- ments of the blood. A transient swelling is a more desirable event than a protracted one, as it is less likely to interfere with the restoration of function. Swelling often proves beneficial, inasmuch as the effusion upon which it de- pends is a means of depletion employed by nature to relieve inflammatory action ; it answers, in fact, the same purpose as topical bleeding. When, however, the deposit is very large, or composed essentially of solid material, immense harm may be produced by it, from the manner in which it com- presses the capillary vessels and interferes with the transmission of their con- tents; in other words, the effusion acts obstructingly, and thus causes fatal constriction. In swelling of the conjunctiva, technically called chemosis, the matter poured out often compresses the vessels of the cornea in such a man- ner as to induce gangrene of this membrane; and a like result occasionally follows phlegmonous erysipelas of the limbs and scrotum. Swelling may prove injurious in another way ; by acting obstructingly, as in oedema of the glottis, which may cause death by preventing the ingress of the air into the lungs. A similar effect may be produced by inordinate tumefaction of the tonsils. A swollen perineum may compress the urethra and occasion reten- tion of urine. The immediate cause of swelling is twofold; first, engorgement of the capillary vessels, and secondly, and mainly, effusion of serum and fibrin ; to which, in the more severe forms of inflammation, may be added pus and blood, the latter of which is sometimes poured out in considerable quantity. 4. Heat.—An increase of heat is one of the most common effects of inflam- mation, and hence a valuable symptom of the disease. A good illustration of this occurrence is observed in tonsillitis, gastritis, pneumonia, and the so- called fevers, in which there is often a remarkable heat of the breath; and also in many of the external varieties of inflammation, where the change is rendered apparent both by the sense of touch and by the rapid evaporation of our applications. The scalding tear in inflammation of the eye is an evidence of the same fact. The degree of heat, emitted in the act of inflammation, has been supposed never to exceed that of the blood in the heart and large vessels. The re- searches of John Hunter would seem to countenance this opinion. He ope- rated upon a man for the radical cure of hydrocele; the temperature of the vaginal tunic immediately after the withdrawal of the fluid being 92°. The cavity was now stuffed with lint, and the next day the thermometer stood at 98f°, thus showing an increase of six degrees and three-quarters, which must have fully equalled the heat of the blood in the heart and large vessels of the subject of the observation. In repeating the experiment subsequently upon a muscular wound in the side of a dog, and upon the vagina of an ass, irritated by a solution of bichloride of mercury, he found no difference whatever, before and after the occurrence of inflammation, in the temperature of the parts. Hence, he naturally concluded that the extrication of heat during the progress of this morbid process was either very slight, or altogether inappreciable. Observations, however, made since the time of the English philosopher, con- clusively show that there is frequently, if not generally, a decided increase of temperature in the inflamed structures; and, although this increase may not 70 INFLAMMATION. render the temperature of the part equal to that of the heat of the blood in the heart, yet it is none the less real and positive. It is well known that the outskirts of the body, as the feet, hands, and ears, are habitually cooler than the trunk, head, and upper portions of the extremities, because they have naturally a more feeble circulation ; hence in inflammation, although their temperature may not reach 98° of Fahrenheit, yet if there be any elevation of heat over and above what these structures enjoy in the healthy state, it is to be considered as an actual augmentation. That this will generally be found to be the fact, in all the more severe forms of inflammation, my observa- tions, many times repeated, fully convince me. In erysipelas of the skin of the trunk, in urinous infiltration of the scrotum, in acute abscess, in tonsillitis, orchitis, bubo, and other affections, I have again and again seen the mercury rise in the instrument above 100°, and in some instances even as high as 105°, 106°, and 107°. It has been ascertained that the oviduct of a frog ready to spawn is two degrees hotter than the heart; and Professor Dunglison has seen the temperature of the uterus during labor as high as 106°. From all these facts, to which others equally convincing might be added, if space permitted, it is impossible to avoid the conclusion that there is generally an elevation of heat in inflammation, in whatever part of the body it may be situated, provided the action which accompanies it is not too slight, or too limited in extent. Our knowledge of the nature of animal heat is hardly sufficient to justify us in expressing an opinion regarding the cause of its increase in inflamma- tion. It may be supposed, however, in the absence of positive information, that it is due to the friction which the blood experiences in its passage through the vessels, not only in the inflamed parts, but in the system at large, and also to the rapid manner in which the oxygen of the air unites with the red particles of this fluid as it is propelled along in its turbulent course. The influence of an accelerated state of the circulation upon the production of animal heat is well exemplified in what occurs in ordinary exercise when the feet are cold. A rapid walk, under such circumstances, in the open air, soon equalizes the circulation, and sends the blood, loaded with oxygen, to every part of the body, warming and fertilizing it as it rushes on. If a horse be rode swiftly round the race track his whole body becomes immensely heated, and his blood surcharged with fibrin and colorless globules ; both evidently the result of the increased friction of the blood against the coats of the ves- sels, and the rapid union of the oxygen of the air with that fluid. Irritating applications, as spirits of ammonia, blisters, sinapisms, and embrocations, by inviting a preternatural afflux of blood to the affected part, produce an analogous effect, accelerating the circulation, and causing an elevation of temperature. Allusion has already been made to the fact that the uterus during parturition is much hotter than it is in the natural state; a circum- stance which can only be explained by the supposition of an increased activity of its vessels approximating a state similar to that which obtains in inflam- mation, although not identical with it. During the growth of the antler of the deer and other animals there is always a marked elevation of temperature* and phenomena of a similar kind are often witnessed during the development of malignant and other tumors. All these circumstances bear directly upon the question under consideration, if they do not positively serve to establish its truth. 5. Functional Disorder.—Disorder of the functions of the affected part is in general a most important symptom, being often present when all, or nearly all, the other phenomena are absent. It manifests itself in various ways as well as in various degrees; at one time in the form of increased sensibility or irritability, at another as a suppression, alteration, or augmentation of the LOCAL SYMPTOMS. 71 natural discharge, and now as an abolition of some special sense; at one time as the slightest possible departure from the normal action of the part, and at another as a total suspension of it. An increase of sensibility is one of the most common effects of inflammation. In peritonitis, gastritis, and enteritis, the sensibility of the affected structures is often so great as to render the slightest pressure of the finger a source of profound distress; and it is for the same reason that, under such circum- stances, the weight even of a sheet is sometimes almost intolerable. Similar effects are noticed in some of the external diseases, as in boil, carbuncle, erysipelas, and in inflamed hemorrhoidal tumors, which are frequently the seat of the most exquisite tenderness, hardly exceeded by that which attends an inflamed eye. Parts which are devoid of feeling, or nearly so, in the sound state, as ligaments, tendons, bone, and fibrous membranes, generally become exceedingly sensitive in inflammation. The change in question is of great importance in a diagnostic point of view, inasmuch as it generally enables us to distinguish readily between inflammatory and spasmodic affections, the latter of which, as before stated, are often immensely relieved by pressure, which never fails to aggravate the former. An increase of irritability is a very constant phenomenon in all inflamma- tions of muscular parts. In cystitis, one of the earliest and most prominent symptoms is a frequent desire to urinate, arising from involvement of the muscular fibres of the bladder; in gastritis, the irritability of the stomach is often so excessive that the organ is incapable of retaining the smallest quan- tity of fluid, however bland ; and in dysentery, the greatest distress which the patient is obliged to endure, during the'progress of that dreadful malady, arises from the incessant peristaltic action of the colon and rectum, the main seats of the morbid action. An increase of the contractility of the voluntary muscles is very common in fractures and dislocations, in severe sprains, and after amputations, usually manifesting itself in spasmodic twitchings, which often require large doses of anodynes for their suppression. Again, inflammation has the effect of diminishing, or even completely sus- pending, the special function of an organ. In ophthalmia, the eye cannot look at objects, however dim; the moment the effort is made the lids con- tract spasmodically, and the smallest ray of light that impinges upon the retina is productive of the greatest distress. In inflammation of the ear the slightest noise, which, in the healthy state would perhaps not be perceived, or which might fall as delightful music upon the tympanum, becomes a source of deep distress; and the sense of hearing is almost destroyed by the buzzing and explosive sounds which succeed the morbid action. In coryza, the sense of smell is abolished; in inflammation of the skin the patient is deprived of the sense of touch ; and in glossitis there is a loss of the sense of taste. In laryngitis the voice is at first merely altered in its character, but as the dis- ease progresses the individual often becomes completely aphonious. In cerebritis there is generally delirium, followed, if the case passes on to sup- puration, by convulsions and coma, the precursors of speedy dissolution. Another prominent symptom of inflammation, one, indeed, which is seldom absent, is disorder of the secretions. Thus, in inflammation of the skin, there is suppression of the perspiration; in hepatitis, of the bile; in nephritis, of the urine. Or, instead of a total arrest of these and other secretions, im- portant changes are effected in their composition, or in their physical, chemical, and microscopical properties. In pneumonia, the characteristic symptom is a rust-colored sputum, and in dysentery, a discharge of bloody mucus. The function of absorption is often seriously impeded, if not completely arrested, in inflammation. The disorder, however, is generally much more conspicuous in the advanced than in the early stages of inflammation, in 72 INFLAMMATION. which this process is sometimes executed, even with a certain degree of vigor, as is demonstrated by the facility with which morphia and other substances are carried into the system when placed upon the skin after vesication by cantharides, ammonia, or hot water. In the more violent grades of inflam- mation, the function is usually kept in a state of abeyance, the action of the absorbent vessels being arrested by the morbid deposits. Afterwards, how- ever, as the disease declines, the function of absorption is gradually re-esta- blished, and then often proceeds with great vigor, rapidly removing the fluids effused during the earlier stages of the inflammation. It is worthy of notice that while the absorbent vessels, when the inflam- mation is at its height, refuse to take up extraneous matter, as, for example, morphia or belladonna, and also effused fluids, they are often very busy in removing affected textures, and that even when they are of a very firm and resisting character. A familiar illustration of this occurrence is afforded in acute abscesses, the natural evacuation of which is frequently accomplished by the agency of the absorbent vessels, where the disease is most intense. In inflammation of the joints, cartilage and even bone often suffer extensively from this cause. There is no doubt that the pressure of the effused fluids always greatly influences and promotes the occurrence. 2. CONSTITUTIONAL SYMPTOMS. Constitutional symptoms do not always attend inflammation. The morbid action may be so mild as to prevent its recognition by the system ; it is strictly a local affection, and therefore causes no general resentment. But the case is very different when the disease is severe, or when, even if it is com- paratively slight, it involves an important structure; then the whole frame feels its irritating effects, and evinces a strong interest in the impending struggle. The group of phenomena thus produced constitutes what is termed inflammatory, symptomatic, or sympathetic fever, and deserves con- sideration as expressive of the sum of suffering of each particular organ. The period which intervenes between the establishment of the inflammation and the occurrence of fever varies from a few hours to several days, depending upon the nature of the exciting cause, the condition of the patient, the intensity of the disease, and, above all, the importance of the organ attacked. Idiopathic inflammation is generally preceded by depression or a sense of lassitude and uneasiness, attended with headache, pain in the back and limbs, bad taste in the mouth, vitiated appetite, and slight chilliness, alternating with flushes of heat. Sometimes the patient is remarkably desponding, or annoyed with disagreeable dreams, and unpleasant forebodings respecting his recovery. He feels uncomfortably, both bodily and mentally, and has a disinclination to exertion. In a word, he is unwell, or in a state interme- diate between health and sickness. These phenomena, which are merely the precursors of the fever, which is as yet only in a state of incubation, may be compared, not unaptly, to the fleeting clouds which precede the outbreak of a storm ; they appear and vanish for a time, but finally coalescing, they assume their allotted station in the chain of morbid changes. When fully established, the fever never intermits so long as the cause which has produced it continues in operation ; but it generally remits slightly in the morning, and sometimes, though rarely, twice in the twenty-four hours. The vesperai exacerbation usually sets in late in the afternoon, and persists, with but little alteration, until towards morning, when the excitement relaxes its hold as if in need of temporary repose to meet the gradually recurring emergency. During the calm which is now present, the patient often falls into a refresh- ing sleep, his thirst and restlessness subside, and the skin is bedewed with a gentle perspiration. Soon, however, the smothered fire is rekindled and CONSTITUTIONAL SYMPTOMS. 73 the same suffering has to be passed through as before, now, perhaps, aug- mented by the spread of the morbid action, and the development of new sympathies. In order to comprehend fully the nature of inflammatory fever, it is neces- sary that the surgeon should personally interrogate, as it were, every organ of the body which may be supposed to evince any sympathy with the affected structures. This inquiry should, as a general rule, embrace an examination of the heart and arteries, the countenance, skin and extremities, lungs, tongue, stomach, bowels, liver, kidneys, and bladder, together with the state of the muscles, brain, and assimilative powers. Derangement of the vascular system is chiefly denoted by the state of the pulse, the principal characteristics of which are frequency, hardness, fulness, strength, and quickness. The number of beats in a minute ranges from seventy, seventy-three, or seventy-five, the average standard in the healthy adult, to eighty-five, ninety-five, one hundred, or even one hundred and twenty, according to the intensity of the disease and the vigor of the consti- tution. A hard pulse is firm and resisting, rolling under the finger like a tense cord, and as if the blood were sent into it with extreme power; some- times the artery thrills or vibrates, owing to a partial displacement synchro- nous with the contraction of the left ventricle of the heart. When the tension is unusually great, it is difficult, by any pressure we can apply, to obliterate the caliber of the vessel. Fulness has reference to the volume of the pulse, which feels as if the artery were expanded beyond its normal size. Strength implies a sensation of preternatural resistance to the finger; while a quick pulse is one in which each beat occurs with great suddenness or abruptness. This quality of the pulse is generally associated with frequency, from which, however, it differs essentially, as the latter has reference merely to the num- ber of strokes in a given time, and not to the rapidity with which the vessel dilates and contracts under the finger. Several of these states of the pulse may be absent, and yet the case be one of great disorder of the vascular system. Their entire co-existence, in fact, is rare; perhaps the nearest approach to it is to be found in gout and rheumatism, hepatitis, pleurisy, splenitis, and the commencement of smallpox. In the examination of the pulse, it is not to be forgotten that its action may be materially modified by the nature and seat of the inflammation and by the idiosyncrasy of the patient. In cephalic affections, the pulse is slow, full, and laboring, in consonance with the oppressed condition of the heart; in peritonitis, it is small, frequent, and wiry, sometimes, in fact, almost indis- tinguishable ; and in acute inflammation attended with internal venous con- gestion, as in certain forms of fever and injury, it is obscure and apparently feeble, but generally rises under the effects of our remedies, or the natural powers of the system. Idiosyncrasy often singularly modifies the state of the pulse. I recollect a middle aged man, once my patient, whose pulse was habitually under forty; and still more remarkable examples of the kind have been witnessed by others. On the other hand, it may be abnormally fre- quent, beating constantly from eighty to ninety in the minute. The above peculiarities, whether the result of morbid action, or of indi- vidual organization, derive a special value from the influence which they must necessarily exert upon our diagnosis and treatment. Thus, in peritonitis, if the practitioner were merely governed by the state of the pulse, without any knowledge of the condition of the system which causes it, he would be almost sure to administer stimulants instead of applying leeches and blisters; thereby feeding in place of diminishing the inflammation, and so hurrying on the fatal crisis. A pulse, habitually slow, might, in inflammation, hardly attain the normal standard of frequency, and yet the system might literally be con- sumed by symptomatic excitement. The surgeon, aware of the possibility 74 INFLAMMATION. of such occurrences, is wide awake; and hence he is rarely, if ever, thrown off his guard, whatever may happen. The countenance, in inflammatory fever, is usually flushed, and often ap- pears unnaturally full, as if it were slightly tumid. The eyes are reddish, suffused, and frequently intolerant of light. The skin is hot and dry, perspi- ration being kept in complete abeyance ; and the extremities are usually so warm and uncomfortable as to be unable to bear any covering. When the excitement is excessive, the sufferer generally finds it impossible to maintain the same posture beyond a few minutes ; he tosses about from side to side, and from place to place, in search of a cool spot. The respiratory organs freely participate in the general disorder. The in- spirations are increased in frequency, and are usually performed with a cer- tain degree of labor; various kinds of rales are heard, and cases occur in which there are well-marked evidences of venous congestion. The digestive organs always suffer in inflammation, and therefore demand careful examination. The tongue is variously affected ; sometimes red and almost clean, but generally loaded, either with a whitish, yellowish, or brown- ish fur, contracted, and somewhat reddish at the tip and edges; nearly always dry, and easily protruded, though often a little tremulous, especially when the accession occurs in a person of nervous temperament. The taste is viti- ated, or entirely arrested, the salivary secretion is suppressed, a thick, dark- colored mucus adheres to the lips, gums, and tongue, and there is a dis- agreeable arid feeling in the fauces and oesophagus. The thirst is intense, and can hardly be appeased by the most frequent and abundant draughts; the appetite, on the contrary, is usually destroyed, and hence the patient often loathes food, in whatever form it may be presented to him. Nausea and a sense of gastric oppression, sometimes attended with bilious vomiting, are common attendants. The bowels are generally constipated, or alternately constipated and relaxed, distended with gas, and somewhat tender under pressure; the alvine evacuations being fetid, and variously altered in color and consistence. Along with this condition of the digestive tube there is usually more or less disorder of the liver, manifesting itself in excess, defi- ciency, or vitiation of its secretion. Such a condition is very apt to be present in symptomatic fever consequent upon accidents and idiopathic inflammation in malarious districts. In what manner, or degree, the func- tions of the pancreas are affected in this disease, we are ignorant. The probability, however, is that it suffers very much in the same way as the salivary glands of the mouth, which it intimately resembles in its structure and uses. Among the more marked changes produced by inflammation are those in the renal secretion. These changes relate chiefly to the quantity, color, and consistence of the fluid. In the normal state, the average quantity of urine, in the twenty-four hours, is from thirty-five to forty-two ounces; but in in- flammatory fever it often does not reach one-half or even one-third this amount. Moreover, instead of being of a clear amber hue, as it naturally is, it is com- monly of a deep red tint, and surcharged with an unusual quantity of extrac- tive matter, mucus, and lithic acid; the latter of which always falls to the bottom of the receiver, in the form of brick-colored sediment. The specific gravity of the secretion is also very much increased, and the odor is often quite offensive from the presence of various kinds of animal substances During the height of very acute inflammation, the fluid is often slightly albuminous, and even pervaded by tubular casts. The chlorides on the°con- trary, are commonly remarkably diminished, especially when there is much exudation with a tendency to cell growth. The excretion of the fluid is very much as in health, though occasionally it is greatly increased in frequency In traumatic inflammation, as after fractures, dislocations, and amputations' CONSTITUTIONAL SYMPTOMS. 75 the bladder is occasionally so much paralyzed as to require the aid of the catheter for the expulsion of its contents. The muscles are generally the seat of great discomfort in this form of fever. Already, during the stage of incubation, the patient is harassed with a sense of lassitude, stiffness, and aching or darting pains, which, gradually aug- menting in severity, at length constitute a real source of suffering. The pains in the lumbar region are particularly violent; they are always worst at night, and are often so intense as to deprive the patient completely of sleep. His back feels as if it would break into pieces, as if it were being sawed in two, or as if it were bruised, and mashed, and comminuted. Not unfrequently every joint is racked with pain, and the whole body is so exqui- sitely sensitive as to be intolerant of the slightest motion, pressure, or mani- pulation. It is this distress in the muscles that causes the patient such weary and painful nights, and which induces him to exclaim in the evening, "Oh that it were morning!" and in the morning, "Oh that it were evening!" The suffering of the brain is evinced by a peevish and irritable state of the mind; by loss of sleep; by disagreeable dreams; and by occasional fits of delirium. In many cases, there is more or less perversion of special sen- sation ; as is proved by the distracting noises in the ears, the intolerance of light, the vitiated taste and smell, and the impairment of the touch.- Finally, the assimilative powers being in abeyance, the body becomes gradually emaciated, and the strength fails in proportion to the impoverished condition of the blood and solids. Such is the ordinary course of events in inflammatory fever. If the morbid action does not go on too long, or if the patient has unusual powers of re- sistance, he may be able to weather the storm, and finally come off conqueror. The disease, and, along with it, the fever which it has produced, will now gradually subside, the occurrence being announced by a diminution of the patient's restlessness, anxiety, and thirst, by a restoration of the moisture of the skin and mouth, and, in short, by a decided improvement in the condi- tion of all the secretions. The sleep becomes more natural and refreshing, the appetite returns, the pulse descends to its normal standard, and the mind regains its natural equilibrium. The cessation of the fever often declares itself by the occurrence, either sudden or gradual, of a profuse sweat, to which the older pathologists applied the term critical, and by a general un- locking of all the secretions. In a word, the clouds which had so long obscured the horizon are once more succeeded by sunshine; disease has vanished, and health is regaining its supremacy. If, on the other hand," the disease progresses, a downward tendency is gradually witnessed of evil, if not fatal portent. The symptoms, losing their inflammatory type, now assume a typhoid character; the pulse becomes weak, soft, and frequent, beating from one hundred and thirty to one hundred and sixty in a minute; the countenance assumes a peculiar shrunken aspect, denominated hippocratic ; the surface is bedewed with clammy perspiration; the extremities are inclined to be cold ; the tongue is dry and covered with a brownish or blackish fur; sordes collect upon the teeth; hiccough and twitching of the tendons supervene; and there is rapid emaciation, with corresponding failure of the strength, and low muttering delirium. Recovery is still possible, although doubtful; a well-directed plan of treatment, or even nature's unassisted efforts, may be sufficient to shake off the oppressive load, and enable the part and system to triumph over the ravages of the disease. But typhoid fever is not always a necessary consequence of the inflamma- tory; it may, and often does, exist as an independent affection, coming on early in the attack, perhaps almost immediately after the commencement of the morbid action, and maintaining throughout a well-marked asthenic type. The most common cause of such an event is severe shock or loss of blood, T6 INFLAMMATION. occurring in an unhealthy, broken state of the system, or actual blood-poison- ing, from the absorption of pus, or the operation of some specific virus, as that of malignant pustule, or that generated in the dead human body, and received by inoculation in dissection. In the more severe grades of erysi- pelas and carbuncle, the fever soon assumes an asthenic character, whatever may have been its type in the first instance, the system being speedily over- whelmed by the depressing influence of the morbific agent. The occurrence of typhoid symptoms early in an idiopathic, specific, or traumatic inflammation, always portends evil, as it is necessarily denotive of great and rapid waste of life-power, which neither medicine nor food can, perhaps, successfully counteract. The nervous system is deeply involved in the morbid process; the blood is gradually deprived of its plastic proper- ties; and, nutrition being at a stand, the body soon becomes pale, emaciated, and withered. The mind is early affected, and typhoraania is generally a prominent symptom throughout. The vital forces diminish more and more, the patient, engaged in constant muttering, picks at the bedclothes, has hic- cough and twitchings of the tendons, and is so weak as to be unable to sup- port himself upon his pillow. Exhaustion, in fact, is extreme, and a few hours generally suffice to close the scene. There is another form of fever which is often seen during the progress of inflammatory affections, and to which the term irritative has been not inaptly applied, as it is generally met with in persons of a nervous, irritable tempera- ment or habit of body. The best idea that can be given of it is that it bears the same relation to the nervous system that inflammatory fever, properly so termed, sustains to the vascular; that is, the fever is characterized in the one case by irritability, or excess of sensibility, and in the other by plethora, or redundancy of vascular action. We find, accordingly, that in irritative fever there is a lively perception of pain, and an unusual exaltation of sensibility, both of the part and system; the mind is peevish and fretful, easily dissatisfied, and often filled with despondency and unpleasant foreboding; the pulse is quick, jerking, small, and sometimes wiry; sleep is imperfect and disturbed by frightful dreams; the skin is hot, dry, and difficult of relaxation; the ex- tremities are inclined to be cold ; and there are frequently nervous rigors, followed by marked reaction, and great restlessness; severe suffering is gene- rally complained of in the loins and muscles; the slightest noise and light are a source of offence; and the head is distracted with severe pain, which often assumes a neuralgic character, and thus becomes a cause of great dis- tress. There are some low forms of inflammation in which the attendant fever nearly always assumes this peculiar type, being present almost from first to last. A good example of it is afforded in dissection-wounds, in certain in- juries of the skull and brain, in phagedenic ulceration, in hospital gangrene, in sloughing chancres and buboes, and in tertiary syphilis, in nervous debili- tated subjects. 3. CHANGES OF THE BLOOD IN INFLAMMATION. That the blood, which plays so important a part in the economy in health, should be seriously altered in its properties in inflammation is what mio-hti d priori, have been anticipated, and what observation has fully established to be a fact. Sent with increased force and rapidity through every portion of the body, however constituted, or however remote from the heart- sub- jected to new actions and new affinities in the suffering structures as if it were exposed to the heat of a laboratory, and deprived, in a great' degree of the stimulus of the oxygen of the air, it is not surprising that it should be almost totally changed in its physical, chemical, and vital properties. The CHANGES OF THE BLOOD IN INFLAMMATION. 77 most important alterations which the fluid experiences relate to the fibrin and colorless globules, the quantity and number of which are always materially increased in every well-marked case of inflammation. To form a proper estimate of the extent of these alterations it will be necessary to inquire, for a moment, into the relative quantity of these ingredients of the blood in the healthy state. In healthy blood the proportion of fibrin to the entire mass is as 3 to 1000; in inflammation, however, it is generally very much increased, ranging from 6 to 8, from 8 to 9, and from 9 even to 10^, according to the intensity of the disease and the general powers of the system. In what proportion the colorless globules are augmented in inflammation we are uninformed; that their number is materially increased is sufficiently obvious, but whether the change, in this respect, is as great as in the fibrin, is still undetermined. In addition to this increase in their number there is a manifest augmentation of their bulk, as well as of their cohesive properties, thereby greatly promoting their tendency to adhesion to each other and to the sides of the vessels, which, as will be seen by and by, forms so striking a phenomenon in well established inflammation. This excess of fibrin and white globules, which is generally observable at an early period of the inflammation, goes on gradually increasing until the morbid process has attained its maximum, when it begins to decline, and finally altogether disappears with the causes that induced it. Although it is most conspicuous in the higher grades of inflammation, there are few cases in which it is wholly absent, unless the disease be so slight as to be incapable of producing any serious structural changes, or material embarrassment in the force and rapidity of the circulation in the part and system. Gout and rheu- matism, pleuritis, pericarditis, pneumonia, hepatitis, splenitis, arteritis, and acute articular affections usually exhibit it in a marked degree. It is also present, but less conspicuously, in inflammation of the skin, cellular tissue, and mucous membranes. What is singular, it also exists in the blood in the latter months of utero-gestation. Where or how this excess of fibrin and colorless globules is developed is still a mooted question, which further observation alone can solve. It may be supposed, in the absence of satis- factory information, that it takes place in the arteries, in consequence of the manner in which the blood is agitated in passing through the different parts of the body, its various ingredients being forcibly pressed and rubbed against each other, and against the sides of the vessels by the increased powers of the heart. Thus a species of disintegration is brought about, which doubtless adds very greatly to the already existing excitement both of the part and of the system. The idea that attrition of the blood against the walls of the arteries is mainly instrumental in the production of the change in question derives support, of a very plausible, if not of a positively confirmatory cha- racter, from what is observed when a horse is subjected to severe exercise upon the turf. If he be bled after having been ridden very rapidly round the track, it will be found that there is a great increase of fibrin and colorless globules, in consequence, apparently, simply of the increased momentum of the circulation, and the friction which the blood has experienced in its passage through the vessels, especially the arteries. Now this is precisely what occurs in inflammation ; the greater the excitement of the heart, or, what is the same thing, the more intense the morbid action, the greater will be the amount of fibrin and white globules, and the reverse. This increase of fibrin and white globules is attended with inordinate con- traction of the crassamentum, and a separation of the red particles, leading to the formation of what is called the buffy coat of the blood. This consists in the appearance of a whitish, bluish, or tallow-like pellicle, upon the top of the crassamentum, which begins to show itself the moment the blood com- 78 INFLAMMATION. mences to coagulate, and attains its greatest height after the process of con- solidation has been completed. Its thickness and density are greatly in- fluenced by internal and extrinsic circumstances as the state of the system, the intensity of the disease, and the manner in which the blood is drawn In some instances it is a mere film, while in others it forms a layer several lines in thickness; its density is also subject to considerable diversi y, being at one time very feeble, and at another very firm, so much so, indeed, as to offer a good deal of resistance to the finger. When the blood is much impoverished by protracted disease, long abstinence, or unwholesome food, the butty coat is generally very thin, soft, dirty, and iridescent, forming a striking contrast with the characters which it exhibits in plethoric states of the system. Various extraneous circumstances materially influence the formation of the buffy coat. Of these the most important, in a practical point of view, are the shape and capacity of the receiver, the size of the stream, and the motion to which the blood is subjected in its passage from the vein. It has been ascertained that the phenomenon is most readily produced when the fluid falls into a deep and rather narrow vessel, and when it issues from a large orifice, at the rate of from two to three ounces in the minute. If the blood runs very slowly, or in a tiny stream, or, if the stream, although quite bold, is received into a cold or shallow basin, it will either not form at all, or so very imperfectly as to be scarcely appreciable. Sometimes the blood is merely sizy, the fibrin resting upon the top of the cruor like a bluish and im- perfectly developed film. Chemically considered, the buffy coat is found to consist essentially of fibrin, in combination with albumen and earthy salts. In fact, it is perfectly identical with the plastic matter that is deposited in inflammation upon the free surfaces and in the interstices of the organs. By a little care it may easily be detached from the upper surface of the crassamentum ; and, if it be well washed in cold water and then immersed in alcohol, it will assume not only the peculiar buff-colored aspect, whence it derives its name, but also a dense, firm consistence, the two properties assimilating it rather closely in its physical characters to the substance of the unimpregnated uterus. * Of the manner in which the buffy coat is formed we are unable to offer any very satisfactory explanation. It was formerly supposed that it was owing to the more tardy coagulation of the blood, thereby permitting the red par- ticles to disengage themselves from the fibrin and to sink, by their greater specific gravity, to the bottom of the crassamen- tum. But this was evidently a mistake; for it is now well ascertained that inflammatory blood, instead of solidifying more slowly than healthy blood, generally concretes very rapidly and firmly, thus impeding instead of favoring the develop- ment of the buffy coat. The most recent opinion upon the subject is that the occurrence is due to a vital repulsion between the fibrin and red par- ticles ; or, what amounts essentially to the same thing, to an unnatural aggregation of these bodies, which, acting like a sponge, force out the fibrin from among them before the general mass of the blood is fully coagulated. Whether this expla- nation is correct or not, it is certain that the for- mation cannot occur at all without a previous Microscopic diagram, showingthe disunion of the prillcipal constituents of the fluid reticulated arrangement of the cor- .11 v • .1 , ° ul luc uumi pusdes in inflammatory blood, in thereby predisposing them to the event in ques- the upper pan, normal ordinary tion. 1° ascertain whether this tendency to the aggregation is shown in contrast, development of the buffy coat exists it is not INTIMATE NATURE OF INFLAMMATION. 79 necessary to make use of a spoliative bleeding, but simply to draw a few drops of blood, and to look at it with the microscope, which will at once detect the slightest deviation from the normal standard. The red corpuscles will be observed to run almost immediately into clusters of piles or rouleaux, as represented in fig. 1. In certain forms of inflammation and conditions of the system the blood is not only buffed, but cupped; that is, the upper surface of the crassamentum exhibits a hollow appearance, as if it had been scooped out with a knife. This occurrence usually denotes a higher degree of morbid action than the mere presence of naked fibrin on the top of the clot, and yet it is not unfrequently witnessed under cir- cumstances which render it very questionable whether there is any inflammation at all, as in anemia, in profuse evacuations from the bowels, skin, and kidneys, in scurvy, and in chlorosis. It is generally not easy to account for such anomalies, but of their practical import every prac- titioner must be fully aware. In my private collection is a beautiful speci- men, which I obtained many years ago from bleeding a young man laboring under pleuro-pneumonia, in which both the buffed and cupped appearances exist in a marked de- gree on both surfaces of the crassamentum, affords a good illustration of the preparation Buffy and cupped blood, from a preparation in the author's collection. The adjoining sketch, fig. 2, 4. INTIMATE NATURE OF INFLAMMATION. In the definition of inflammation, given in the early part of this chapter, no attempt was made to specify its true character or essential nature. To have done so would have been premature; but now that we have studied its various local phenomena and traced its constitutional effects, we are fully prepared to enter upon the subject, and to ask the question, What is inflam- mation ? To answer this question in an intelligible and satisfactory manner, it is necessary to consider, 1st, the nature of the capillary vessels, in which the morbid action is mainly carried on ; 2dly, the character of the blood, which, as already seen, is so singularly changed in this affection; 3dly, the part played by the nervous system, or, perhaps, more properly speaking, by the nerves of the affected structures; and 4thly, the condition of the tissues at the seat of the disease. The capillaries are those minute canals which are everywhere interposed between the arteries and veins, of which, in fact, they are only so many con- tinuations. That their structure is similar to these vessels is analogically extremely probable, although it is doubtless somewhat modified to enable them to fulfil their various duties, since they are not merely designed as chan- nels for the transmission of the blood, but also as organs for the elaboration of various kinds of fluids, as those of nutrition and secretion. With regard to their caliber, these vessels are divisible into two classes. The one em- braces those minute tubules which, though invisible to the naked eye, are 80 INFLAMMATION. found, when microscopically examined, to be capable of carrying a continuous stream of blood, so as to give the part in which they are situated a red appear- ance. The other group includes those delicate vessels, the cavity of which is so small as to admit only a single globule at a time, and which it is often difficult to detect even with a strong magnifier. The blood, as it circulates through the body, and immediately after it has been drawn from a vein of the arm, has the appearance of a homogeneous fluid; but a careful examination shows it to consist of numerous component elements, intended for widely different purposes in the economy. Coagula- tion separates it into two parts, one of which is solid, and hence called the crassamentum ; the other is fluid, and named the serum. The crassamentum consists of a pale, whitish, transparent fluid, known as the blood-liquor, plastic matter, plasma, or coagulating lymph, and of minute particles, globules, or corpuscles, entangled in it and suspended by it as the blood is passing the round of the circulation. The particles are of two kinds, the red and the colorless; the former, which have long been familiar to anatomists, and which impart to the crassamentum its red hue, are exceedingly abundant, and vary in size from the s^Vir to the -5^-5 of an inch in diameter; they are of a flattened, globular shape, and their office seems to be to absorb oxygen from the atmosphere and to convey it to the different parts of the system, for the purpose of invigorating its several organs and tissues. The colorless or pale corpuscles have only been recently discovered ; their number is very limited, except in certain forms of disease, when it is much increased; they are round, much larger than the red, and finely granulated on the surface, thus giving them a rough appearance. What the precise office of the white corpuscles is has not been determined, but it seems probable that it is connected, in some way, with the process of nutrition, which is also the case, only more certainly, with the blood-liquor, which is essentially associated with this operation. In the vessels of the living body, the white globules seem to have no dis- position to mingle with the red; on the contrary, they keep in close contact with the inner surface of the vessels, coasting, as it were, slowly along in the blood-liquor, outside of the general current. The red particles, on the other hand, pass quietly and gently along the centre of the vessels, regardless, so to speak, of the colorless, and in a much more rapid and lively manner, with- out any adhesion to each other, to the white particles, or to the coats of the containing vessels. The essential elements of the inflammatory process, so far as we are able to comprehend them, are, 1st, slight contraction of the capillaries, with a retardation of the flow of blood; 2dly, dilatation of these vessels and an in- creased rapidity of the circulation ; and, 3dly, a quiescent state of the capil- laries with complete stagnation of their contents. While these changes are going on in the interior of these vessels, important changes are wrought in the blood, both in regard to its consistence, its color, the arrangement°of its globules, and the character of the plasma. Finally, the coats of the vessels are themselves seriously altered, being rendered preternaturally soft and fragile, and therefore temporarily incapable of transmitting the vital fluid These various changes are so important as to demand for each separate consideration. ^ If a drop of rectified spirits, or any slight stimulus, be applied to a capil- lary vessel in the web of a frog's foot, or the wing of a bat, the effect will be to cause slight contraction of its caliber, with a partial arrest of its contents the particles of blood moving to and fro for a few seconds, when they will be observed to regain their proper course, and to pass on as if nothing had oc- curred. If the irritation be more severe, as when a drop of tincture of capsicum is applied, the vessel, instead of diminishing, is instantly dilated INTIMATE NATURE OF INFLAMMATION. 81 or, if there be any contraction, it is so slight and transient as to be inappre- ciable by the sight. However this may be, the dilatation soon becomes marked and decided, as is proved by the fact that the vessel now carries a much larger quantity of blood than in the natural state, the red particles being sent into it in increased numbers, as well as with increased force and velocity, evidently in consonance with the augmented action of the heart, which, beating perhaps from ninety to one hundred and ten in the minute, throws the blood with extraordinary impetus into the inflamed part. The disease advancing, the dilatation of the vessels steadily and regularly augments, until, at length, its tunics having been expanded to their utmost, the artery becomes a mere passive tube, palsied and crippled in its action, and therefore not only incapacitated for transmitting its contents, but for per- forming any of its more delicate functions as an organ of nutrition and secre- tion. In the condition now described, the capillary is not only distended to its utmost, but it is distinctly elongated and tortuous, sometimes almost knotty, as if it were affected with aneurismal enlargements, or real varices. Its coats are also preternaturally soft and lacerable, from intermolecular changes in their structure. The blood, which is the immediate cause of this dilatation, is literally im- pacted in the vessel, pressing everywhere upon its sides, and thus causing, by degrees, complete remora, or stagnation. The white and red particles, in- stead of pursuing an orderly, quiet, and independent course, as in the natural state, are now observed to be more or less intermixed; and such is the man- ner in which they are crowded together, that both are materially changed in their shape, being irregularly flattened, elongated, and distorted, as well as adherent to each other and to the sides of the vessel. When there is com- plete stoppage, the distinction between the two sets of globules is entirely lost, the blood forming a stagnant pool, of a dark, homogeneous aspect. These various changes, which are brought about gradually, not suddenly, may be studied with great advantage in what occurs in inflammation of the conjunctiva. If this membrane be irritated, as, for example, by the contact of a foreign body, there will be an immediate rush of blood to the part, thus causing a great seeming increase of its vascularity. In a few minutes hun- dreds of vessels, previously invisible, will be seen shooting out in different directions, and connecting themselves with the sides of those that appeared in the first instance. These are not new channels, but old ones appertaining to the second class of capillaries, rendered evident by the intromission of red particles, which, in the healthy state, pass along in so slow and gradual a manner as to elude detection. It is not to be supposed that the globules of the blood, as they are sent by the heart into the irritated arteries, are able, all at once, to pass through them without any difficulty. Instead of this, after having proceeded a certain dis- tance, they rebound against themselves and the sides of the vessels, so as to undergo a kind of oscillatory movement; but, gradually yielding to the force exerted upon them from behind, they are urged onward and onward until they reach the corresponding veins, into which, as their caliber is much larger than that of the arteries, they rush as into a vortex, and instantly disappear in the current beyond. A similar oscillatory movement of the globules of the blood is observed when the circulation is about to be re-established after it has been completely arrested. Some time is required for the detachment of these bodies, and when they have finally succeeded in effecting this, instead of passing on at once into the corresponding vein, they are propelled forward and backward until the diseased arteries have become sufficiently dilated to admit of their escape. The dilated condition of the vessels is wrell seen in the accompanying cuts, vol. i.—6 82 INFLAMMATION. representing the two ears of a rabbit, one in the natural state, and the other in a state of inflammation, from the application of cold. They were injected simultaneously, and consequently with the same degree of force, with size colored with vermilion. Fig. 3 is the natural ear; fig. 4, the inflamed one. The vessels of the latter are not only much_ larger and more tortuous than in the The contrast is striking. Fis. 3. Natural ear of a rabbit. Inflamed ear of a rabbit. former, but also apparently much more numerous ; the main artery in the one is likewise greatly increased in size, while in the other, namely, the natural one, it is quite small. But it requires no experiments upon the inferior animals to prove the existence of increased vascu- larity in inflammation ; the remark- able change in the color of the part is sufficient evidence of the fact, to say nothing of the circumstance that, if an incision be made into it, the blood will gush out in much larger quantity than from a similar cut in the corresponding healthy structure. When the morbid action is fully established and very intense, with- out, however, there being as yet complete cessation of the circulation, the contents of the affected vessels not unfrequently break through their softened and lacerable walls, occasioning thus a real extravasa- tion of blood, as seen in fig. 5, representing a magnified portion of inflamed serous membrane. Sometimes, again, although rarely, the blood escapes from the vessels, and, forcing its way through the cellular tissue, forms new channels, through which it afterwards con- tinues to circulate. Immediately around the seat of the great- est intensity of the morbid action, marked congestion exists, and the blood, conse- quently, passes along very slowly, and with difficulty. Beyond this point the pheno- mena are somewhat different; the excite- ment is less considerable, but still sufficient to cause active vascular determination ; the blood moves in a continuous stream, and with extreme velocity, but unable, as it ap- proaches the focus of the inflammation, to make its way through the stagnant tubes, it is sent onward through collateral chan- nels, now for the first time fairly opened for its reception. Thus it will be seen that, while at the centre of the morbid action stagnation occurs, and around this a sluggish circulation prevails, an increased activity is goin'"- on in its neighborhood. The arteries leading to the affected part are distended, and pulsate strongly, but not, as some have asserted, with preternatural fre- quency. Extravasated blood in an inflamed serous membrane. INTIMATE NATURE OF INFLAMMATION. 83 The changes produced in inflammation are admirably depicted in fig. 6, from Bennett, representing a portion of the web in the foot of a young frog, Fig. 6. a b d after having been irritated by a drop of strong alcohol; it is magnified two hundred diameters, and exhibits a deep-seated artery and vein, somewhat out of focus, with capillaries running over them, the whole being interspersed with pigment cells. On the left of the figure the circulation is in its normal state; at the centre it is retarded, the vessels are crowded with corpuscles, and the column of blood is oscillating; on the right there is deep congestion, with exudation : a represents the vein, occupied by dark blood, moving more slowly than in the artery, and running in the opposite direction ; the lymph space on each side is filled with yellowish plasma, and contains a number of colorless corpuscles, some clinging to the sides of the vein, others moving tardily along; b represents the artery, with a rapid current, per- mitting nothing to be seen but a reddish-yellow broad streak, with lighter spaces at the sides. Opposite c, a vessel has given way, and caused an extravasation of blood, resembling a brownish-red pool. At d, there is complete congestion; the corpuscles are closely adherent to each other and to the sides of the vessels, which they entirely fill, being one semi-transparent reddish mass. The intervascular spaces are abnormally thick and opaque, and occupied by exudation. The part played by the nerves in inflammation is very imperfectly under- stood. It is evident, however, that it is very important, although we are unable to define its character, or specify its degree. In traumatic inflamma- tion, as well as in many cases of the idiopathic form of the malady, the primary impression is probably nearly always made upon the nerves, from which it is immediately reflected upon the capillary vessels, inducing, at first, contraction, and then dilatation, of their caliber, with a preternatural influx of blood, and, finally, an increase of color. The sensibility of the part being awakened, the heart is instantly roused into action, followed by serious dis- turbance of the circulation at the seat of the morbific impression, as if nature were making an effort to shake off the cause of the disease. It is this occur- rence that generally gives the patient the first intimation of the impending mischief; the nerves, resenting the encroachment, apprise the brain, or cerebro-spinal axis, of the attack, and the consequence is that the heart, acting with unusual vigor, throws an undue quantity of blood into the suffer- ing structures. If this explanation be correct, it follows, almost as a neces- 84 INFLAMMATION. sary sequence, that inflammation, instead of being, as has sometimes been imagined, a process of perverted nutrition, is in reality merely an attempt on the part of the affected tissues to rid themselves of some hurtful impres- sion. All the rest of the process is easily understood ; the discoloration, swelling, pain, heat, and disordered function, being merely so many links in the chain of morbid action. As the inflammation increases in intensity, the nerves actively participate in the morbid process, their substance becoming injected, softened, com- pressed, and otherwise altered, in conformity with the peculiarity of their structure and function. The effect of such a change upon the welfare of the affected textures must be extremely pernicious, as it must materially diminish the nervous current, if not entirely arrest it, and thus weaken and prostrate the vital powers of the part. The joint agency of the nervous and vascular systems, in the production and maintenance of inflammation, has been happily illustrated by the re- searches of modern physiologists. It has been ascertained, for example, that, when the ophthalmic branch of the fifth pair of nerves is divided in the cranial cavity of a rabbit at the Varolian bridge, inflammation is speedily lighted up in the surface of the eye, eventuating in opacity of the upper segment of the cornea. What is still more remarkable is, that, when the nerve is cut on the petrous portion of the temporal bone, so as to involve the ganglion of Gasser, the resulting irritation is not only more violent, but much more deeply seated and deplorable, the consequence being complete disorganization of the organ. Analogous effects follow the division of the pneumogastric nerves. When these cords are cut high up in the neck, the lining membrane of the air- passage assumes a dark color, the lungs are engorged with black blood, and an abundance of serosity is poured out into the parenchymatous texture, as well as into the pulmonary vesicles and the minute branches of the bronchia?. The pleura generally participates in the irritation, and there is almost always more or less inflammation of the stomach, with a suspension of the secretion of the gastric juice. Animals in which the brachial plexus of nerves has been tied are soon seized with inflammation of the integuments of the remote parts of the limb, which gradually progresses until all the soft structures are invaded by gan- grene. A friend of mine removed a section of the peroneal nerve on account of a neuroma; the wound was long in healing, and two of the small toes sloughed before the patient recovered. These facts enable us to explain cer- tain circumstances that have long been noticed by practitioners in particular morbid states of the system. A part affected, for instance, with palsy is much less capable of withstanding the ordinary impressions of physical agents than one receiving its customary supply of nervous influence. A burn°in a paralytic person creates much more serious mischief than in one that enjoys perfect health ; and the same is true in regard to blisters and other irritants the injudicious application of which often leads to the destruction of lar"-e portions of the skin and subjacent cellular tissue. There is little doubt that the inflammation of the bladder, which always supervenes upon serious injury of the spinal marrow, is caused in the same way ; that is, by the interruption of the natural supply of the nervous influence. In whatever manner parts are deprived of their nervous influence it is pre- sumable that they are brought under relations somewhat analogous to those of a frozen limb. The temperature is lowered, the sensibility impaired the process of nutrition perverted; in a word, the natural connection between the vessels and nerves is broken up, and hence that series of phenomena known under the name of inflammation. The tissues at the seat of the inflammation, considered apart from the ves- INTIMATE NATURE OF INFLAMMATION. 85 sels and nerves which are distributed through them, and which, as has been seen, play such an important part in the morbid process, are variously altered, becoming not only the recipients of various deposits, but experiencing, espe- cially in the advanced stages of the disease, marked softening, and sometimes also fatty degeneration, the latter being more particularly liable to occur when the morbid action is tardy, and rather below the ordinary acute stand- ard. The principal deposits are serum and lymph, either alone or in union with pus and blood. When these products are very abundant, there will necessarily be much swelling, and the consistence of the parts will be soft or hard, according to the structure of the affected tissues and the nature of the effusions. A careful study of the inflammatory process leads to the conviction that, in its earlier stages, it is one of increased action, both of the capillary vessels and of the tissues through which these vessels pass, and of which, conse- quently, they form a most important integral part. Microscopical and clini- cal observations clearly prove the truth of this statement. Subsequently, however, when the disease is fully established, when the vessels are crowded to excess with blood, and when this fluid manifests a tendency to stagnation, or when stagnation has actually occurred, there is every evidence of decided debility. The capillaries are now partially paralyzed, and distended to the utmost with non-oxygenated blood; the different tissues are surcharged with inflammatory products; nutrition, secretion, and absorption, are interrupted, or completely suspended ; in short, everything is indicative of enfeeblement and prostration. Moreover, the tissues involved in the inflammatory process soon evince a disposition to become disorganized, and to undergo the fatty degeneration, especially if they are loaded with plastic deposits. The earliest indications of these changes are the confused appearance of the affected structures when viewed with the microscope, and the presence of minute globules of oil scat- tered through their substance. If the fibrinous matter is spoiled, or trans- formed into pus, the quantity of oil greatly increases, and the tissues acted upon by the absorbents and by chemical influences are liquefied and de- stroyed. If, on the other hand, it becomes organized, the parts are in danger of falling into a state of atrophy, being partially robbed of their nourishment, and choked as vegetables are choked by weeds. Much discrepancy exists among writers and teachers in regard to what constitutes inflammation ; some, among whom I include myself, believing that but a slight degree of action is necessary, while others maintain that the departure from the healthy standard must be very great. Thus, Dr. Miller, Professor of Surgery in the University of Edinburgh, declares that true inflammation, properly so called, is always attended with suppuration ; apparently forgetting that thousands of human beings daily die from this affection, long before it has attained this crisis. Dr. John H. Bennet, another eminent Scotch professor, makes fibrinous exudation the indispensable condition of the process; and he goes so far even as to propose the word exudation as a substitute for that of inflammation. For myself, I cannot see that such a change of nomenclature would have any other effect than that of confusing the mind of the student; the term is ill chosen, and cannot, therefore, advantageously replace one which, although merely conventional, is yet sufficiently expressive for practical purposes. But there is still a more serious objection to the adoption of this word, and that is, that it does not convey a correct idea of the nature and extent of the morbid process. Dr. Bennet, and those who think and reason with him on the subject, must be aware that there are inflammations of certain organs and tissues in which the morbid action is so great as to destroy life, and yet the most careful exa- mination, microscopical and chemical, fails to detect the existence of fibrin S6 INFLAMMATION. in the affected structures. It is only necessary to instance the arachnoid membrane, the aponeuroses, cartilages, and nerves, in which this disease is often, if not generally, unattended by a deposition of fibrin. But while it is certain that inflammation is frequently present, and that, too, to a serious extent, without fibrinous exudation, it is equally true that this substance is usually poured out in this disease, especially if it has already made consi- derable progress. Much will necessarily depend upon the nature of the affected organs and tissues, some furnishing plasma much more readily, and in much greater quantity, than others. Moreover, it requires very nice judg- ment, particularly in the living subject, to define the boundaries between con- gestion and inflammation, or to determine where the one terminates and the other begins. Inflammation, in its inceptive stages, may be compared to a latent or smothered fire, kept in abeyance by a redundancy of surrounding material interfering with its development; exudation cannot occur all at once, some time is necessary to prepare the vessels for their new office; so it is with the flame in the furnace, it does not break forth immediately on the application of the kindling, and yet no one would say that fire was not actually present. Most of the disputes that have grown out of this question have arisen from a misunderstanding on the part of observers as to the amount of disease, or change in the affected part, necessary to constitute inflamma- tion ; and it is obvious that there never can be any fixed or settled views upon the subject so long as this is the case; nor can the question be satis- factorily disposed of, unless it be studied with reference to the nature and functions of the different organs and tissues of the body; or, if I may use the expression, the conduct and habits of the organs and tissues in their healthy and morbid relations. Another source of difficulty, in the settlement of this question, is the fact that many pathologists are seemingly incapable of divesting themselves of the idea that inflammation must necessarily be treated by depletion, particu- larly by the lancet and leeches, purgatives and starvation. It is apparently impossible for them to disconnect the two things, and yet it requires but little reflection, and certainly no great amount of experience to showr the errone- ousness of such a conclusion. Cases of inflammation are daily met with which imperatively demand the use of stimulants from their very commence- ment ; and it is not going too far to assert that there is a period in almost every attack of the disease, if at all severe, in which the patient will be greatly benefited by the use of brandy, wine, quinine, and nutritious food. Professor Virchow, of Berlin, whose cellular pathology is now attracting so much attention, asserts that inflammation is not a real entity, or a process everywhere identical in its character, as has been so often alleged, but a process essentially similar to other morbid actions, differing, in fact, from them only in its form and course. He believes that irritation is to be considered as the starting-point in inflammation ; for it is impossible, he remarks, to conceive of such an occurrence without the application or intervention of some hurtful stimulus. The principal sources of this irritation are three__ the functional, nutritive, and formative—the first playing, as he imagines, the least important part in the process. "If, therefore," to use Virchow's own language, "we speak of an inflam- matory stimulus, we cannot properly intend to attach any other meaning to it than that, in consequence of some cause or other external to the part which falls into a state of irritation, and acting upon it either directly, or through the medium of the blood, the composition and constitution of this part undergo alterations which at the same time change its relations to the neighboring structures, whatever may be their nature, and enable it to attract to itself and absorb from them a larger quantity of matter than usual and to transform it according to circumstances. Every form of inflammation with which we are TREATMENT OF INFLAMMATION. 87 acquainted may be naturally explained in this way. With regard to every one, it may be assumed that it begins as an inflammation from the moment that this increased absorption of matter into the tissue takes place, and the further transformation of these substances commences." Virchow discards the idea that hyperaemia, or vascular turgescence, is pre- sent at the commencement of inflammation, alleging that, in certain parts, as the cornea, the cartilages and tendons, in which no vessels exist, the changes produced by this morbid process are in no respect different from those in the vascular structures. He also, as will be seen by and by, asserts that fibrin is not a transudation from the blood-liquor, but a direct product of the inflamed structures brought about by a change in their condition, and by the local metamorphosis of matter. 5. TREATMENT OF INFLAMMATION. Two leading indications present themselves in every case of inflammation when sufficiently grave to demand interference. The first is the removal of the exciting cause of the disease ; the second, the establishment of resolu- tion. In regard to the first of these points, it is obvious that, although the dis- ease may be modified in its character, or rendered comparatively harmless, by treatment, yet it will be impossible to arrest it completely so long as the exciting cause is operative. Thus, for example, in strangulation of the bowels, it would be folly to expect to establish resolution of the inflammation which the strangulation has produced, without the removal of the stricture which is the cause of the morbid action. In such a case, one of two things must happen ; either the sufferer must die from the effects of the disease, or he must be relieved by the knife, or by nature's operation, that is, the forma- tion of an artificial anus. An inflammation of the lungs from the presence of a foreign body in the air-passages cannot be effectually cured so long as the foreign body remains, and keeps up the morbid action. The same thing is true in relation to inflammation of the bladder from hypertrophy of the prostate gland. The gland, acting obstructingly to the flow of urine, is the cause of the cystitis, and just so long as the cause remains will the disease continue, although, as remarked above, it may be materially modified by our therapeutic measures. But it does not follow, on the other hand, that the inflammation shall at once subside because the cause which produced it has been removed. The malady may have already made so much progress as to render the restoration of the part either impracticable, or possible only after a long time and after much suffering. In our attempts to get rid of the ex- citing cause by mechanical means, it is hardly possible to exercise too much care and gentleness, or to institute them too early. All officious interference, rude probing, or rough manipulation, must be carefully avoided, lest we add, as it were, fuel to the flame, aggravating and perpetuating the disease. Splinters, nails, needles, pieces of bone, are gently extracted with the finger and forceps; the calculus is cut out of the bladder ; the speck of steel is picked from the cornea; and the aching tooth is lifted from its socket; all in as gentle and easy a manner as possible. It is not always, however, that the exciting cause of the malady can be detected, even if we avail ourselves of all the lights furnished us by modern research. Very frequently the cause is latent, the morbid action having, to use a very common but unphilosophical expression, arisen spontaneously. Such an occurrence is, of course, impossible; there is always a cause for every disease, though it is not always in our power to discover it; and hence to wait for its removal before we begin our treatment might sadly endanger both part and patient. 88 INFLAMMATION. The second indication is to establish resolution or to disperse the morbid action, with the least possible detriment to the structures and functions of the diseased parts. To effect this, various remedies may be necessary, some being addressed to the general system, others directly to the affected parts: cir- cumstances which have given rise to the division of the treatment of inflam- mation into constitutional and local. I. Constitutional Treatment.—The constitutional treatment of inflam- mation consists of bloodletting, cathartics, emetics, depressants, mercurials, diaphoretics, diuretics, anodynes, and the antiphlogistic regimen. It must not be supposed, however, that all these means, or even a majority of them, are necessary in every case of this disease ; so far from this being true, the morbid action often disappears spontaneously, or under the mildest and sim- plest remedies. Whenever constitutional treatment is demanded, it should be employed as early as possible, and with a determined hand, in the hope of being able to arrest the inflammation while it is yet in its inception, and, consequently, before it has made any serious inroad upon the part and sys- tem. A few doses of medicine, judiciously administered at the outbreak of the disease, often do more good than twenty administered after it has attained its full development. 1. Bleeding.—General bleeding may justly be regarded as standing at the very head of the list of the constitutional remedies for inflammation, as it is at once the most speedy and the most efficient means of relief. The blood is usually drawn from one of the larger veins, and is permitted to flow until a decided impression has been made upon the system. When we consider the singular changes which this fluid undergoes in inflammation, the fact that it is sent in an unusually large quantity to the affected parts, and the cir- cumstance that it is mainly instrumental in supporting the powers of the heart, it will not be difficult to form a correct idea of the importance of this operation, or the influence which it exerts in combating morbid action. Its value was not over-estimated by the older writers when they designated it as the summum remedium in the treatment of inflammation ; yet, strange to say, bloodletting, notwithstanding the high rank which it has always occu- pied, as an antiphlogistic agent, has, of late, fallen very much into disrepute, particularly on this side of the Atlantic, where it had at one time so many advocates. A great change has come over the profession, in this respect, within the last fifteen years, and is steadily gaining ground, subverting all' our preconceived notions upon the subject, and rendering it very question- able, in the opinion of many, whether bloodletting is really ever required as an antiphlogistic. Whether this change has been the result of a modification of the type of disease, of a more improved method of treatment with other remedies, or simply of the whim and caprice of a few prominent and influen- tial practitioners, from whom the rest of the profession have imbibed their views, I am unable to assert, but the fact does not admit of a doubt that more quarts of blood were formerly spilt than ounces are spilt now Bleeding- is no longer the fashion ; the operation is denounced by every one Public sentiment has got to an extreme upon the subject, and we may therefore soon look for a reaction in favor of the opposite opinion. For myself I cannot but regret this state of things, because I feel satisfied that it does not rest upon a just and proper basis. If we formerly bled too much too fre quently, too copiously, and too indiscriminately, it is equally certain at least to my mind, that the operation is not often enough resorted to at the present day. Many a deformed limb, blind eye, enlarged spleen, and crippled lung bear testimony, in every community, to the justice of this remark General bleeding is employed with different views. In the first place it CONSTITUTIONAL treatment. 89 diminishes plethora; secondly, it changes the qualities of the blood, or, more correctly speaking, it places it in a better condition for resisting the effects of inflammation ; thirdly, it weakens the powers of the heart and nervous system, and, consequently, the momentum of the circulation ; and, lastly, it promotes the action of other remedies. To obtain these effects in the most prompt and thorough manner, the blood should be taken from a large orifice in a large vein, the fluid running in a bold, full stream to the amount of at least three ounces in the minute, the patient being either seated upon a chair or standing up at the time. If the operation is performed while the patient is recumbent, a much larger quan- tity will be required to be drawn before the system and part become sensible of the loss. When the object of the bleeding is merely spoliative, or in- tended to rob the vessels of an unusual amount of their contents, it may be done in this way; but even then the better plan will be to bleed in the semi-erect position, reopening the vein a second and even a third time, if premature syncope should take place to interfere with the requisite abstraction. The difference in the effect of these two methods of bleeding is forcibly exempli- fied in conjunctivitis. The patient who is bled in the erect position soon begins to feel faint, and to experience relief from pain, the eye at the same time exhibiting a blanched appearance, instead of the scarlet hue which it had a moment before ; whereas the one who is bled in the recumbent position will retain his strength for a much longer time, and when, at length, he is rendered unconscious, the inflamed surface will be found to be still compara- tively discolored. The impression, moreover, will generally be much more permanent in the former than in the latter, and the return, consequently, of the capillary injection more slow and less perfect. The circumstances which call for this operation are generally considered to be a hard, strong, full, and frequent pulse, a plethoric state of the system, and great intensity of morbid action. When such a conjunction exists, the surgeon cannot possibly go amiss in regard to the abstraction of blood, consti- tutionally considered. He may, perhaps, it is true, combat the disease with- out such recourse ; by the use of antimony, purgatives, and other means, he may gradually bring down inordinate excitement, and thus afford the affected structures an opportunity of throwing off the burden with which they are oppressed; but if he wishes to make a prompt and decided impression, spo- liative and depressive, upon the system and part, he can accomplish his ob- ject much more readily and effectually with the lancet than with any other remedy in the whole catalogue of antiphlogistics. If nauseants depress the heart's action equally with the lancet, they certainly do not produce the same effect in unloading the engorged capillaries at the seat of the inflammation, in restoring the circulation, and in reclaiming morbid structure. The ope- ration of the one is gradual, and, at times, almost imperceptible; of the other, prompt and decisive, often cutting down the disease with a single blow; or, at all events, leaving it in a condition to be afterwards easily dealt with by other and more simple means. When bleeding is required, the earlier it is performed the better. Ten ounces of blood taken at the beginning of an attack of inflammation will usually do more good than four times that quantity drawn after the disease is firmly rooted. Indeed, when a part is once overburdened with deposits, the salutary period for general bleeding may be considered as passed; for, although the operation may aid in reducing the force of the heart, and in promoting the action of other remedies, yet it certainly does not exercise the same happy influence upon the capillary vessels at the seat of the disease. The quantity of blood drawn at a single operation must vary according to circumstances, the object being effect, and not ounces ; for what would be a large bleeding for one person might be a small one for another. From 90 INFLAMMATION. sixteen to twenty ounces is a good average loss. Some individuals faint almost as soon as the blood begins to flow, while others can scarcely be made to faint, no matter how they are bled, or how much blood is drawn. Ihe best plan, therefore, always is to continue the operation until it has made a decided impression both upon the nervous and vascular systems, avoiding actual syncope, but inviting an approach to it, and then guarding against the danger of excessive reaction. We now and then hear of enormous quantities of blood being removed for the cure of inflammation. The memoirs of the French Academy furnish us with instances where three hundred ounces were abstracted within a week; and equally remarkable examples are recorded among British writers. The late Dr. Francis, of New York, while laboring under a violent attack of * croup and tonsillitis, was bled to the extent of nearly two gallons and a half in a few days. Such cases are remarkable as showing the wonderful power of endurance of the system, but they are not to be held up as examples for the imitation of the practitioner. It must be understood, however, that inflammation often engenders a tolerance of bleeding. Thus, a nervous person who in the healthy state will faint from the loss of a few ounces of blood, will, when laboring under severe inflammation, bear with impunity the loss of perhaps ten times that amount. A similar tolerance of remedies is frequently established by disease. In delirium tremens, opium may be given in doses that would destroy half a dozen healthy persons; in pneu- monia, the stomach acquires an extraordinary degree of tolerance for tartar emetic; and in certain forms of syphilis mercury may be given in large quan- tities without salivation, the system being seemingly insusceptible of its in- fluence. The first effect of a loss of blood upon the system is a sense of muscular debility. Presently, the individual begins to look pale, to see indistinctly, to have a confusion of ideas, to perceive noises in his ears, and to feel light in the head. If the flow be not immediately stopped, he will next become deadly sick at the stomach, convulsive tremors will pervade his limbs, the pallor of the countenance will increase to a deadly white, the respiration and pulse will nearly cease, and, if he is not supported, he will fall down in a state of unconsciousness. He has fainted. Such an effect is sometimes pro- duced by the loss of a drachm of blood ; at other times not until many ounces have been drawn. To recover a person from this condition, he must be immediately placed in the recumbent position, cold water dashed upon the face, and a free access of air obtained by throwing open the doors and windows of the apartment, aided, if necessary, by the fan. If he is slow in regaining his consciousness, the body is raised a little higher than the head, hartshorn is held near, not to, the nose, and sinapisms are applied to the extremities and the precordial region. Sometimes a draught of cold water will do more in reviving the patient than anything else. If, from idiosyncrasy or excessive loss of blood, the syncope assumes an alarming character, a stimulating enema is used, and mustard applied along the spine ; but no stimulants are given by the mouth, unless it is certain that there is still some power of deglutition. The reaction which succeeds the stage of depression is characterized by a gradual return of the various functions of the body to their natural condition. Color reappears upon the cheeks, the heart and lungs act with more energy, the limbs regain their warmth, the surface often becomes slightly moist and the mind recovers from its confusion. The only treatment necessary, during this stage, is proper vigilance, lest the reaction should become too vigorous- depression being rather favored, when the morbid action is at all severe than rapidly relieved. When the loss of blood has been disproportionably great to the powers of CONSTITUTIONAL TREATMENT. 91 the system, the stage of depression may be succeeded by death, or reaction may at length occur, the struggle for many hours, perhaps, being one of life and death. This state may be induced by one copious bleeding, or by several small ones, establishing an undue drain upon the vital current. It is charac- terized by unusual pallor of the countenance, feeble pulse and respiration, coldness of the extremities, clammy perspiration, frequent sighing, great thirst and restlessness, vigilance, and a tendency to delirium. While the system, is in this condition, local congestion, followed by inflammation, is not uncommon, the organs which are most prone to suffer being the brain, the arachnoid membrane, and the lungs. Sometimes the symptoms here described are mixed up with those of feeble reaction, and the countenance, perhaps, is flushed, the eye and ear are intolerant of light and noise, the respiration is quickened, the skin is hot and dry, and the pulse is thready, hard, and fre- quent. The proper treatment does not vary essentially in the two cases, our main reliance being upon opiates in full doses, milk punch, ammonia, and quinine, with elevation of the head and cold applications, exclusion of light and noise, and blisters, if there is marked tendency to local determination. Further bleeding would only cause further sinking. In the abstraction of blood various circumstances are to be taken into consideration, among which the most important are the age, temperament, and habit of the patient, the character and progress of the disease, the struc- ture and functions of the affected organ, and the peculiar constitution of the atmosphere. As a general rule, young and robust individuals bear bleeding much better than children and aged persons, who often experience great exhaustion from the loss even of a few ounces. Old subjects, in particular, are prone to suffer in this way, the system being often a long time in reacting, while in not a few instances the operation is followed by sinking. Infants and children are also slow in recovering from the effects of bleeding, but reaction having taken place there is much less danger of ultimate exhaustion. Persons of a nervous temperament are less tolerant of the loss of blood than the sanguine and bilious. Corpulent persons are bad subjects for the lancet, and the habitually intemperate are often thrown into delirium tremens by it. The inhabitants of densely crowded cities do not bear the loss of blood nearly as well as people residing in the country. In epidemics, as erysipelas, scar- latina, smallpox, measles, and puerperal fever, bleeding in any form is gene- rally inadmissible. Finally, the abstraction of blood must be practised with the greatest circumspection in all cases of inflammation likely to be at all protracted, and in all persons suffering under grave accidents, as fractures, dislocations, and lacerated wounds, attended with danger of excessive drainage and hectic irritation. After operations and injuries, excessive loss of blood may seriously interfere with the restorative principle. The more violent the inflammation is, the more reason will there be, other things being equal, for early and active bleeding; so also if the organ affected be one highly essential to life. Blood is seldom taken when the inflammation is inconsequential as it respects its degree and seat, milder means generally sufficing for its subjugation. In regard to the repetition of the bleeding, the practitioner must be go- verned, first, by the intensity and persistence of the morbid action; secondly, by the importance of the organ attacked; and, lastly, by the state of the blood. The disease continuing with little or no mitigation, there will be the same reason for bleeding that there was in the first instance, and the last may now, perhaps, be borne much better, the previous abstraction having, it may be, engendered a certain degree of tolerance. Intensity of action will be an additional reason for the act. The importance of the organ attacked must not be overlooked. An inflamed lung requires more energetic measures 92 INFLAMMATION. than an inflamed skin, and an inflamed skin than an inflamed finger. As it respects the buffy coat of the blood, its value as a sign of the necessity of a repetition of the operation has already been pointed out, and need not, therefore, be again discussed here. Associated with a persistence of dis- eased action, and a vigorous state of the circulation, it is of some practical importance, but much less than was at one time supposed. 2. Cathartics.—Cathartics constitute a most important class of remedies in the treatment of inflammation, being even more valuable than bleeding, be- cause of their almost universal applicability. Their exhibition, however, should always be premised by the abstraction of blood, provided the nature of the case is such as to admit of it. Where this is contra-indicated, they may be given at once, and there are few diseases which fall under the province of the surgeon in which they will not prove eminently beneficial. They are usually divided into purgatives and laxatives, which differ from each other merely in the one being more active than the other. The distinction, how- ever, is not without its importance in a practical sense. Cathartics, considered as antiphlogistic agents, are employed for different purposes. In the first place, they may be administered simply to evacuate the bowels; secondly, to deplete the mucous membrane, and thus diminish the quantity of blood in the system; thirdly, to excite the action of the liver and mucous follicles ; fourthly, to produce a revulsive effect, or to set up a new action at a distance from the original one ; and, finally, to stimu- late the absorbents, thereby inducing them to remove inflammatory deposits. The importance of exhibiting cathartics as mere evacuants cannot be too strongly insisted upon when we consider that an overloaded state of the bowels is one of the most fertile sources of disease. Many of the so-called idiopathic inflammations evidently owe their origin to this cause, as is proved by the fact that a dose of active purgative medicine often promptly removes them, especially if administered at the commencement of the attack. An incipient ophthalmia, tonsillitis, or fever, is frequently cut short in a few hours simply by clearing out the contents Of the bowels, and getting rid of irritating fecal matter and vitiated secretions. Besides, as long as the bowels are constipated, it is impossible for other remedies to produce their specific effect, or for the various secretions to recover their natural tone. Secondly, this class of remedies proves useful in depleting the bowels, by abstracting the serous portions of the blood from the vessels of the mucous membrane, and thereby diminishing the quantity of fluid in the general system. This practice is often beneficially adopted in inflammation of the large intestine, in what is termed dysentery, and in the milder forms of in- flammation in various parts of the body, where the loss of the red particles of the blood is of questionable propriety. An ounce of Epsom salts, or half a pint of citrate of magnesia, will often bring away from eight to twelve ounces of serum from the bowels in the course of a few hours, with the greatest advantage as it respects the morbid action. Cathartics may be given, in the third place, with a view to stimulate the liver, pancreas, and mucous follicles of the bowels. There are few inflamma- tions, or diseases of any kind, in which disorder of the liver does not play'a conspicuous part, either in exciting or maintaining the morbid action The quantity of fluid poured out by this organ, in a state of health, in the twenty- four hours amounts to many ounces, and it is, therefore, not difficult to form a tolerably correct idea of the ill effects that must result from the interrup- tion, modification, or complete suspension of its functions. The irritating material which it is destined to eliminate being retained in the blood there must arise, as a necessary consequence, serious derangement of the nervous and vascular systems, as denoted by the excessive lassitude, headache ex- CONSTITUTIONAL TREATMENT. 93 cited pulse, and other symptoms, so conspicuous in disordered states of the liver. But a diminished supply of bile is not the only difficulty; on the con- trary, the fluid may be secreted in unnatural quantity, and yet, being vitiated in quality, the effects will hardly be less obvious. The pancreas, too, may have its functions deranged, which the well directed cathartic may readily restore to their normal condition. Of the vast influence exercised upon the health by the mucous follicles of the alimentary canal, it is hardly possible to form an adequate conception. Existing, as they do, everywhere in vast numbers upon the mucous surface, the suppression of their"functions, even for a short time, cannot fail to be followed by local inflammation in different parts of the body, or the material aggravation of it, if it has been already lighted up. Hence, remedies calculated to restore, modify, or improve the secretions of these several structures constitute important objects of treat- ment, not only as preventives, but as means of cure. Fourthly, the administration of cathartics proves useful in another way, namely, on the principle of revulsion, metastasis, or counter-irritation, by establishing a new action in a part more or less remote from that originally affected. During the action of a brisk purgative, as well as for some time after, a larger amount of blood flows to the alimentary canal than is natural to it, and the consequence is that the suffering organ is temporarily relieved of vascular turgescence, on the principle that two morbid processes cannot go on, to any extent, at the same time. This action may be intermittent or permanent, according to the character of the cathartic and the mode in which it is exhibited. In inflammation of the head, throat, and, in fact, of the supra-diaphragmatic portions of the body generally, this principle is never, for a moment, lost sight of by the practitioner, constituting, as it does, a most important element of treatment. Finally, cathartics, by clearing out the alimentary canal, and restoring the secretions, pave the way for the more successful action of other remedies, as diaphoretics, anodynes, diuretics, and sorbefacients. They exert, in this re- spect, very much the same influence, only in a slighter degree, as venesection and leeching, diminishing the volume of the circulating mass, and diverting the blood from the suffering organ. Removing obstruction, restoring secre- tion, and establishing new action, they enable the absorbent vessels to recover from their torpor, and to render themselves useful in removing inflammatory deposits. Cathartics are particularly valuable in inflammations of the brain and its membranes, of the eye and ear, the throat, respiratory organs, the liver, skin, and joints. In gastritis, enteritis, peritonitis, cystitis, wounds of the intestine, and strangulated hernia, they are either contra-indicated, or exhibited with the greatest possible circumspection, and only in the mildest forms. In most, if not in all, of these affections, the best purgative is the lancet, aided by large anodynes, either alone or in union with calomel. Tranquillity, not perturbation, is what is sought to be attained under such circumstances, on the principle that whatever excites peristaltic action must prove prejudicial to the inflamed surface. Cathartic medicines must not be exhibited merely with a view to the cor- rection of disordered alvine evacuation. Such a procedure could not fail to prove injurious. The action of these remedies is perturbating, and therefore subversive of healthy function; hence, it would be folly to expect that the passages should be entirely natural so long as they are exhibited. The more frequently they are given the more likely will this be the case. When these medicines act tardily, their operation may be aided by injec- tions ; and cases occasionally occur where the latter remedies may advan- tageously, and entirely, take the place of the former. The number of purgatives and laxatives is very great, and the surgeon 94 INFLAMMATION. may therefore give himself considerable latitude in the choice of his articles. A few, however, either alone, or judiciously combined, will answer his purpose in nearly every case that may come under his observation. Where a merely evacuant effect is desired, nothing is better than a dose of castor oil, rhubarb, or jalap ; the saline cathartics produce watery passages ; calomel, blue mass, and gray powder act specifically upon the liver; and where an irritating, re- vulsive, or metastatic effect is wished for, the proper articles are compound extract of colocynth, scammony, gamboge, and aloes. In external inflamma- tions, as well as in inflammations of the supra-diaphragmatic organs generally, one of the most useful cathartics, as I have found from long experience, is an infusion of senna, or of senna and Epsom salts. It operates not only promptly and powerfully upon the bowels, but also upon the liver, stimulating this or- gan to increased action, and proving itself hardly inferior, in this respect, to calomel and blue mass. The only objection to it is that it is apt to gripe, but this tendency may usually be effectually counteracted by combining with it some carminative. Croton oil is rarely used, except to relieve obstinate constipation. It will hardly be necessary to say that the greatest caution is required in its administration. Injections, clysters, or enemas may be prepared of various articles, as gruel and common salt, water and mustard, castor oil, spirits of turpentine, infusion of senna, jalap, and other substances, according to the intended effect. What- ever material be used, the important rule is to mix with it a sufficient quantity of fluid, warm or cold, to distend the lower bowel. It may be administered, as I usually prefer, with a common pewter syringe, having a long nozzle, and capable of holding at least from sixteen to twenty ounces ; or, where there is obstinate constipation, with an ordinary stomach tube. Recently an ex- cellent enema-syringe has been manufactured of gum-elastic, of the same shape as the old metallic one, only much superior in its mode of action, and much more easily kept in repair. Whatever instrument be employed, care must be taken that the patient be placed upon his side or belly during its in- troduction, and also that he be properly held, for fear of accident, especially if he be delirious or otherwise unmanageable. Professor Pope, of St. Louis, published, some years ago, the particulars of a case of a child that perished from perforation of the rectum during the administration of an enema. 3. Mercury.—The reputation of mercury, as an antiphlogistic, has long been established. Although the precise mode of its action is still imper- fectly known, its beneficial effects are well understood. Its virtue in con- trolling inflammation is hardly inferior to that of the lancet and of tartar emetic, while, during the decline of the disease, as a powerful sorbefacient or promoter of the removal of morbid deposits, it is without a rival in the materia medica. It may, therefore, be given during the height of the maladv with a view of arresting its progress, and subsequently, after this object has been accomplished, for the purpose of getting rid of effused fluids or re- claiming oppressed and disorganized structure. The efficacy of the remedy in both these relations, is particularly conspicuous in the phle°-masias of the fibrous and fibro-serous tissues, in gout and rheumatism, synovitis carditis arteritis, hepatitis, splenitis, pneumonia, laryngitis, iritis, orchitis' osteitis' and in syphilis. It is less apparent, though not without its value in inflam- mation of the brain, the skin, and mucous membranes, bronchitis' nephritis cystitis, and metritis. ' F ' It is rarely that the treatment of inflammation is commenced with the ex- hibition of mercury. It is only in very urgent or neglected cases that this rule is departed from, its potency and activity being always augmented by previous depletion. Whenever, therefore, there is evidence of plethora bleeding and purgation should precede its use. There is a mercurial point' CONSTITUTIONAL TREATMENT. 95 so to speak, in inflammatory affections, prior to which the employment of this remedy either proves positively injurious, or greatly disappoints expecta- tion. This point is characterized by softness of the pulse, a relaxed condi- tion of the skin, moisture of the tongue, and a general tendency to restora- tion of the secretions. Administered during the height of the morbid action, when the whole system is enveloped, as it were, in flame, it can hardly fail to act as an irritant, and to increase the general excitement. For want of atten- tion to this rule, a great deal of mischief is often done, and a remedy, other- wise of inestimable value, permitted to fall into disrepute. Of the manner in which mercury acts in relieving inflammation we have, as already intimated, no very definite information. That it affords powerful aid in controlling the action of the heart and vessels, both large and capillary, is unquestionable, but how this effect is produced, whether by any direct sedative impression it may exert, or by merely correcting the secretions, is a point concerning which our knowledge is entirely at fault. Nor is our information anymore reliable in regard to the changes which mercury induces in the state of the blood. We know very well how greatly the properties of this fluid are modified by inflammation, what increase there is of fibrin and white globules, and how promptly, in many cases, these changes are cor- rected by the judicious use of mercury; but in what manner this is effected is, in the present state of the science, altogether inexplicable. The thera- peutist may' speculate about these things as much as he pleases; he may invent theory after theory, and entertain us with the most elaborate and in- genious arguments, and yet he will utterly fail to throw any real and sub- stantial light upon them. In a matter so abstruse as this experience alone can guide us, and this ought surely, for all practical purposes, to be sufficient. During the decline of inflammation, and, indeed, in many cases long after the morbid action has been completely checked, the exhibition of mercury is of the greatest advantage in effecting riddance of the morbid products. Of the manner in which this is done we have occasionally direct ocular demon- stration in some of the external phlegmasias. Thus, in iritis, if the system be placed under the influence of mercury, the effects of the remedy are ren- dered obvious by the daily progress which the affected structures make in freeing themselves of the plastic matter that was effused during the height of the inflammation, and which frequently proves so destructive to them by the changes which it induces in the pupil. Similar effects are witnessed in in- flammation of the cornea, attended with interstitial deposits. The opacities which result from these deposits often vanish in a short time under the in- fluence of slight ptyalism, the effect being frequently apparent before the action of the medicine is fairly developed. In orchitis, after the disease has measurably subsided, the swelling and induration in general promptly disap- pear under the use of mercurials, aided by rest, light diet, and purgatives. In all these, and similar cases, the beneficial effects of the agent are evidently due to its sorbefacient properties, or to the manner in which it stimulates the absorbent vessels, compelling them to remove the products left by the pre- vious action. Administered merely as a sorbefacient, the effects of this remedy are often insensible, its action being exerted in a very slow and gradual manner, yet hardly any the less efficiently. This kind of action is particularly desirable in chronic diseases, attended with a crippled condition of the tissues from semi-organized deposits, and an enfeebled state of the general system. Under such circumstances, active mercurialization is altogether inadmissible, from its irritating and prostrating effects; while a more gentle and persistent course is often followed by the greatest benefit, the gums being merely touched, or rendered slightly red, tumid, and tender, as an evidence of the silent operation of the remedy. 96 INFLAMMATION. The best form of exhibition of the remedy is calomel, blue mass, or mercury with chalk. Where a prompt and powerful impression is desired, as when there is hitrh inflammatory action, likely to prove speedily overwhelming in its effects, not only threatening structure but life, the medicine should be given in large and "frequently repeated doses, so as to keep up a decided and well-sustained influence. For this purpose the best article is calomel, in doses of from three to five grains, administered every three, six, or eight hours, until we have attained the object of its exhibition. When the case is at all urgent, as, for example, in croup, pneumonia, or carditis, no time is to be lost; whatever is done must be done quickly, with a bold, vigorous hand, and a determined mind ; the remedy must be given in full, not in small, in- sufficient quantities, or in a faltering, hesitating manner. There is but a short step between the disease and the grave, the struggle is one of life and death, and the victory must be accomplished, if accomplished at all, at all hazard, present or future. When the disease is less violent, or the organ involved less important to life, the medicine is exhibited in smaller doses, and at longer intervals, and then, too, instead of calomel, the milder forms may be used, as blue mass, or the gray powder. Where a chronic or insensible impression is desired, the bichloride may be given instead of calomel or blue mass, or the latter may be employed in smaller doses. Other forms of mercury, to be mentioned hereafter, as the iodide, cyanuret, and deuto- phosphate, are often beneficially prescribed in chronic disease of the skin, in glandular enlargements, in chronic affections of the joints, and in tertiary syphilis. Mercury with chalk, or gray powder, is a great favorite with some practitioners in inflammatory diseases of children and aged persons; but I now rarely use it in any case, having frequently found it to be nauseating, and generally too uncertain to be worthy of reliance. To prevent the mercurial from running off by the bowels, it is usually necessary to combine with it a certain quantity of opium, as a fourth of a grain, half a grain or even more, with each dose, according to the exigencies of each particular case. In children, and in all cases affecting the brain, opium should be given with great caution, especially during the violence of the morbid action. When the skin is hot and dry, the mercurial should either be entirely withheld until further depletion has been accomplished, or it should be combined with some diaphoretic, as tartar emetic, ipecacuanha, or Dover's powder. Griping, which is so liable to occur during the progress of the treatment, should be counteracted by carminatives and the use of laxa- tives, as oil, salts, or magnesia. It need hardly be said that the administration of so potent a remedy as mercury should be most faithfully watched. No honest or judicious practi- tioner uses it heedlessly or sakelessly. He knows that it is a remedy for good or for evil, and he therefore employs it wisely and properly ; oppor- tunely, not out of time. As soon as he discovers, by the fetid state of the breath, the red and tumid appearance of the gums, the metallic taste, and the increased flow of saliva, that the object of its exhibition has been attained, he either omits it altogether, or gives it only in very small quantity, and at long intervals. He does not persist in its administration, as was the custom with our silly forefathers, until the tongue is too big for the mouth, the teeth drop from their sockets, articulation, deglutition, and even breathing are almost impossible, and the countenance presents a distorted and hideous aspect; but he simply touches the gums, maintaining the impression thus made, if necessary, on account of the continuance of the morbid action or letting it die out, if the disease has been arrested. There are certain individuals who, in consequence of idiosyncrasy or the former use of mercury, cannot take this medicine, even in the smallest quan- tity, without being violently salivated. To avoid such an occurrence which CONSTITUTIONAL TREATMENT. 97 is always exceedingly disagreeable both to patient and practitioner, inquiry should always be made with a view to the ascertainment of this fact, in every case, previous to the administration of the medicine. On the other hand, there are persons who cannot be constitutionally impressed with mercury, however largely it may be used, under any circumstances. They are com- pletely mercury proof. It fails to enter the system in any form, combination, or mode of exhibition. In such cases, and also when the system is not as prompt in responding to the use of the medicine as is desirable, the article should be conjoined with some nauseant, as ipecacuanha or tartar emetic, with a view to more thorough relaxation of the system. The operation of the medicine may also be aided with frictions of mercurial ointment upon the groin, the inside of the thighs, the arm, and axilla, thrice in the twenty-four hours, for fifteen minutes at a time, the inunction being performed near a fire with the hand well protected with a pair of gloves, otherwise the assistant may salivate himself long before he succeeds in affecting the patient. From one to two drachms of the ointment will suffice at each application. Em- ployed in this way, the effect is sometimes more rapid than when the medicine is given internally, though the constitutional impression is more mild and evanescent. The practice, however, is a very filthy one, and on that account is seldom resorted to by the modern practitioner. There are circumstances which altogether contra-indicate the use of mer- curials in almost any form. Most of the horrible effects which are so often witnessed in this country, especially in the southwest, where this medicine is more liberally administered than in any other section of the United States, are, I am satisfied, entirely attributable to the reckless and indiscriminate manner in which the article is given in all states of the system, and in every possible variety of circumstance. Persons of a strumous habit of body, the old, the infirm, the ill-fed, the badly-clothed, and the anemic, are particularly prone to suffer from the use of mercury, even when exhibited only in small quantity. It is in subjects of this description, more especially, that we so frequently witness those frightful ravages of the mouth, teeth, jaws, and cheeks, that have almost led to the creation of a new department of surgery for their relief, and which have thrown so much discredit upon the profession in certain regions of the United States. Finally, when salivation sets in, the best remedies are astringent gargles, cooling laxatives, emollient applications to the face and neck, and the liberal use of anodynes, to allay pain and nervous irritation. The lotion that I have found to answer better than any other is a solution of Goulard's extract, in the proportion of one drachm to eight ounces of water, used every hour or two, the only objection to it being that it discolors the teeth, an effect which, however, soon disappears of its own accord. Gargles of alum, tannin, copper, zinc, and other astringent substances also prove beneficial, especially if not employed too strong. When the inflammation runs very high, leeches to the throat and jaws may become necessary; and it may even be required to sca- rify the tongue, to prevent suffocation. The best internal corrective of salivation is the chlorate of potassa, admi- nistered in doses of from fifteen to thirty grains three or four times a day, in a large quantity of sweetened gum-water, or lemonade, to render it more soluble. This medicine seems to act with peculiar efficacy upon the digestive organs, and may often be advantageously resorted to as a prophylactic during the exhibition of mercury. It may also be beneficially employed as a gargle, from one to two drachms being dissolved in a pint of water, and the solution used every two or three hours. In very intractable cases of ptyalism, an emetic of ipecacuanha, morning and evening, will often answer when almost everything else has failed. vol. I.—7 98 INFLAMMATION. 4. Emetics.—Emetics are not as often used now as they were formerly in the treatment of inflammation, their employment having been, in great measure, superseded by cathartics and other evacuants. Their exhibition, at the present day, is limited almost exclusively to cases in which there is marked gastric and biliary derangement, as denoted by the nausea and vo- miting, the headache, lassitude, and aching of the back and limbs which sometimes so greatly oppress the patient in the earlier stages of his illness. When these symptoms are present, and there is no contra-indication, an emetic often acts like a charm, not only ridding the stomach of irritating matter, but allaying vascular excitement, promoting perspiration, and, in fact, unlocking all the secretions. Emetics are, of course, not used in the phleg- masias of the sub-diaphragmatic organs, as gastritis, enteritis, peritonitis, hepatitis, and cystitis, for the reason that the concussion caused by their action would inevitably prove injurious. For the same reason they are withheld in wounds of the intestines, hernia, fractures, and dislocations. In cephalic and cardiac affections they should also be carefully avoided. The best forms of administration are tartar emetic, and ipecacuanha; com- mon salt, alum, and ground mustard, also occasionally answer a good pur- pose, their effect being generally prompt and efficient. Whatever substance be employed, its use should always be followed by large draughts of tepid water, chamomile tea, or infusion of valerian, the latter being particularly beneficial in nervous and hysterical subjects. As a general rule, tartar emetic should never be given, on account of its sedative and irritating effects, to very young children and to persons who have become enfeebled by age and disease. 5. Depressants.—Depressants, or nauseants, are justly entitled to a high position in the scale of antiphlogistic agents. As their name implies, they are remedies which, by lowering the action of the heart, lessen the momentum of the circulation, and diminish the flow of blood to the affected tissues. This, however, is not the only good which they are capable of doing; by the impression which they make upon the nervous and sanguiferous systems, they become instrumental in re-establishing and improving the secretions, and in thus indirectly controlling the morbid action. There is, in fact, not a single organ which does not feel, to a greater or less extent, their influence, or which is not brought, more or less, under their dominion. The effect of this operation is often witnessed during the exhibition of tartar emetic in nauseat- ing doses, in the relaxed skin, the softened pulse, the moistened tongue, and the pallid countenance, all bearing testimony to the universal impression of the remedy. Judiciously employed, depressants are among the most valuable and efficient antiphlogistic means that we possess, and they have the advan- tage that they may often be used without any preliminary depletion of any kind. Their beneficial effects are particularly conspicuous in inflammation of the respiratory organs, of the eye, the joints, and fibrous structures; also in certain forms of inflammation of the skin and cellular tissue. In many of these affections, if not in all, they have almost entirely superseded the use of the lancet and other evacuants, their controlling influence over the morbid action being generally most striking and satisfactory. Their efficacy is hardly less apparent in many of the diseases of the sub-diaphragmatic vis- cera; but their exhibition here demands greater care and vigilance, as their emetic effects could not fail to prove prejudicial. Their employment is par- ticularly adapted to the treatment of acute inflammation of young, robust subjects, whose systems require to be rapidly impressed in order to arrest the progress of their diseases. Infants and children, the old, infirm and decrepit, bear their use badly, and often sink under their injudicious adminis- tration. CONSTITUTIONAL TREATMENT. 99 The most trustworthy depressants are tartar emetic and ipecacuanha, to which may be added aconite, veratrum viride, and digitalis, which, however, hold a subordinate rank. Of the depressing effects of bleeding I have already spoken, and pointed out the circumstances under which they may be most readily produced. Tartar emetic, as a depressant, may be administered in doses varying from the eighth to the fourth of a grain, repeated every two, three, or four hours, according to their impression, which should be steadily maintained until the object of the administration of the remedy has been fully attained. It will generally be safest to begin with a small quantity, and to increase it gradu- ally if it be found to be borne well by the stomach. Sometimes the first few doses, even if small, will produce pretty active emesis, but this, so far from being injurious, will commonly be highly beneficial, by relaxing the system and opening the emunctories. By and by, gastric tolerance will be estab- lished, and then the remedy will often be borne in extraordinary quantities, though we never employ it in the enormous doses recommended by Rasori, Thomasoni, and other disciples of the Italian school. In this country, in- deed, we seldom give as much at a single dose as half a grain, the average quantity rarely exceeding one-half or one-third of that amount. The Italian practitioners, on the contrary, often gave five, ten, and even fifteen grains at a dose. The beneficial effects of tartar emetic, as a depressant, may often be greatly enhanced by the addition to each dose of a small quantity of the salts of morphia, just enough to produce a calming and diaphoretic impression. Such a combination is particularly serviceable in nervous, irritable persons, and in subjects who have been debilitated by intemperance and other causes of exhaustion. When the article, given by itself, is productive of vomiting, it should never be used in any other way. In children, too, such a mode of exhibition is, as a general rule, indispensable. Sometimes the article may be advantageously administered along with the neutral mixture. The dose of ipecacuanha, as a depressant, varies from a fourth of a grain to a grain, and may be used alone or in combination with an anodyne, as, indeed, is usually found best. A nauseant effect may be kept up in this manner almost as long as may be desired, but the impression is less pervasive and far inferior, in every respect, to that produced by tartar emetic. On this account, however, the medicine is peculiarly adapted to the treatment of inflammatory affections of children, who, as already stated, usually bear the operation of antimony very badly. Whichever of these two articles be employed, it will be well to withhold all drinks for from fifteen minutes to half an hour after the exhibition, as, when this precaution is neglected, they are very apt to cause vomiting. At the end of this time, however, diluents, cool or tepid, may be used with the greatest benefit, from their tendency to promote relaxation and secretion. Of digitalis I have not been led to form a very favorable estimate as a depressant or sedative. I was formerly in the habit of employing it a great deal in various forms and combinations, as well as in various forms and stages of inflammatory disease, and yet it would be difficult for me to recall a soli- tary case in which I derived any appreciable benefit from it. I have, there- fore, of late years altogether abandoned its use. Modern materia raedica has gained an important accession in the addition of aconite as an antiphlogistic agent. The form in which it is usually ex- hibited is the saturated alcoholic tincture of the root, prepared according to Fleming's formula, the dose of which is from one to five drops repeated every two, three, or four hours, until it has produced its peculiar depressing effect. The best, because the safest, plan is to begin with a small quantity, and to increase it gradually and cautiously until it brings down the pulse, 100 INFLAMMATION. which, in the course of a few hours, often descends from ninety-five or one hundred to sixty-five or even fifty, the surface at the same time becoming bathed with perspiration. In large doses, it is powerfully sedative and ano- dyne, but it should never be given in this way on account of its prostrating influence. It is particularly adapted to neuralgic, gouty, and rheumatic affections, and to the higher grades of traumatic fever; and my practice generally is to combine it with tartar emetic and sulphate of morphia, as this insures a more prompt and beneficial action than when given by itself. Yeratrum viride is an American remedy, introduced to the notice of the profession by Dr. Osgood, of Providence. Its properties were subsequently investigated by Dr. Norwood, of South Carolina, who found it to exert a powerful influence upon the action of the heart and pulse, very similar to that of aconite, only, if possible, still more certain. The dose of the satu- rated alcoholic tincture of the root, the form of the medicine most generally employed, is from five to eight drops, repeated every two, three, or four hours, until it has sensibly reduced the force and frequency of the pulse, when it is either suspended or given in smaller quantity. As veratrum viride is an article of great potency, it is impossible to be too careful in its use. If carried too far, it causes nausea and vomiting, excessive prostration, faintness, vertigo, dimness of sight, and other dangerous symptoms. It is applicable to the same class of cases as aconite, and may be exhibited either by itself or in union with morphia and tartar emetic. The best means for over- coming the nauseating and depressing effects of this medicine, are opiates and alcoholic stimulants. 6. Diaphoretics.—Diaphoretics, in their mode of action, bear the same rela- tion to the skin that cathartics do to the bowels. They constitute, therefore, a highly important class of remedies in inflammation, from the faculty which they possess of restoring and modifying the cutaneous perspiration, the sup- pression of which is a frequent source of disease. The quantity of perspira- tion daily thrown off by the skin, in the normal state, varies from twelve to sixteen ounces, and the retention of such an amount of material in the system must necessarily exert a most prejudicial influence upon the suffering organ. The importance of a critical sweat, as it was called by the ancient physicians, in putting a stop to disease, has long been familiar to the practitioner, and the employment of diaphoretics is only an attempt to imitate nature's efforts, in removing a cause of morbid action, or restoring a secretion which has been suppressed in consequence of the changes which that action has induced in the general system. As in the case of purgatives, depletion should always precede the employment of the remedy, so should it in the case of diaphore- tics, a relaxed condition of the body always powerfully predisposing to a favorable action of the medicine. The class of diaphoretics is very large, but there are only a few that are really at all reliable, or that are much employed by the experienced practi- tioner. These are tartar emetic, ipecacuanha, and Dover's powder, aided, if necessary, by tepid drinks, and sponging of the surface with tepid water! The spirit of Mindererus, in combination with a small quantity of spirit of nitric ether, makes a mild diaphoretic, and is often used in low states of the system. The efficacy of antimony, which deserves the highest rank in this class of remedies, will be greatly increased if given in union with morphine the two articles thus counteracting the bad effects which they would produce if exhibited singly, at the same time that they subdue the heart's action re- lax the skin, relieve pain, and induce sleep. The best form of exhibition is a watery solution, each dose containing from the sixth to the tenth of a grain of antimony, with from one-fourth to one-eighth of a grain of morphia re- peated every two, three, or four hours. Ipecacuanha is adapted chiefly to CONSTITUTIONAL TREATMENT. 101 children and old persons, and to the latter stages of the disease, and may be given alone, or, what is preferable, with some of the salts of opium. The ordinary dose of Dover's powder, for an adult, is ten grains, but in my own practice I seldom use less than fifteen, and frequently as many as twenty, repeated every eight, ten, or twelve hours. The action of these remedies should always be aided by tepid drinks, and, if there be much dryness of the surface, by frequent sponging of the body with tepid water. During very hot weather, and in high states of inflammation, cool ablutions are often more efficient, as well as more grateful, than warm. Bathing is not often employed in the treatment of acute inflammation, on account, chiefly, of the inconvenience and fatigue attending its use. In the chronic form of the disease, however, it is a remedy often of great value, especially in affections of the skin, joints, and abdominal viscera. The water, which may be simple or medicated, is used at various degrees of temperature, the tepid bath ranging from 85 to 92 degrees of Fahrenheit, the warm from 92 to 96, and the hot from 96 to 112. A very excellent and convenient mode of conveying moist and heated air to the patient's body, as he lies in bed, consists in attaching one end of a tin tube, from three to four feet in length, to a teakettle filled with hot water, the other end being placed under the bedclothes. Copious perspiration usually promptly follows the applica- tion, which may be maintained for any desirable period. The foot-bath is occasionally used with advantage, but to derive full benefit from it the patient should be well covered up in bed, his feet hanging in the water placed in a suitable tub upon a chair, the immersion being continued from thirty to sixty minutes. The hip-bath is employed chiefly in affections of the genito-urinary organs. 7. Diuretics.—Diuretics are medicines intended to restore and modify the renal secretion, which is almost invariably more or less changed in inflamma- tory affections. Their employment is always, as a general principle, preceded by various depletory measures, and they are never given in inflammation of the kidneys and bladder. Their administration is usually accompanied by mucilaginous drinks, but these are not at all necessary to their beneficial effects, ordinary fluids answering quite as well. They may be conveniently arranged under three distinct heads: The first includes those articles which, when received into the system, depurate the blood, and increase the quantity of solid matter of the urine, as the nitrate, acetate, and bitartrate of potassa. The second class comprises colchicum, squills, and other vegetable diuretics, which carry off the watery portions of the blood ; and the third consists principally of copaiba and cubebs, which not only augment the renal secre- tion, but exert a peculiar influence upon the mucous membrane of the blad- der and urethra, as is shown in cystitis and gonorrhoea. Of these various articles, the most important, in the treatment of acute inflammation, are ni- trate of potassa and colchicum. The former may be exhibited in doses of from fifteen to thirty grains every three, four, five, or six hours, in a large quantity of water. Colchicum is generally given in the form of the vinous tincture of the seed, in doses varying from ten to fifty drops, several times in the day and night. My own practice usually is to employ one drachm along with half a grain to a grain of sulphate of morphia every evening at bedtime. In this way the medicine produces a much more decided impression upon the system, as well as upon the renal secretion, increasing its quantity, and free- ing it of lithic acid, and probably, also, of other nitrogenized elements. Moreover, it usually acts upon the bowels, bringing away thin watery evacuations, especially when employed by itself; and in large quantities, it often vomits. One full dose, administered in this manner at bedtime, is far superior to three or four small ones, which often only fret and irritate the 102 INFLAMMATION. kidneys and bowels, placing them in a condition ill calculated to correct morbid action. 8. Anodynes.—There is no class of remedies which require a greater amount of nice judgment and correct discrimination in respect to then- selection, mode of combination, and time of administration than that of anodynes. The subject, therefore, is one that should be carefully studied with reference to these particular points, by every one desirous of acquiring correct views of the practical application of anodynes to the treatment of in- flammatory affections. My conviction is that these remedies are used much less freely than they should be, and that they are capable, if properly exhi- bited, of affording an immense amount of benefit, not only in allaying pain and inducing sleep, but frequently also in controlling morbid action, and, consequently, in abridging its course and preventing its ravages. Want of space will not permit me to enter fully into this subject, and I shall, there- fore, confine myself to a brief statement of a few of the leading facts, giving them as practical a bearing as possible. The same rules, as respects the premising of depletory measures, are appli- cable to anodynes as to cathartics. Thus, first, whenever there is plethora, fecal distension, or disorder of the secretions, their correction should, if possible, precede the exhibition of the opiate. Sometimes a full dose of morphia is made to succeed a large bleeding, or an active purgative, the medicine then exercising a decidedly sedative and soothing influence. Administered before the system has been properly relaxed, it rarely fails to increase the vascular action, to lock up the secretions, produce headache, prevent sleep, and augment thirst and restlessness. Secondly, the medicine should always be exhibited in full doses, experience having shown that it makes a much stronger, as well as a much more soothing, impression in this way than when it is taken in small, and frequently repeated doses. With the precautions pointed out, an adult will bear, when the symptoms are at all urgent, from two to four grains of opium, or its equiva- lent of morphia, every twelve or twenty-four hours. The effects of the remedy must be steadily watched, especially if the patient be a child, or if there be any undue cerebral excitement. Should the pulse increase in ful- ness and vigor under its influence, the skin become more hot and dry, or the vigilance and restlessness augment, repetition is temporarily suspended, until, by farther depletion, the system is placed in a more favorable condition for its reception. Thirdly, the best period for the exhibition of the medicine, when there is no immediate necessity for its use, is towards bedtime, the patient being thus more likely to obtain quiet and refreshing sleep after the removal of the light and other external stimulants. Fourthly, when there is excessive pain along with great dryness of surface, and the depletion has been already carried to a sufficient extent, the anodyne should be combined with a diaphoretic, as ipecacuanha, or, what is better, tartar emetic, or, instead of this, a full dose of Dover's powder is o-iven. Anodynes are particularly beneficial in all cases of inflammation0attended with violent pain, which, by its persistence, might rapidly wear out the powers of life. Their value cannot be too highly appreciated in the phleg- masias of the skin and cellular tissue, the joints, the sub-diaphragmatic viscera, the eye, ear, pleura, heart, and respiratory organs. Within the last few years enormous doses of opium have been given by Professor Clark and others in peritonitis with the most happy results, and I am sure that the same mode of treatment might be advantageously extended to inflammation of many of the other parts of the body. The importance of absolute rest to the affected organ is universally conceded, and is daily witnessed in the CONSTITUTIONAL TREATMENT. 103 management of external inflammation. Instinct alone is often sufficient to secure it, but where this fails the surgeon endeavors to procure it by means of various mechanical appliances. In the internal phlegmasias no such means are applicable, but here the object may be readily attained by opiates, given in full and sustained doses to control the movements of the suffering structures. In gastritis nothing so promptly and effectually quiets the muscu- lar fibres of the stomach as a suitable quantity of morphine, and the same treatment has long been successfully employed in dysentery, or inflammation of the lower bowel. In cystitis nothing affords relief so speedily and perma- nently as a full anodyne. In pleuritis and pneumonia, how is it possible to give rest to the lungs and respiratory muscles, except by the same means ? The more quietly the parts are kept while laboring under disease, the sooner, other things being equal, will the patient recover from its effects, and the less pain he will have to endure from the constant and rude contact of the affected surfaces upon each other. Even in inflammation of the brain and its menin- ges, after proper depletion has been practised, anodynes are frequently indis- pensable, not only to allay pain and induce sleep, but to control the morbid action. And how do they do this ? Simply, in the first place, by subduing the action of the heart, and thus preventing it from sending out to the brain its accustomed quantity of blood ; and, secondly, by making a direct impres- sion upon the brain itself, thereby, in some degree, controlling its movements, so injurious both to its own substance and to its coverings, when thus affected. Anodynes, in most of these cases, as well as in many others, literally consti- tute nature's splint. The best anodynes are opium and its different preparations, as the salts of morphia and laudanum. These may be given either by the mouth or rectum, double the quantity being usually required to produce the same effect in the latter as in the former case. Sometimes the remedy is employed endermi- cally or subcutaneously, in the form of injection. There are some persons who cannot bear opium in any form. When this is the case a substitute should be sought in lupuline, hyoscyamus, Indian hemp, and other kindred articles; or, in what I have generally found to answer very well under such circumstances, a union of morphia with tartrate of antimony and potassa. 9. Combination of Remedies.—There are few acute surgical diseases or severe accidents in which a combination of several of the remedies now de- scribed may not be advantageously employed. In nearly every case of the kind the patient will be found to be oppressed with fever, thirst, pain, and restlessness; or, in other words, to labor under incited action of the heart and arteries, attended with diminished, if not suspended secretion, and all the evils consequent upon such a state of the system. To meet the indications of treatment, under such circumstances, there is no prescription which, ac- cording to my experience, is capable of conferring greater benefit than the saline and antimonial mixture, as it is termed, consisting of the following in- gredients :— fy.. Antimonii et potassse tart. gr. iij. Magnesise sulph. gij. Morphise sulph. gr. jj. Aquae destil. ^x. Syr. zingiber, vel simplicis §ij. Acid, sulph. aromat. 5SS- Tinct. veratr. virid. 5iss- M. Of this combination the proper average dose is half an ounce, repeated every two, three, four, or six hours, according to the exigencies of the case. Should it produce emesis, or distressing nausea, the dose must be diminished. 104 INFLAMMATION. Properly administered, it rarely fails rapidly to subdue vascular excitement, to cause copious perspiration, to allay pain, thirst, and restlessness, to main- tain the bowels in a soluble condition, and to induce sleep and general tran- quillity. Instead of the veratrum aconite may be used ; but in general I give the former the preference. Colchicum may be added when there is a rheumatic or gouty state of the system, and quinine when there is a tendency to periodicity. The quantity of morphia may be increased when there is much pain. 10. Antiphlogistic Regimen.—Under this head are comprised the patient's diet, and the care which he may require during his confinement. The sub- ject is one which rarely receives the attention its importance demands. Few persons, fortunately, have any appetite during the height of an in- flammatory attack, and hence the surgeon seldom experiences any difficulty in regard to the regulation of the diet. The stomach being oppressed with nausea, or a sense of uneasiness, either loathes food, or rejects it almost the moment it is swallowed. It is well it should be so; for any ingesta, however mild, taken at this period, would only become a source of further trouble, by increasing the morbid action, perhaps already progressing at a furious rate. When the appetite remains, it must be repressed, steadily and courageously, until all danger from over-excitement from its indulgence has been safely passed. The mildest and least nutritious articles only are admissible in the earlier stages of the disease; such as panado, gruel, arrowroot, sago, and tapioca. Not even the lightest animal broth is permissible, unless there is decided tendency to prostration, or an irritable state of the system, clearly dependent upon the want of proper nourishment, as occasionally happens in persons of a nervous, irritable temperament, or who are habitually huge feeders. The drinks should be cooling, consisting of iced water, gum-water, linseed tea, or barley-water, either simple, or slightly acidulated with lemon- juice, tamarind, or any of the subacid fruits ; care being taken that, while they are used freely, they are not employed in such quantity as to produce gastric and intestinal oppression. The promptings of nature should not be disregarded during the progress of recovery; for their tendencies are generally wholesome, and should there- fore be gratified to at least a reasonable extent, unless there are well-marked contra-indications. Acid drinks and food are particularly apt to be craved, and a moderate use of them is often eminently beneficial, not only in whetting the appetite, but in promoting the digestion, by supplying the exhausted stomach with substances calculated to atone for the want of a due amount of gastric juice, so essential to healthy chymification. Improper indulgence should, of course, be avoided, and care must also be taken that the articles are of such a character as to prevent acidity and flatulence. Rest of mind and body must be carefully observed. The importance of this is so self-evident that it would be folly to attempt to enforce it by any labored argument. Whatever has a tendency to excite the heart's action must necessarily increase the momentum of the circulation, and, through it, the inflammation. In all severe attacks the patient must keep his bed°from . which he must not rise even to answer nature's calls; light and noise are carefully excluded from his apartment, especially if he is 'sufferino- from in- flammation of the eye, brain, or ear; and no persons should be permitted to be about him, except such as are absolutely necessary to nurse him. Many a patient is killed by the kindness of his friends and relatives. Attention must be paid to the temperature of the patient's room this being regulated, not by his feelings, which are often deceptive, but by the thermometer. On an average, it should not exceed 65°, but in some cases it may range as high as 70°, and in others as low as 60°. The apartment LOCAL TREATMENT. 105 should be frequently ventilated. When it is recollected how soon the air becomes vitiated during sickness, and how important a due supply of oxygen is to the proper maintenance of the health, the importance of attention to this subject will not be doubted. Cleanliness of the body, and of the bed- clothes, is another subject of vital importance in the treatment of inflammation, and one to which, I am sure, few practitioners pay sufficient attention. To medicate the inside of a patient while we neglect the outside is one of those singular inconsistencies of which we see daily proofs in the sick chamber. I would not insist upon too frequent ablutions and changes of the body and bedclothes, but they should certainly, in ordinary cases, be effected at least once in the twenty-four hours ; care being taken to avoid unnecessary ex- posure and fatigue during their performance. Even the arrangement of the furniture should be attended to, on the principle that an agreeable impression, of whatever kind, is more conducive to comfort and recovery than one of an opposite character. II. Local Treatment.—The local remedies of inflammation consist of rest and elevation of the affected part, the abstraction of blood, cold and warm applications, compression, destructives, and counter-irritation. 1. Rest and Position.—Without rest, steady and persistent, of the affected part, little progress can be made toward the cure of inflammation. The practitioner who neglects attention to this important circumstance, performs only half his duty. The patient, ignorant of its advantages, often continues to exercise the affected organ long after it has become unfitted for the dis- charge of its functions, much to his present discomfort and ultimate detriment. A simple conjunctivitis, that might be cured in a few hours, is often urged, for the want of a little rest of the eye, into a violent and protracted ophthal- mia, perhaps, at length, eventuating in total loss of vision. An inflamed joint is frequently, for the same reason, rendered permanently stiff and useless. Hence, rest is universally considered as one of the most essential elements of the local treatment of inflammation. In general, it is easily procured, simply by the patient's own efforts ; but where this is not the case, it must be in- sured by appropriate splints, and other means, applied so as not to interfere with the other treatment. In inflammation of some of the internal orgaus, as the heart, stomach, peritoneum, bowels, and urinary bladder, the object is sought to be obtained by the liberal use of anodynes, which, by temporarily paralyzing the muscular fibres of the affected structures, effectually prevent peristaltic motion, and thus place them in a better condition for speedy recovery. But there is a period when rest must not be enforced too rigidly, for when it is continued too long, it may be productive of much harm. Its great utility is in the earlier stages of inflammation, when morbid action is grave- scent, and for some time after it has reached its culminating point. As soon as recedence has fairly begun, motion, gently and cautiously conducted, is often of great utility. Not only should the part be kept at rest, but it should also be maintained in an elevated position, the success of the treatment being thereby greatly enhanced. The importance of attention to this point is well exemplified in many familiar diseases. The patient himself is often conscious of it, and, therefore, resorts to it, as it were, instinctively. Who that has ever had an attack of whitlow, does not remember the great relief which he experienced from carrying his hand in an elevated position ? The effect of position is nowhere more strikingly evinced than in odontalgia. During the day, the patient, while attending to business, is, perhaps, hardly sensible of suffering, but, at night, no sooner does his head touch the pillow than the tooth begins to ache and throb, compelling him to get up and pace his room. In orchitis, 106 INFLAMMATION. the beneficial effects of our remedies are always greatly aided by elevation conjoined with rest of the affected organ. It is quite easy to understand why this should be so. In inflammation, the vessels carry an extraordinary quan- tity of blood, which is still further increased when the suffering structures are placed in a dependent position, because the flow, not being opposed by gravity, has then free scope, thus crowding the already distended capillaries to the very utmost, and proportionably aggravating the morbid action. _ _ Finally, the inflamed part should also be maintained in as easy a position as possible, mere rest and elevation not sufficing to insure comfort. All re- straint must be taken off; all muscular contraction counteracted. Thus, in inflammation of the knee-joint, the limb should recline upon its outer surface, a pillow being placed in the ham, this being the best position for preventing tension. In synovitis of the elbow-joint, the forearm is bent at a right angle with the arm ; and in hip-joint disease, the thigh is slightly flexed upon the pelvis, and turned towards the sound one. 2. Local Bleeding.—Blood may be abstracted locally by scarification, puncture, leeching, and cupping, each being more or less serviceable, in its own way, in particular cases and under particular circumstances. The manner in which topical bleeding affords relief is sufficiently evident in some of these forms of depletion, but not very apparent in others. Thus, in scarifying and puncturing a part, the blood is taken directly from the en- gorged vessels, which are thus drained of their altered and vitiated contents. If the operation be carried to any considerable extent, as it often may be, especially in the former of these procedures, we may, at the same time, make a powerful impression upon the general system, nearly as rapidly and quite as effectually as when blood is drawn from a vein at the bend of the arm, although, in general, such an effect is neither aimed at nor desired. A simi- lar influence is exerted by leeching and cupping, provided the operation is performed upon the inflamed surface, or in its immediate vicinity. Fre- quently, however, it is performed at a remote point, and then its mode of action is rendered more difficult of comprehension. Thus, in inflammation of the brain, it is difficult to determine how leeches and cups, applied to the nape of the neck, the temples, or back of the ear, afford relief to the affected organ. It is certainly not possible, in such a case, to make any direct im- pression upon the seat of the disease; whatever influence is exerted, must be exerted through the general system. This is a self-evident proposition. The vessels of the neck and scalp have no direct communication with the vessels of the brain; and hence, in leeching and cupping these parts, we can no more drain the cerebral capillaries than we can drain those of the hand, chest, or any other distant part. We may assume, then, that, when topical bleeding is practised by either of the latter methods, its beneficial effects are due not to any direct drainage of the suffering structures, but indirectly to the depressing influence which it exerts upon the heart and nervous system, and, through them, upon the morbid action, diminishing the momentum of the circulation, aud, consequently, the flow of blood in the capillaries at the seat of the inflammation. But whatever may be its mode of action ; whether it affords relief in the manner in which we have attempted to explain, or by some revulsive agency, so much insisted upon by some of the older practitioners, and which it is so difficult to comprehend, topical bleeding, to be efficient, should always, if possible, be preceded by general depletion. When the force of the morbid action has thus been broken, the rest of the malady is often well dealt with by local abstraction of blood. It is only when the disease is very mild, or when there is no marked constitutional disorder, that this rule should be dis- regarded. Under such circumstances, the treatment may occasionally be LOCAL TREATMENT. 107 very properly commenced with the application of leeches, cups, or scarifica- tion, followed or not, as the exigencies of the particular case may seem to require, by other measures. The manner of taking blood topically will be pointed out in the chapter on Minor Surgery. 3. Cold and Warm Applications.—These remedies, which are more parti- cularly adapted to external inflammations, comprise a great number of articles, in the form of water dressings and cataplasms, with the character of which every practitioner should be perfectly familiar. Both classes of remedies may be simple or medicated, according to the tolerance of the part and sys- tem, and the nature of the morbid action. (1.) Cold water has been employed in the treatment of inflammation almost from time immemorial; but its beneficial effects were almost forgotten, until attention was recalled to it by some of the military surgeons of Europe, early in the present century. In this country, the subject has hardly yet received the consideration it deserves, the use of the article having hitherto been con- fined chiefly to hospital practice. From its value, however, as a topical application, it must soon find its way to general favor, and take its place among the great remedies for the cure of inflammation, especially as it occurs in the external parts of the body. It is not difficult to conceive how cold operates in subduing morbid action. Its chief effect is evidently that of a sedative, lowering the temperature of the part, and causing contraction of the vessels, thereby relieving pain, swell- ing, and tension. It is particularly applicable to inflammation in its incipi- ent and gravescent stages, while there is, as yet, little effusion, and no serious structural lesion. When the action has reached its acme, threatening sup- puration, or, what is worse, tending to gangrene, it is usually hurtful both to part and system, and must be promptly discontinued. Besides, it should not be forgotten that cold, when intense, or protracted, may of itself cause gangrene. Young and robust persons usually tolerate such applications much better than the aged and feeble; they are also better borne in summer than in winter. As it is impossible always to determine beforehand, in any given case, what their effects will be, their action should be carefully watched, in order that, if they should become a source of annoyance, they may either be entirely dispensed with, or employed in a modified form. The water may be rendered anodyne, astringent, or antiseptic, according to circumstances, by the addition of opium, acetate of lead, or some of the chlorides. The best way to use it is to cover the affected part with a piece of old porous linen, and to direct upon it a constant flow of water from a basin with a stop-cock, slung to the top of the bedstead, the limb lying on an oil-cloth trough, from which the fluid is conducted into another vessel standing near the bed. Or the part may be covered with a wide, thin piece of sponge, spongio-piline, or common linen, over which is placed a bladder partially filled with pounded ice. Or the water may be conveyed from a basin by means of a candle wick to a layer of lint upon the inflamed surface, the wick acting on the principle of a syphon. Finally, when ice cannot be obtained, the water may be rendered cold by means of alcohol, in the propor- tion of one part to six of the fluid ; by pyroligneous acid and alcohol; or by the admixture of a strong solution of hydrochlorate of ammonia and nitrate of potassa. In whatever manner the fluid is employed, the part to which it is applied should be constantly exposed to the air, to favor evaporation. (2.) The use of warm water is also of great antiquity, having been em- ployed by Hippocrates and other practitioners in gangrene and various cutaneous affections. It has, however, only been within the last fifteen years that it has assumed anything like the rank to which its importance as an antiphlogistic remedy entitles it. In my own practice, I generally give a 108 INFLAMMATION. decided preference to warm water over cold, the impression made by it upon the part and system being usually more agreeable and soothing, while there is much less danger of metastasis, or of a sudden transfer of disease from the external to the internal parts of the body. It is particularly adapted to nerv- ous, irritable individuals, who are easily chilled by cold applications, and to cases in which the inflammation has already made considerable progress, where there is much tension and swelling, or where suppuration is impending, or has already taken place. A good rule, both in regard to warm and cold applications, is to consult the feelings of the patient, using one or the other according to the tolerance of the part and system, or simply so long as they seem to be beneficial. When a change becomes requisite, care must be taken that it is not too sudden, lest it produce harm. Thus, hot applications should be succeeded first by warm, then by tepid, afterwards by cool, and finally, if necessary, by cold, the transition being gradual and wary, not great and sudden, so as to shock the part and system, and thus cause undue reaction. Warm water may generally be advantageously combined with opium, or with opium and acetate of lead, or with opium and hydrochlorate of ammonia. The latter is the preparation which I generally prefer, the opium and am- monia being dissolved in hot water, in the proportion of about two drachms of the former and an ounce and a half of the latter to the gallon of fluid. A piece of old flannel of suitable size, and arranged in several thicknesses, is then wrung out of the solution, and laid upon the inflamed surface, a covering of oiled skin being spread over the cloth, to confine the heat and moisture. As the cloth becomes dry, it is wet, from time to time, not by re-immersion, but simply by pressing the solution upon it from a sponge ; dressing by substitution being necessary only in the event of the flannel becoming soiled and offensive by the discharges. The only objection to the hydrochlorate of ammonia is its liability to cause slight pustulation, especially in persons of a delicate skin ; when this happens, its use must be suspended. In the em- ployment of cold water, the part is exposed; in the use of warm, it is covered. The former does good by constringing the inflamed tissues, and opposing effusion; the latter by relaxing them, and favoring effusion. (3.) Fomentations, which may be considered as a species of local bathing, are often beneficially employed in inflammation of the joints and of some of the internal viscera, being particularly calculated to relieve pain, tension, and spasm. In cystitis, gastritis, enteritis, and peritonitis, as well as in wounds and other injuries of the pelvic and abdominal organs, their employ- ment can rarely be dispensed with in any case. The most simple fomentation consists of a large, thick flannel cloth, wrung out of hot water, or water near the boiling point, by means of two sticks turned in opposite directions, and applied lightly to the part as hot as it can be borne. If a soothing narcotic, or sedative influence is required, chamomile flowers, poppies, hops, or what is much better, laudanum, or laudanum and brandy, will be found to form valuable additions. In whatever manner they are used, they should be fre- quently renewed, care also being taken that there are two cloths, so that, while one is taken off, the other may be immediately applied, all danger of shock and reaction from exposure to the air being thus avoided. (4.) Stuping is a variety of fomentation serviceable in many cases, but particularly in affections of the eye, nose, ear, mouth, and throat. It is'con- ducted with a piece of flannel, rolled into a kind of ball, which the patient holds in a small pitcher, at such a distance from the affected surface that the vapor may ascend to it, care being taken to wet the cloth as often as it be- comes cool. The remedy may be medicated, if desired, with laudanum, camphor, belladonna, hemlock, or any other article, anodyne, astringent, or sorbefacient. When it is desirable to apply steam more directly, a funnel may be inverted LOCAL TREATMENT. 109 over the hot fluid, and the tube held towards the affected surface at a suitable distance. Steam may be conveyed to any part of the patient's body, under the bedclothes, by means of a large gutta-percha tube, attached to a small tin boiler, placed upon a table, and heated by a spirit lamp. (5.) Poultices, technically called cataplasms, are an important class of remedies, intended for external application in inflammation, wounds, ulcers, abscesses, and other affections. They are modifications of fomentations, and are made of various substances, either simple or medicated, according to the object they are intended to fulfil. They should be of such consistence as to accommodate themselves accurately to the surface to which they are applied, without being so tenacious as to adhere firmly to the skin, or so thin as to spread over the neighboring parts. They should never be heavy nor bulky, and they should be renewed as often as they become dry and cold; otherwise they lose their good effects and are converted into irritants. In general, it is sufficient to change them thrice a day; but in warm weather, or when there is much discharge, it may be necessary to reapply them every four, five, or six hours. Their temperature should be about the same as that of the body, that is, from 85 to 92 degrees of Fahrenheit, and they should be placed di- rectly upon the affected surface in a uniform layer of from three to four lines in thickness, a piece of bobbinet, gauze, or thin netting being interposed to prevent sticking and facilitate removal. The action of a poultice is usually limited to the skin, or, at all events, to the parts to which it is immediately applied ; it is only when it is composed of very strong materials that its influence is more deeply felt. In using medicated cataplasms, it is necessary, especially when there is ulceration or abrasion of the skin, to be aware that the active ingredient may be absorbed, and thus produce the same effects as when introduced directly into the stomach. Poultices differ very much in their mode of action ; thus, some are altogether emollient, that is, they soften and relax the parts to which they are applied, at the same time that they promote exhalation and absorption; some are anodyne; some astringent; some antiseptic. The following list comprises nearly all that are now in use, with brief direc- tions for their preparation :— a. The bread poultice is made by pouring boiling water upon the crumbs of stale wheat bread and stirring the mixture in a basin with the back of a spoon until it is of a thick, mushy consistence. It is then spread upon a piece of folded cloth large enough to cover not only the affected surface, but to extend a short distance beyond it. Milk may be used as a substitute for the water, but when thus prepared the poultice requires to be more frequently changed, as it soon becomes sour and offensive. b. The arrowroot poultice is prepared in the same manner as when that article is used for food, only that it is rendered more consistent; it is mixed at first with cold water, and then with a sufficient quantity of boiling water to convert it into a thick, gelatinous paste. This poultice is admirably adapted for irritable sores, and deserves to be more frequently employed than it is. c. The slippery-elm poultice is prepared from the powdered bark of the slippery-elm, moistened with hot water. It is very light and demulcent, and, therefore, well adapted for burns, excoriations, and irritable sores. d. The linseed poultice, perhaps the best and most convenient of all, from its emollient properties, is made of ground linseed mixed with boiling water, and stirred until it is converted into a thick, cohesive mass. This poultice is always very easily prepared, retains its heat for a long time, and has a sufficiency of oil to keep it soft and prevent it from adhering. Excellent emollient poultices may be prepared from apples, carrots, turnips, or any of the more tender culinary roots, by boiling them, after having re- 110 INFLAMMATION. moved the skin, and mashing them into a soft pulp. They possess, however, no peculiar virtues, and are therefore seldom used. A poultice may be variously medicated. Thus it may be rendered astrin- gent by the admixture of acetate of lead, Goulard's extract, alum, or a decoction of oak bark ; anodyne, by laudanum, opium, morphia, poppy-heads, or hemlock; stimulating, by chloride of sodium, vinegar, or port wine; ab- sorbent, by iodine and other articles. The fermenting poultice, used in foul, fetid, and painful ulcers, in hospital gangrene, and in mortification, is prepared by incorporating a pound of wheat flour with half that quantity of yeast, the mixture being afterwards exposed to a gentle heat until it swells. The port-wine poultice, which belongs to the same class as the fermenting, is made in a similar manner, except that it is not boiled. The charcoal poultice, also a good antiseptic application, though now rarely used, is prepared from recently burned charcoal, reduced to a very fine powder, and mixed with bread, oatmeal, or ground flaxseed. The objection to this poultice is its liability to discolor the affected parts, so as to prevent us from observing their real condition. This, may, however, be obviated, in great measure, by the interposition of a thin linen cloth. A poultice may be rendered refrigerant by means of a freezing mixture, or a bladder partially filled with pounded ice and spread over its surface. Such an application, however, for reasons already stated, requires great care. 4. Nitrate of Silver.—There is no article which enjoys a higher reputation, as a local antiphlogistic agent, than nitrate of silver ; certainly none that is more frequently employed. Without understanding its precise mode of action, experience has taught us its great value in the treatment of a large number of inflammatory affections, some of which it would be exceedingly difficult to cure without it, while nearly all are more or less benefited by it. Ever since its introduction into practice by Mr. Higginbottom, of England, as a topical antiphlogistic, it has been employed in almost every form of external in- flammation, both in a solid and a fluid state. Indeed, very recently it has been employed, in the latter form, in cases of laryngitis, and one gentleman, Dr. Horace Green, of New York, has gone so far as to assert that he has even mopped the trachea and bronchial tubes with it. Its beneficial effects in dis- eases of the eye, throat, and genito-urinary organs have long been acknow- ledged by practitioners. In cutaneous affections, too, it enjoys a high and well-deserved reputation. In erysipelas it is perhaps more frequently used than any other single remedy, iodine alone excepted. Its value in the treatment of this disease, so common in this and other countries, is fully established, both in a curative and prophylactic point of view. In inflammation of the tonsils and fauces, whether the result of ordinary causes, of a strumous diathesis, or a syphilitic state of the system, no article is so generally employed, or enjoys so great a reputation, as the nitrate of silver. In gonorrhoea and gleet, in strictures and morbid sensibility of the urethra, in spermatorrhoea, in vagini- tis, and metritis, nitrate of silver has become an indispensable means of cure. Indeed, it would be difficult to find an accessible disease, attended with pre- ternatural vascularity and disordered structure, in which its application would not be productive of benefit. Nitrate of silver may be used as a vesicant, as when it is applied to the skin or simply as an alterant, or modifier of diseased action; for, as already stated' nothing definite is known of its mode of operation. When employed for blistering purposes, the solid form is usually preferred, the stick being passed lightly but efficiently over the surface, previously a little moistened with soft water, until there is evidence of slight coagulation of the albuminoid matter of the epidermis. A cloth, pressed out of warm water, is then applied, when LOCAL TREATMENT. Ill vesication will soon follow. The same result may easily be produced by a saturated solution of nitrate of silver; but, as the remedy is less manageable, it is not often employed with that view. Unless applied in a very concen- trated form, and for an unusual length of time, nitrate of silver never acts as an escharotic, or as a destroyer of the tissues. The solid nitrate of silver is often used with great advantage in ulceration of the mouth and throat, the cornea, the skin, vagina, and uterus, the appli- cation being usually made very lightly, and repeated not oftener than once every third, fifth, or eighth day. Employed too frequently or too abundantly, it often does immense harm, not only occasioning severe pain, but sometimes seriously aggravating the morbid action. These effects may be produced equally by a strong solution as by the solid stick. A strong collyrium of nitrate of silver has destroyed many an eye, or urged on an inflammation, perhaps on the very verge of resolution, to a most distressing extent. Ureth- ritis is often aggravated, and greatly protracted, by a strong injection of this description. Much judgment, then, it will be perceived, is requisite in the local use of this remedy, not only as it respects its strength, but also the mode and time of its application. Carefully adapted to the exigencies of each particular case, it exerts a powerful impression upon the diseased struc- tures, diminishing vascular action, relieving pain, and destroying morbid sensibility, often so conspicuous in inflammation of the eye and throat, and which nothing else can so well control. 5. Iodine.—Hardly less valuable than nitrate of silver, as a topical remedy in inflammation, is iodine, first introduced to the notice of the profession, in this relation, by Mr. Davis, an English surgeon. It is generally used in the form of the officinal tincture, either pure or diluted with alcohol. Its great value seems to consist in its alterant and sorbefacient properties, changing the action of the capillary vessels, and promoting the removal of effused fluids. That this is the case is sufficiently apparent from what takes place in erysipelas of the skin, where the effects of the remedy may always be easily watched. Within a few hours after the application has been made the swelling is usually observed to be so much diminished as to cause a marked corrugation of the surface, attended with a diminution of pain and hardness ; circumstances plainly denotive of lessened vascular activity, and progressive absorption. Similar effects are witnessed when the application is made to an oedematous uvula, scrotum, or eyelid, there being not only no further effusion afterwards, but a removal of what was previously deposited. From these facts, it may be inferred that iodine, locally applied, is not merely, as has sometimes been asserted, a sorbefacient, but also an alterant, or modifier of secernent action. Although exceedingly valuable as an antiphlogistic, it is questionable whether iodine has received the attention it really deserves, or whether we are sufficiently acquainted with the class of cases to which it is more particu- larly applicable. Its reputation in erysipelas seems to be fully established, and I have certainly myself found no article at all comparable to it in that affection as an enderraic remedy. It is also of great service in boils, car- buncle, whitlow, corns, bunions, and inflamed, irritable ulcers of the extremi- ties. Its beneficial effects are hardly less conspicuous in active oedema of the uvula and tonsils, the legs, scrotum, prepuce, and pudendum, a single appli- cation often sufficing to produce the most marked change in the condition of the part. As a collyrium and an injection, the value of iodine has not been sufficiently tested to enable us to form any definite opinion, but the trials that have been made with it, in this respect, are encouraging, and deserving of repetition. For external use, I generally employ the tincture of iodine with an equal 112 INFLAMMATION. amount of alcohol, applying the mixture by means of a camel-hair pencil until the skin becomes of a deep yellowish color. The application may be repeated once every eight, twelve, or twenty-four hours, according to the exigencies of each particular case. If the remedy be used stronger than this it will be very apt to produce severe pain and to excite capillary action ; two circumstances concerning which it is impossible to exercise too much caution. When intended for the tonsils, uvula, and other delicate parts, the dilution should, for the reason just mentioned, be still greater. 6. Compression.—Compression, as an antiphlogistic agent, has been too much neglected, nor has it always been judiciously used when resorted to. That it is capable of doing an immense deal of good, when employed with pro- per care, and under suitable circumstances, my experience fully justifies me in asserting. AVhy it is so rarely used, it is difficult to determine, unless it is that practitioners do not possess the requisite skill in its application and mode of management. Very little, certainly, is said about it in surgical treatises; and, as to our teachers, few seem to be aware that there is such an agent. My space will not permit me to enter as fully into the subject as I would de- sire ; a mere outline of a few of the more important facts connected with it must, therefore, suffice. Compression, although more particularly applicable to the latter stages of inflammation, is yet not without its value in the incipient and gravescent periods of the disease. Affording support to the affected structures, it is well calculated, when early employed, to give tone to the distended capilla- ries, enabling them to urge on their sluggish contents, and, consequently, to prevent their effusion into the surrounding cellular tissue. Immense good is often done in this way, as every one knows who has ever treated erysipelas, wounds, fractures, and dislocations, by compression. If two cases of any one of these affections, of precisely the same character, could be treated, one with the bandage, and the other without the bandage, simply by the ordinary topical remedies, the difference would be most striking. The compressed limb would be comparatively free both from pain and swelling, whereas the other would be highly sensitive and greatly enlarged, from inflammatory de- posits. We see, in such circumstances, how, in the one limb, action is con- trolled, and how, in the other, it pursues its wayward course. But this is not the only benefit which systematic compression is capable of affording. When judiciously employed, it controls muscular contraction, and thus pre- vents spasm, both of which are frequently so annoying in fractures, disloca- tions, amputations, and various affections of the joints. Another effect, and that by no means the least striking and important, is the sorbefacient influ- ence which it exerts, rousing the absorbent vessels, and compelling them to remove the fluids that were deposited prior to the employment of the remedy. It is for this reason that compression may be so advantageously used in the latter stages of most of the external inflammations, attended with effusions of serum and fibriu, there being no means known to the surgeon so well calcu- lated to effect this important object, and to assist in restoring the functions of the suffering parts. The treatment of orchitis by compression affords a beautiful and satisfactory illustration of the mode of action of the remedy under such circumstances. When this disease has been shorn of its violence by depletion, the swelling and induration, consequent upon the morbid action, often promptly disappear under the influence of systematic compres- sion ; generally, indeed, in one-fifth of the time in which they disappear under the use of mercury and ordinary sorbefacients. The absorption is frequently so rapid as to render it necessary to change the dressings twice in the twenty-four hours. Similar effects are sometimes observed in inflamed and enlarged joints. LOCAL TREATMENT. 113 The means of compression are the common bandage and adhesive plaster, applied in such a manner as to make gentle and equable pressure over the whole of the affected structures. Whenever the part admits of it, the band- age deserves the preference, as it is more easily managed, and equally effi- cient; but there are certain organs, as the testicle and mamma, where adhe- sive strips alone can be used. When an additional sorbefacient effect is desired, strips of gum ammoniac and mercurial plaster may be substituted for the ordinary plaster. 7. Destructives.—Destructives are remedies which the surgeon employs to destroy the germs of certain diseases, as that of chancre, hydrophobia, and malignant pustule; and to neutralize certain poisons, as that of the snake, and the dead subject. Their action is either curative or prophylactic ; most generally the latter. The most speedy and effectual remedy that can be used in the incipient stage of chancre is excision with the knife, or the destruction of the affected structures with some escharotic substance, as nitric acid, bichloride of mer- cury, or the acid nitrate of mercury. This plan should always be adopted whenever it is found that the poison has not yet had a chance of diffusing itself among the surrounding parts, inasmuch as it not only at once removes the local disease, but protects the system effectually from contamination, the little sore left by the knife or escharotic generally healing in a few days. The parts inoculated by the poison of hydrophobia and malignant pustule should be treated in a similar manner. When the knife is not admissible, on account of the timidity of the patient, the best remedy, according to my ob- servation, is the acid nitrate of mercury, in the form of Bennett's formula, applied by means of a soft piece of wood, as a common match, or the point of a probe, inserted, if possible, into the part, and held there until the tainted structures are deprived of vitality. The same remedy, either pure, or pro- perly diluted, is admirably adapted to the treatment of phagedenic ulcers and spreading gangrene, by whatever cause induced. It should not, however, be used without due precaution, as it is an agent of great power, and may extend its destructive influence much beyond the diseased limits. The ordi- nary nitric acid is less manageable than the acid nitrate of mercury from its liability to spread over the adjacent parts, and is now seldom used as an escharotic. Bichloride of mercury, dissolved in alcohol, in the proportion of two scruples to the ounce, is a most efficient caustic, producing a thin, soft, grayish eschar, which separates in a few days. It is used chiefly in venereal buboes, and always acts more promptly when its application is pre- ceded by a blister. A powerful escharotic effect may be produced by a combination of three parts of bichloride of mercury with one of opium, made into a thick paste with concentrated sulphuric acid. The only objection to these preparations is the excessive pain they occasion, which is sometimes almost insupportable. Similar means may be employed for neutralizing the poison of the rattle- snake and of other venomous reptiles, and for destroying the virus of wounds received in the dissection of dead bodies. In the former case, free excision is practised, followed by the use of the hot iron, or some escharotic sub- stance ; in the latter, the part is held for a considerable time under a stream of cold water, then well sucked, and next thoroughly cauterized with acid nitrate of mercury. 8. Counter-irritants.—Counter-irritants are remedies which, when applied to the surface of the body, excite a new disease, or a new action, in a part more or less remote from the one originally affected. They are never used, or at least not as a general rule, until after pretty thorough depletion has vol. I.—8 114 INFLAMMATION. been practised, by which the inflammation has been robbed of its violence, their effect beiiU alwavs more prompt and decisive under these circumstances. The new disease is generally established close to the original one, but occa- sionally at some distance from it. Thus, in inflammation of the hip-joint, the counter-irritant is usually applied as near as possible over the acetabulum and head of the thigh-bone, the immediate seat of the morbid action, and so with the other articulations. In disease of the neck of the bladder and pros- tate gland, it is applied to the perineum ; of the pleura and lungs, over the nearest point of the chest. In inflammation of the eye, on the contrary, the irritation is established on the nape of the neck, behind the ear, or on the arm, and not in the immediate vicinity of the suffering organ. Great judg- ment is often required to determine the precise point where, as well as the precise time when, the new action ought to be instituted. If it be too near the original affection, it may run, as it were, into it, and thus cause an ag- gravation, instead of a mitigation of the mischief; if, on the other hand, it be too remote, it may entirely fail of the object for which it was employed. Counter-irritation, as already stated, is never resorted to until the system has been relieved of plethora, and the morbid action weakened by other remedies. Used in the height of the morbid action, it can scarcely fail to be productive of local and constitutional disturbance, calculated to exercise a prejudicial influence upon the progress and termination of the case. Although the class of counter-irritants comprises a large number of articles of a very diversified character, they may with great propriety be arranged under two heads, according to their mode of action, as vesicants, and suppurants. (1.) Vesicants are remedies which, when applied to the skin, elevate the epidermis in the form of blisters filled with serum. They are of great value in the treatment of inflammation, both acute and chronic, and are applicable to a great variety of circumstances, with which the practitioner should be fully acquainted. The articles commonly used for this purpose are cantha- rides, either in powder or in the form of collodion-liquid, ammonia, and hot fluids. In acute disease these means, especially the first, are always preceded by active depletory measures, it being well known that, if they are employed before there has been a proper reduction of the system, they are liable to do mischief by increasing the local and general excitement. In chronic inflam- mation, however, they may often be advantageously used at the very com- mencement of the treatment. The vesicating agent is generally placed as near the affected part as possible ; sometimes, indeed, directly over it. Blisters, properly so called, are prepared with the common fly ointment of the shops, and vary in shape and size according to the object they are in- tended to fulfil, or the region to which they are applied. The part, if covered with hair, is previously shaved, and the plaster is confined with a compress and roller, or, what is better, with a few adhesive strips. To prevent stran- gury, an object of great importance in all cases, but particularly in persons of a nervous temperament and in young children, the surface of the blister should always be sprinkled with a few grains of morphia and camphor. The same end may be obtained, though less certainly, by the interposition of a piece of tissue paper, steeped in spirits of camphor. In addition to these precautions, the patient should be requested to make free use of some mucilaginous drink, as flaxseed tea, or gum Arabic water, either alone or combined with a little spirit of nitric ether. If strangury should occur, prompt relief may usually be afforded by a laudanum enema, and hot fomenta- tions to the genitals and hypogastric region, aided, if necessary, by a dose of morphia by the mouth. A blister should, on an average, remain upon the part from six to eight hours, unless the skin is very delicate and sensitive, when a shorter period LOCAL TREATMENT. 115 will suffice. In children, the desired effect is usually produced in from two to four hours, and it is necessary in them to be very careful, otherwise violent inflammation and even gangrene may be the result. I have seen horrible suffering, and, in two instances, death, follow the application of a small blister in children. In the very aged and infirm, similar accidents occasion- ally happen. Parts affected with paralysis often suffer severely from the pro- tracted use of blisters. The plaster need not, in general, be kept on until there is thorough vesication; it is sufficient if the skin is quite red, or if there be here and there a little vesicle, the process being speedily completed by the warm-water dressing, or an emollient poultice, which are always the most suitable applications after the fly has been taken off. It is of great conse- quence to remove every bit of the salve, and also not to break the epidermis, but simply to puncture it with a large needle or small bistoury, to admit of the necessary drainage, it being a matter of great moment to exclude the at- mosphere from the raw surface beneath. The dressings already mentioned may be continued until new skin has formed. Should the surface, however, become red, inflamed, and irritable, bleeding upon the slightest touch, and rendering the patient feverish and restless, recourse must be had to the starch, arrowroot, or slippery-elm poultice, or to the common white lead paint, than which nothing is generally more soothing. It should be put on in a thick layer, which is then to be covered with a sheet of cotton, the whole being supported by a roller. Pencilling the part with a weak solution of nitrate of silver has sometimes a good effect, and so has also the dilute ointment of the oxide of zinc, especially when the surface is studded with large irritable granulations. Cantharidal collodion is a more elegant preparation than the common fly plaster, and may therefore advantageously take its place. It is best applied by means of a camel-hair brush, the surface to be vesicated being thoroughly covered with it, and the evaporation of the ether restrained by a piece of oiled silk, placed immediately upon the part. Unless this precaution be used, the article will require nearly as long a time to produce its specific effect as an ordinary blister. The principal advantages of cantharidal collo- dion are, that it can be more evenly applied to the skin, that it does not shift its position, that it is more rapid in its action, and that it is less liable to produce strangury, especially if it contain morphia in solution, an addition I would always advise. Cantharidine blistering tissue is another elegant preparation for vesicating purposes; easily applied and removed, producing its effects promptly with- out strangury, and leaving no sores. Ammonia is used only when the effect is desired to be strong and imme- diate, as, for example, in croup, where the inflammation, if not promptly checked, may speedily destroy life. Equal parts of lard and powdered harts- horn will produce small vesicles in five or six minutes; and similar effects will follow the application of Granville's lotion or liquid ammonia. Boiling water, the concentrated mineral acids, and the heated iron, cause rapid vesication. All these applications, however, are very painful, and they can never take the place of cantharides. Perhaps the least exceptionable article of this class of vesicants is the nitrate of silver, which often blisters the skin in a few minutes, especially when it is rather delicate, and has been previ- ously well cleansed. The remedy is particularly well adapted to infants and children, as it is never followed by sloughing and other ill effects. (2.) Suppurants are the most powerful counter-irritants we possess. They are much more permanent in their character than vesicants, and are therefore more serviceable in eradicating chronic disease. As their name implies, the discharge which they produce is of a purulent nature, and hence they are sometimes described under the name of pyogenic counter-irritants. The 116 INFLAMMATION. class comprises permanent blisters, setons, and issues, which will receive particular attention in the chapter on Minor Surgery. SECT. III.—CHRONIC INFLAMMATION. Chronic inflammation is distinguished from acute by a variety of circum- stances, which it is of the greatest importance to be able thoroughly to appreciate and understand. Its study, in fact, is of paramount consequence, and I am sure it is not placing too high an estimate upon its value when it is asserted that there is much greater merit in being able to diagnosticate a chronic disease, than to determine the nature and seat of an acute one. When a lesion declares itself, openly and boldly, by a well-marked train of symptoms, the practitioner must indeed be ignorant, if not positively stupid, if he cannot discriminate with tolerable accuracy between it and other affec- tions which may simulate it, or bear some resemblance to it; but it is very different when the malady is of an obscure, chronic character, lurking in the system, no one, perhaps, knowing where, even after the closest and most patient scrutiny. It is under such circumstances that the intelligent patho- logist and observant practitioner often appears to the greatest advantage, by turning his knowledge to the best account for his patient. It does not comport with the design or scope of this work to enter into any of the more minute details of this subject; a large volume might be written upon it, and even then it would not be exhausted. A mere sketch of its more prominent features is all that I shall attempt. Chronic inflammation is of great frequency, and is liable to appear in all organs and tissues of the body; it is generally a consequence or sequela of the acute form, but cases occasionally arise in which it would seem to be a primary affection. Strictly speaking, such an occurrence is of course im- possible ; all that we mean, when we use the word in this sense, is that the disease which it serves to designate is of so stealthy and insidious a charac- ter as to escape, for a considerable time, the attention both of the patient and his physician ; the person is unwell, perhaps occasionally a little fever- ish, or the subject of headache, want of appetite, or a sallow complexion and constipated bowels; or, it may be, he has a cough, and a pain in his side; or a joint becomes sore and stiff; and still he is able to go about, and attend to business, although he is soon fatigued, and rendered uncomfortable by it. Thus a week, a fortnight, or a month may be passed, when, a careful exami- nation being instituted, the discovery is made that there is grave disease in some important organ, and that it has perhaps already gone so far as to render recovery absolutely impossible, however skilfully the case may now be treated. The disease has been latent, or nearly so; it has failed to make itself known by any distinctive train of phenomena, and the result has been that both patient and practitioner have been lulled into fatal security. The morbid action has been lying all this time in ambush, and is now, in the true sense of the term, chronic. Such cases are by no means unfr'equent, and they should serve to admonish us never to neglect any symptoms, however trivial, in our clinical investigations. A pain, a soreness, a cough,' a halt in the gait, may, if properly interpreted, afford useful information hi'regard to the diagnosis of chronic disease, and should teach us the value and import- ance of patience and caution in the examination of the sick. The slightest neglect may be fatal; a little spark may kindle a devouring flame Chronic inflammation, however provoked, is generally tardy and sluggish in its movements, creating little constitutional disturbance, but not on this account, the less surely and effectually undermining the part and system In the acute variety, the action is rapid, bold, daring; suffering is severe • and constitutional response loud and unmistakable. In chronic inflammation on CHRONIC INFLAMMATION. 117 the other hand, the symptoms are, as already stated, often obscure, if not absolutely masked, and the embers of disease never break out into open flame. The disease may continue for weeks and months ; now stationary, smothered, or apparently receding, and now advancing, and seemingly almost ready to assume the acute type. The origin of chronic inflammation is often, if not generally, intimately connected with disorder of the digestive apparatus ; seemingly, at all events, the first link in the chain of morbid action is frequently referable to the state of the stomach and bowels, especially to the effects of dyspepsia or constipa- tion. Idiopathic inflammation of the eye and other organs often owes its origin to gastro-intestinal irritation. At other times the disease is awakened by derangement of the menses, defective action of the kidneys, suppression of the cutaneous perspiration, or disorder of the biliary secretion. Anxiety of mind, grief, anger, fatigue, intemperance in eating and drinking, and in- ordinate sexual indulgence are all so many predisposing and exciting causes of chronic inflammation. The effects of this form of disease are various ; if not closely watched and soon checked it may prove fatal, by the induction of serious structural changes, which neither nature nor art may be able to repair. The most common and important of these changes are suppuration, ulceration, soften- ing, adhesion, contraction, induration, and enlargement, according to the intensity of the morbid action, the texture and situation of the affected organ, and the condition of the general system. The formation of pus and molecular disintegration, whether by softening or ulceration, are exceedingly common attendants upon this variety of inflammation, and often proceed to a most destructive extent. Adhesion is most liable to occur in the serous tissues ; contraction in the bloodvessels and excretory tubes. Induration and enlargement usually coexist, although occasionally they occur independ- ently of each other. Examples of these two changes are constantly met with in surgical practice, especially in the lymphatic ganglions of the neck, axilla, and groin, in chronic disease in and around the joints, in various affections of the skin, cellular tissue, and bones, and in inflammatory hyper- trophy of the tonsils, testicle, mamma, and prostate gland. When existing in a high degree, they lead to serious functional embarrassment of the affected parts, growing out of alterations of structure, which the best directed efforts of the surgeon often fail to relieve. Gangrene, as an effect of chronic inflammation, is rare; nevertheless it is occasionally met with, as is witnessed, for instance, in the mortification of the toes and feet, so graphically described by Pott, and dependent upon ossifi- cation and inflammation of the arteries. In most cases, when the disease passes into gangrene, it first assumes the acute type, which renders the transition much easier, and, in some degree, a necessary preliminary. The symptoms of chronic inflammation are generally much less prominent than those of the acute variety; the pain is less, and usually also more dull or obtuse; the discoloration is dusky, livid, or purple; the swelling, often considerable, is characterized by unusual hardness, or by hardness and oede- ma ; and the heat is nearly always less conspicuous than in acute inflamma- tion. Functional disturbance is variable, being extensive at one time, and slight at another. Symptomatic fever may be entirely wanting, and it is this circumstance which so frequently causes this variety of inflammation to be overlooked, especially when it is of idiopathic origin. In time, the fever may assume a hectic type, or it may be of this character almost from the commencement. When the disease is extensive, or seated in an important organ, adynamic fever generally exists. The vessels of the affected parts are generally very much dilated and dis- tended with red and white globules, on which account the blood is propelled US INFLAMMATION. through them in a very tardy and sluggish manner, strikingly contrasting with the force and rapidity with which it is transmitted in the acute form of the disease, where all is power and activity, especially in its earlier stages. When the imflammation is very protracted, many of the smaller vessels have a varicose, tortuous appearance, and are so crippled as to be almost unable to send on their contents at all. Hence, congestion, often deep and exten- sive, is generally present, both at the focus of the morbid action and for a considerable distance around. Treatment.—In the treatment of chronic inflammation, the indications are, first, to remove the exciting cause of the disease; secondly, to correct con- stitutional disorder; and lastly, to promote the absorption of effused fluids and restore the tone of the crippled and dilated vessels. The removal of the exciting cause of the disease obviously demands the same attention here as in the acute variety of inflammation ; whenever it is accessible it should be promptly disposed of. All officious interference must of course be avoided. Restoration of the secretions constitutes a most important indication, as it is upon their derangement or suppression that the morbid action in chronic inflammation so often depends. The remedies that are chiefly to be relied upon, for this purpose, are mercury, tartrate of antimony and potassa, iodine, bromine, nitro-muriatic acid, purgatives, and a judiciously regulated diet. In placing mercury at the head of this list of remedial agents, I am only endeavoring to show the high estimate that is so justly attached to it in the treatment of chronic inflammation. If its administration is of doubtful pro- priety in many cases in the acute variety of the disease, there are few in- stances of the chronic in which it may not be beneficially exhibited, and yet, in making this remark, it must not be understood that I would give mercury indiscriminately or sakelessly. Its value is unquestionable, but, still, there are cases and circumstances in which it is utterly inadmissible; this is especially true of those cases of chronic inflammation which are so often met with in scrofulous children, and in persons of enfeebled and broken-down constitu- tion, where mercury, in almost any form, is generally most pernicious, the smallest quantity sometimes producing profuse ptyalism, or gangrene of the mouth. In administering this remedy for the cure of chronic inflammation, the sur- geon has it in his power to make choice of a much greater number and variety of articles than in acute inflammation, in which he is obliged to restrict him- self chiefly to calomel and blue mass. In the chronic form of the disease he has, in addition, the bichloride, the protoiodide, cyanuret, and phosphate which exert a most salutary influence in changing the capillary action of the part, and promoting the removal of effused fluids. Whatever substance be selected, the dose should be very small, and not repeated oftener on an average, than twice or thrice in the twenty-four hours. The object is to pro- duce a slow and gradual effect, and for this purpose it will generally be neces- sary to continue the remedy for several successive weeks. Active ptyalism is carefully avoided; it will be quite sufficient if we succeed in obtaining slight soreness of the gums. If calomel be used, a good average dose will be from one-sixth to one-half of a grain. In children, the most suitable mercurials are blue mass, corrosive sublimate and the hydrargyrum cum creta, or gray powder, given either alone or in union with soda, soda and columba, quinine, or Huxham's tincture of bark ^ Iodine and its various preparations, as iodide of potassium, iodide of iron iodide of cadmium, and Lugol's solution; bromide of potassium • barium- and tartar emetic; often exert a most salutary influence over chronic'inflammation and are particularly indicated where a slow, alterant effect is required With CHRONIC INFLAMMATION. 119 the exception of mercury, I know of no article of the materia medica which produces so powerful an effect as tartar emetic in controlling chronic inflam- mation, and favoring the absorption of effused fluids. My practice is to give it in small doses, as the eighth, tenth, or twelfth of a grain, in combina- tion with a little morphine, three times in the twenty-four hours. The different acids are sometimes administered with advantage, especially the dilute nitro-muriatic, which was formerly so much employed in the treat- ment of hepatic affections. They are particularly indicated in chronic syphi- litic and scrofulous inflammations, attended with impaired digestive powers. The bowels must be kept in a soluble condition, the nature and dose of the purgative being regulated by the exigencies of each particular case. The compound calomel pill, which, while it operates on the bowels, also excites the action of the liver and skin, constitutes one of the most eligible cathartics we possess in the treatment of chronic inflammation, accompanied with visceral obstruction. Particular attention should be paid to the skin. This will appear the more necessary, when we consider that, in most cases of chronic disease, the per- spiration is either entirely suppressed, or greatly changed in its properties. Frequent ablutions with cool, tepid or warm water, impregnated with com- mon salt, soap, mustard, or potash, and followed by dry frictions, will often prove eminently serviceable. The renal secretion should also receive proper attention; sometimes elaborate chemical and microscopical examinations will be required to determine its character, and enable us to direct a suitable plan of treatment. Exercise in the open air, either on foot, in a carriage, or on horseback, will often effect a wonderful improvement in cases of chronic inflammation, especially when of long standing, and attended with great debility. At other times, nothing but the most perfect rest will answer the purpose; as, for exam- ple, in serious disease of the brain, bones, and joints. The subject of diet must claim special attention in the treatment of chronic inflammation. The indiscriminate use of food in this form of disease cannot be too severely reprehended. Too great abstinence, however, is often as in- jurious as too great indulgence. As a general rule, it may be stated that all stimulating and indigestible articles should be avoided, as being calculated to increase the local disease, and exercise a prejudicial effect upon the patient's recovery. If the system be inclined to plethora, the diet should be of a strictly farinaceous character, and daily be limited to a few articles, which may be varied from time to time as they become disagreeable to the palate, or offen- sive to the stomach. If, on the other hand, the patient is pale and feeble, it should be partly farinaceous, and partly animal, the meat being taken at breakfast and dinner, and its effects carefully watched. The different kinds of animal and vegetable broths, beef-essence, milk, arrowroot, rice, sago, and tapioca, are all eligible articles in chronic inflammation, and often prove of the greatest service in nourishing and sustaining the system. Their flavor and efficacy may be improved by the addition of spices, wine, and brandy, as may be deemed proper. When the patient is much exhausted, the use of brandy, wine, ale or porter, will often be indispensable to recovery. When marked debility exists along with emaciation, recourse may be had to cod- liver oil; rather, however, as an article of nourishment than with a view to the attainment of any alterant effect it may be supposed to possess from the presence of iodine and bromine. The dose should then be as large as may be consistent with gastric tolerance. Finally, in the female, proper regard must be had to the state of the men- strual function; prompt measures being adopted for its improvement, or, in the event of its suppression, for its restoration. There are numerous com- 120 INFLAMMATION. plaints which owe their origin, either directly or indirectly, to disorder of the uterine functions. The local treatment of chronic inflammation is often a matter of paramount importance. It comprises, first, rest and elevation of the parts, the same as in acute disease; secondly, leeching, scarification, blistering, iodine, and nitrate of silver, especially in the earlier stages; thirdly, counter-irritation by croton oil, tartar emetic, issues, setons, and the actual cautery; and, lastly, sorbefa- cients, such as stimulating liniments, embrocations, and unguents, the cold douche, compression with the bandage, or adhesive strips, electricity, and dry friction. DELITESCENCE AND RESOLUTION. 121 CHAPTER IV. TERMINATIONS AND RESULTS OF INFLAMMATION. SECT. I.—DELITESCENCE AND RESOLUTION. These terms are used to denote the restoration of the inflamed structures to their normal condition. The word delitescence is of Latin derivation, and literally signifies to abscond; it was introduced into surgical nomencla- ture by the French writers, and is employed to designate the sudden disap- pearance of inflammation, before it has passed through its different stages, and, consequently, before it has occasioned any serious structural changes. It is unquestionably the most desirable mode of termination, and may occur either spontaneously, or from the slightest treatment. A catarrh, caused by exposure to cold, and perhaps threatening to be quite severe, often aborts during a profound sleep induced by a warm bed, or a hot foot-bath and a grain of opium. An inflammation of a lymphatic ganglion of the neck, coming on late in the evening, and attended with great tenderness on motion and pressure, together with considerable swelling, often rapidly disappears under similar measures. An incipient gonorrhoea frequently aborts under the use of a mild injection of nitrate of silver or acetate of lead; and who has not seen a bubo promptly vanish under steady, systematic compression, aided by the application of a solution of iodine ? Inflammation produced by the presence of a foreign body generally rapidly disappears after the removal of the exciting cause of the morbid action. The above facts, with many others that might be brought forward, if it were deemed necessary for my purpose, teach us two most important lessons: the first, is always to remove as early as possible the exciting cause of the inflammation; and the second, to enter upon the treatment of every case of the disease without the least delay. The object, invariably, should be to save structure, and the best way to do this is to make the disease abscond, or delitesce. Such an event, however, is only desirable when the inflammation can be dislodged more or less completely without the risk of throwing it upon some other and, perhaps, more important organ. Thus an attack of gout in the great toe would be a trifling affair in comparison with an attack of gout in the heart, brain, or stomach; and hence it would be far better, where there is danger of such a translation of irritation, to let the original disease pursue its course than to attempt to arrest it by means calculated to favor such a result. A severe injection may suddenly arrest an incipient gonorrhoea, but it may do infinite harm by the rapid induction of orchitis, which perhaps no treatment, however judiciously conducted, may be able to dispel completely under several weeks, if, indeed, under several months. The sudden disappearance of inflammation from one structure, or set of structures, and its invasion of another, usually known by the term metastasis, suggests the importance of proper watchfulness on the part of the surgeon to prevent such an occurrence; or, if it have already taken place, to employ such means as shall be calculated to recall the morbid action as speedily and as effectually as possible to its original situation. For this purpose free use should be made of counter-irritation, in the form of stimulating embrocations, 122 TERMINATIONS AND RESULTS OF INFLAMMATION. sinapisms, and blisters, aided, if the organ affected be one of great im- portance to life, by the abstraction of blood and full doses of opiates. If, in this way, the disease cannot be recalled, the treatment will go far to put a speedy "stop to its violence and its tendency to extension. The term resolution denotes the gradual dissipation of inflammation after the disease has made some progress and done some mischief, but before it has reached the suppurative crisis, or committed such ravages as to prevent the affected tissues from regaining their original properties. With such an issue effusion of serum and lymph is not at all incompatible, as these fluids may be entirely absorbed; a similar remark is applicable to pus, provided it exist in small quantity, and not in the form of an abscess, in which there is always more" or less waste of tissue ; and even to pure blood, which, if not too abund- antly effused, or deprived of its vitality, is generally readily amenable to the action of the absorbents. When resolution is about to occur there is a gradual and steady subsidence of the morbid action, as denoted by the changes in the local and constitu- tional symptoms. The discoloration, heat, pain, and swelling become less and less inconsequence of the contraction of the vessels and the absorption of the effused fluids; the febrile disturbance goes off; and the part and system, nu longer feeling the effects of the disease, at length regain their former condi- tion. Often many weeks, and even several months, elapse before the restor- ation is finally completed. The absorbent vessels, kept in abeyance by the vascular action and the effused fluids, are slow to resume their functions ; they act at first hesitatingly, as if afraid to enter upon their labor, but as the work progresses they acquire confidence, and, at length, setting about it in good earnest, they ere long finish their task, drinking in, as it were, all that their oppressors, the seceruents, had previously poured out, and thus leaving the parts in a condition to regain their primitive characters. The bloodves- sels usually remain dilated, feeble, and sluggish for some time after the com- plete subsidence of the disease, and there is also frequently more or less per- version of special sensation. SECT. II.—DEPOSITION OF SERUM. A deposition of serum, or of the watery elements of the blood, is a common attendant upon inflammation, and in some cases constitutes the principal, if not the only evidence of its presence. The structures which supply it in greatest abundance, when thus affected, are the cellular and serous, the secernent vessels of which are generally extremely active, even when the dis- ease is comparatively mild. Large quantities of serum are also occasionally poured out by the mucous membrane of the alimentary canal, especially by that of the colon and rectum, as is observed in certain forms of diarrhoea and infantile cholera. Inflammation of the skin, unless produced by scalds, blisters, erysipelas, and the various bullar diseases, yields this fluid generally very sparingly. Very little is also effused in inflammation of the muscles and fibrous membranes, the nerves and vessels ; while tendon, cartilage, and bone do not afford any, however severe the lesion. A similar remark is applicable to inflammation of the parenchymatous and glandular organs, as the lung and liver. In the cellular tissue serous accumulations are particularly liable to occur wherever this substance is most loose and abundant- hence they are very common in the eyelids, scrotum, prepuce, labia, nymphJe, legs, and feet, which are often enormously distended in consequence. Oedema of the glottis is an example of watery deposit in the submucous cellular sub- stance of the edges of the windpipe. In the splanchnic cavities and the movable joints serum often collects in immense quantities; sometimes as an effect of acute, but more frequently as a result of chronic inflammation DEPOSITION OF SERUM. 123 Particular epithets are employed to designate certain collections of serum, based either upon the appearance of the part, or the anatomical name of the cavity which serves to receive the fluid. Thus we are in the habit of speak- ing of oedema of the glottis, oedema of the eyelids, and oedema of the legs, simply because these structures, when thus affected, have a swollen, glossy aspect. The older writers applied the word anasarca to all aqueous accumu- lations of the inferior extremities, as the appearance thereby produced bears some fancied resemblance to a mass of flesh. Dropsy of the legs is another familiar expression intended to designate the same thing. The latter term, however, is generally restricted to the collections of serum in the various cavities of the body. Thus, when we speak of water in the peritoneum, we say that the individual has dropsy of the abdomen, and so of the chest, head, pericardium, joints, and vaginal tunic of the testicle. Or, instead of this term, we use a Greek one, either simple or compound, as being somewhat more classical. In this manner a dropsy of the abdomen becomes an ascites ; of the chest, a hydrothorax; of the head, a hydrocephalus; and of the va- ginal tunic, a hydrocele. The appearance of the serum is generally limpid, but cases occur in which, from the admixture of extraneous matter, or hematin, it is yellowish, milky, or even quite dark. The latter appearance is generally present in the peri- toneum in strangulated hernia, and is to be viewed as an evidence of intense inflammation. A similar phenomenon is witnessed in the blebs of incipient gangrene, and in the enormous serous accumulations which occasionally occur in the limbs-in consequence of snake-bite and other severe injuries. The fluid occasionally contains flakes of lymph, pus, and pure blood, although the latter is uncommon. It is often quite unctuous to the touch, is saline in its taste, but free from odor, and is readily coagulable by alcohol, acids, and corrosive sublimate; circumstances which show that it is composed principally of albumen, in combination with some of the earthy salts, espe- cially the sulphates. Its quantity in acute inflammation is usually small, ex- cept in the splanchnic cavities, where it is sometimes immense, amounting to many quarts, or even several gallons. Under such circumstances, too, it always contains more or less fibrin. Much diversity of sentiment has been expressed in relation to the kind of action by which this fluid is produced ; some declaring that it may be de- posited without the aid of inflammation, while others maintain that it is in- variably the result of this morbid process. I have long been impressed with the truth of the latter doctrine, and have strenuously advocated it in my writings, as well as in the lecture-room, for the last twenty-five years. I can- not, indeed, see how it is possible to reach any other conclusion, unless we assume, which, however, I am not inclined to do, with certain pathologists, that there is no real or genuine inflammation without suppurative action, or, at all events, plastic exudation. Such a doctrine as this would, of course, be fatal to the idea that serous effusion is a result of inflammation. But these pathologists, notwithstanding their attempts at theorizing, are well aware that inflammation often, if, indeed, not generally, proves fatal long before it reaches this height. There is, therefore, but one alternative in regard to this question ; we must assume either that there may be inflammation with- out exudation of fibrin and the formation of pus, or that thousands of persons daily perish without any disease whatever, simply from perverted nutrition, or functional disorder. To entertain such an opinion would be absurd, and we are therefore forced to the conclusion that, whenever there is an effusion of serum, such an effusion is denotive of the existence of inflammation, even when there has been no tangible evidence of the ordinary phenomena of the disease, as heat, pain, and discoloration. We have an illustration of this fact in chronic dropsies, where the inflammation is often so extremely mild 124 TERMINATIONS AND RESULTS OF INFLAMMATION. that, save the mechanical inconvenience which the fluid occasions, the patient is hardly conscious of any suffering whatever. Yet even in such cases it will generally be found, on dissection, that the serous membrane which furnished the water, exhibits sufficient indication of the lesion, as afforded by the opaque and thickened condition of its substance. It may be questioned whether mere congestion is capable of producing serous effusion. At first sight such an occurrence would seem to be quite probable; but a careful examination of the subject soon dispels the illusion. Permanent obstruction of the ab- dominal cava will cause ascites ; not from congestion of the vessels of the peritoneum, but as a consequence of its inflammation, the result of the pre- vious vascular engorgement. It is easy to see that vessels habitually dis- tended must soon take on incited action, followed by abnormal deposits. A familiar illustration of this is afforded in the conjunctiva, where, if the vessels are at all engorged even for a short time, inflammation is sure to fol- low, unless the exciting cause of the determination be removed. If this mode of reasoning be correct, it follows that obstruction of the circulation, however induced, will, if permitted to continue, be soon succeeded by inflam- mation, of a grade and character sufficient to cause at least an effusion of serum, if not also of other fluids. Of the nature of the morbid action, when serum is rapidly supplied, or when it is associated with other deposits, as lymph or pus, there can be no doubt; it is eminently inflammatory, and nothing else. The concomitant symptoms, and dissection after death, clearly establish the fact. The rapid and profuse serous exhalations which occur in acute pleurisy, peritonitis, and arachnitis admit of explanation in no other way; they are the appropriate products of these structures, and hence they are generally poured out quite early in the disease. Effusion of serum is often associated with, if not remotely dependent upon, an impoverished and watery condition of the blood, accompanied by a marked decrease of fibrin and red particles. If, under such circumstances, inflamma- tion be lighted up in almost any of the tissues, especially the cellular and serous, serum cannot fail to be supplied in large quantities, since, in conse- quence of the diminution of the plastic properties of the blood, there is nothing to restrain its exudation. Hence such action is very prone to be followed, externally, by anasarca, or oedema, and internally by dropsy. The symptoms produced by this deposit are such, mainly, as are denotive of mechanical obstruction. In the eyelids, scrotum, prepuce, vulva, glottis, and legs, it is marked by a soft, inelastic swelling, which pits on pressure, and imparts a peculiar glossy appearance to the affected surface; attended, especially in the inferior extremities, with pain, heat, and more or less dis- coloration, usually of a pale dusky hue. A sense of distension is also com- monly a prominent symptom. In oedema of the glottis there is serious impediment in the respiratory function, while in accumulations of water in the splanchnic cavities there must necessarily be more or less oppression, with displacement of the contained viscera. A large collection of water in the chest may not only cause collapse of the lung on one side, but greatly encroach upon the opposite one, and at the same time throw the heart com- pletely out of its natural position, depress the diaphragm, and tilt up the intercostal spaces so as to give the thorax a vaulted configuration. In infil- tration of the cellular tissue of the legs, feet, scrotum, and vulva, the fluid may, by its pressure upon the capillary vessels, cut off the supply of blood from the skin, and thus become a source of mortification, as we see exempli- fied in erysipelas and anasarca. Treatment.—In the treatment of serous effusions, the main indication is to promote the absorption of the offending fluids by the use of hydrago^ue cathartics, diuretics, and mercurials; followed, when these means fail, by a LYMPHIZATION. 125 puncture for their efficient evacuation. The most important cathartics, after thorough purgation, are jalap and bitartrate of potassa, citrate of magnesia, and elaterium, given in doses proportioned to the strength of the patient and the tolerance of the stomach and bowels. These remedies, as well as others of a kindred nature, produce their beneficial effects by establishing a drain upon the serous capillaries of the alimentary canal, which leads indirectly to the absorption of the serous accumulation. When mercurials are required, as they will be when there is obstruction of the portal circle, with deficiency of the biliary secretion, the most eligible articles will be calomel, blue mass, or corrosive sublimate, either alone or in union with elaterium, squills, digitalis, or antimony, according to the nature of the collateral disorder. Deficiency of the renal secretion must be met by suitable diuretics. When the accumulation of serum is very great, as in cases of dropsy of the chest, abdomen, or pericardium, all internal treatment will be likely to prove abortive, from the fact that it is generally impossible, under such circum- stances, to arouse the absorbents to a sense of their duty; the pressure of the fluid keeps them in a crippled and paralyzed condition, altogether incompati- ble with the healthy exercise of their functions. Hence, instead of wasting our time and the strength of our patient, as is unfortunately too often done in such cases, early recourse should be had to an operation with a view of afford- ing vent to the pent-up matter. I am certain, from frequent observation, that serious and even fatal errors are constantly committed by practitioners from their indisposition to early interference with the trocar in these accumulations. They forget that their purgative, diuretic, and alterative remedies, if available at all, cau prove beneficial only at the expense of much distress and exhaus- tion of the system, which too often leave the sufferer, in the event of his recovery from the disease, with shattered and broken health for years after- wards, if not during the remainder of his life. An operation, on the other hand, generally affords prompt and efficient relief to the urgent symptoms, and places the part in a condition to be influenced by sorbefacient measures. Local remedies are available chiefly in serous effusions in the external parts of the body. In oedema of the extremities vast benefit is often derived from steady and persistent elevation, and regular, equable compression with the bandage, extending upwards from the distal portion of the limb. In this way support is given to the capillaries, while a salutary stimulus is imparted to the absorbents, well adapted to rouse them into action. This treatment often derives important aid from frictions with sorbefacient unguents, lini- ments, and embrocations, and the application of the dilute tincture of iodine. When the distension is inordinate, or threatens to eventuate in gangrene, early punctures and even free incisions are called for. In oedema of the glottis nothing short of prompt and decisive scarification will prevent suffo- cation. SECT. III.—LYMPHIZATION, OR FIBRINOUS EXUDATION. Lymphization is the act of separating lymph from the blood and depositing it into the organs and tissues, or upon their free surfaces. The term, which I was the first to introduce into science, has been objected to, on the ground, as is alleged, that it is not well chosen, because the word lymph is given to the fluid contained in the lymphatic vessels. I can perceive no reason, how- ever, why it should not be retained and generally adopted, for it is certainly quite as appropriate and classical, in reference to the substance which it serves to designate, as the word suppuration is in relation to pus, which is the pro- duct of that act. I am the more inclined to this view, seeing that the word "lymph" is still in general use, notwithstanding the attempts that have re- cently been made to discard it by substituting the term " plasma," which is, 126 TERMINATIONS AND RESULTS OF INFLAMMATION. if possible, still more objectionable. Perhaps the least obnoxious term is "fibrin," which is now also much in vogue, and which is expressive of at least one of the most important attributes of that substance, namely, its chemical constitution. The phrase "plastic matter" would be very appro- priate, were it not that it is too circuitous for easy use. There is rarely any inflammation, however slight, in which there is not some deposit of lymph. Indeed, in many cases, and in certain situations, it constitutes almost the only product of the morbid action. Thus, in croup and peritonitis, the chief evidence of the existence of these diseases, after death, is the presence of lymph; in general, however, it is associated with other deposits, especially serum, which is often poured out along with it in large quantities. When the inflammation is at all severe, and particularly if it has already made considerable progress, there may be, in addition, puri- form matter, pus, and even pure blood. Its presence, whether occurring singly or combinedly, is always, as a general rule, denotive of a higher grade of action than the mere effusion of serum. The capacity of furnishing lymph, in inflammation, is possessed in different degrees by different organs and textures, depending upon the peculiarities of their organization. It is always, other things being equal, poured out most freely by the serous membranes, especially the pleura and peritoneum, by the cellular tissue, and by certain portions of the mucous system, as the faucial, laryngeal, intestinal, and uterine. Very little is effused, under any circum- stances, by the fibrous membranes, the muscles and their tendons, the vessels, nerves, cartilages, and bones, except in cases of fracture and other injuries, when it is sometimes thrown out in great abundance. In the parenchymatous organs, the same diversity obtains in respect to this deposit as in the tissues, properly so called. In some, as in the brain, liver, and kidneys, it is usually supplied very sparingly, whereas, in inflammation of the lungs and spleen, it is often effused quite freely, leading to rapid solidification of their proper structure. Large quantities of lymph are sometimes exhaled during the progress of abscesses, many of which it serves to inclose in a distinct cyst, known as. the pyogenic membrane. The deposit of lymph generally begins soon after the inflammatory action, and often continues for an indefinite period, increasing and declining with the disease. It is surprising how soon it sometimes shows itself. From my experiments upon inferior animals, as well as from my observations upon the human subject, I have been led to believe that it" generally begins much sooner than is commonly supposed. In 1841, I had occasion to see repeated proofs of this fact, while engaged in an elaborate series of experiments upon dogs, with a view of elucidating the nature and treatment of wounds of the intestines. I found, in many of these animals, that the bowels had become extensively adherent, not only to each other, but likewise to the walls of the abdomen, within the space of a very few hours after the operation. In the case of a gentleman whose abdomen I opened some years ago, on account of a twist in the small intestine, I ascertained that, although death happened at the end of four hours, nearly the whole peritoneum, visceral and parietal, was coated with a thin film of fibrin, of which hardly any traces existed anywhere at the time of the operation. In another case, that of a young lad, who died within nine hours after he had been shot in the side, the ball wou'ndiii"- the abdomen, diaphragm, and chest, large quantities of lymph were seei^both upon the peritoneum and pleura. The flaps made in amputation become speedily glazed with fibrin, and a similar phenomenon is often witnessed upon incised wounds, the edges of which frequently adhere quite firmly within a very short time after the application of the dressings. From the preceding facts, it may be concluded that the process of lymphi- zation generally begins at an early period of the inflammation, and that, if LYMPHIZATION. 127 the circumstances are at all favorable, it proceeds with great vigor. If the reverse, however, be the case, then it goes on comparatively slowly, or it may even fail entirely. Such an event will be most likely to happen in low and depraved states of the system, attended with an impoverished condition of the blood, and consequent lesion of the innervation. Lymph, plasma, or fibrin, considered as an effect of disease, is a direct product of the vessels of the affected structures, the process by which it is elaborated being one of a vital character, analogous to, if not actually iden- tical with secretion. No one, so far as I know, doubts this opinion, except Virchow, who maintains that this substance has an extra-vascular origin, or, in other words, that it is a local product of the tissues, on and in which it is found, being essentially composed of the material generated in the inflamed part itself through the changes in its condition. He denies that there is, in the usual acceptation of the term, any inflammatory exudation whatever ; or, what is the same thing, he insists upon it that there is no real transuda- tion from the blood-liquor. Time will prove whether this opinion is true or erroneous. Lymph exhibits, when first effused, a whitish, pale straw, or opaline ap- pearance,, though occasionally it is somewhat reddish, from the admixture of hematin. In cases of protracted jaundice, I have occasionally found it of a pale-orange hue. It is of a soft, unctuous consistence, like hot glue, or a thin solution of starch, without smell, and of a faint saline taste. Its chemical constitution is fibrin, in union with albumen and serum. Immersion in alco- hol renders it tough, and changes its color from white to buff. Examined microscopically, lymph is seen to consist of numerous globules, of a spherical shape, nearly homogeneous, and about the o 5V0 °f an inch ^n diameter. Delicate fibrils, straight, parallel, and interspersed with innumer- able granules, are also visible in it. It is derived directly from the blood by a process of secretion, and is identical with the buffy coat and the blood- liquor ; possessing vital and organizable properties, and therefore capable of performing important duties in the economy. Being always deposited in a fluid state, it soon arranges itself in various forms; now as an amorphous mass ; now as a tube, as in the larynx, and bowel; at one time as a lamella, and at another as a distinct band ; its conformation being materially influ- enced by that of the organ, tissue, or cavity in which it is effused. Lymph does not always exhibit the same appearances under the microscope any more than it does under the naked eye. In this respect it shares the same fate as other morbid products. I cannot, therefore, recognize the doctrine of an essential difference in the character of the effused substance, so strenu- ously maintained by some recent pathologists, believing, as I do, that this difference is entirely due to a difference in the state of the part and system in different individuals, localities, and grades of the morbid action. Corpus- cular lymph, as it has been termed, differs from ordinary lymph only, or chiefly, in having a greater number of exudation globules, and less of healthy fibrin. Hence, it is generally met with in persons of deficient vital powers, with an impoverished state of the blood, and usually manifests a disposition to break down and become effete. Fig. 7 displays a portion of recently-effused lymph, opaque, white-colored, friable, and magnified about 380 diameters, from an inflamed pleura. It is composed of globules, smaller molecules, and granular matter in a hyaline matrix. In the lower part of the figure the granules and molecules are shown as floating in serous fluid. In fig. 8, the structure of the effused matter is somewhat different. It forms, in fact, a sort of false membrane, magnified 800 diameters. Numerous corpuscles are seen, more or less globular, and having the character of primary cells; the intervening texture is formed of 128 TERMINATIONS AND RESULTS OF INFLAMMATION. most delicate fibrils. A few minute granules are interspersed through tissue. Fi-. 7. Fig- S" Fig. 7. Plastic corpuscles and filaments in recent lymph exuded on the pleura, a. The corpuscles, unchanged by acetic acid. Fig 8. Recent lymph, forming false membrane. The period at which the organization of this substance takes place varies with a number of circumstances, of which the most important are, the plasti- city of the effused matter, the nature of the affected tissue, and the state of the general system. To enable it to attain this point at all it is necessary that it should have a strong cell-life, or cell-force; for when this is wanting the development of cytoblasts and nuclei is either impracticable, or it occurs so imperfectly as to be soon arrested, or, at all events, very much impaired. When everything is favorable, the development proceeds very rapidly; cells and nuclei are formed in great numbers, and these, connecting themselves with each other, are gradually spread out into fibres, lying, for the most part, in straight, parallel lines, and profusely inlaid with granules, as in fig. 9. Soon after this process has begun, vessels show themselves in the new pro- duct, either as an offspring of a new epigenesis, or as an extension from the neighboring structures, the latter being by far the more common source of the supply. The walls of the vessels are, at first, very frail and yielding, so Fig. 9. Fig. 10. Fig. 11. Figs. 9 and 10, frbm Bennett, show nuclei and cells developing themselves into fibres: whilst fig. 11 exhibits a perfect fibrous tissue. that the least pressure is sufficient to rupture them and cause an extravasa- tion of their contents. Gradually, however, as they increase in age, they become better qualified for the discharge of their functions, and In time acquire all the properties of the natural vessels. When fully developed they can be easily discovered with the naked eye, and readily admit fine injecting matter. The veins are usually disproportionably large to the arteries but this defect also ultimately disappears. Nerves and absorbents likewise exist LYMPHIZATION. 129 but whether they are supplied by the surrounding tissues, or by the inherent powers of the effused matter is undetermined. The arrangement of the newly-formed vessels is represented in the annexed sketches. Fig. 12 is a portion of coagulating lymph attached by a narrow neck to the peritoneal coat of an inflamed intestine. The vessels have a ramiform disposition, and freely anastomose with each other. Fig. 13 is a Fig. 12. Fig. 13. Newly-formed vessels in plastic lymph. piece of false membrane of the pleura and farther advanced than in the other sketch. There are some situations where fibrin is never organized, however strong its vitality may be at the moment of its deposition. Such an occurrence, for example, is nearly always impossible in the alimentary canal and urinary bladder, for the reason that the irritating and heterogeneous contents of these reservoirs speedily deprive the lymph of its organizable properties. Site, then, exercises an important influence upon the process, which, it may be added, is also materially affected by the state of the blood and solids; the more feeble and impoverished these are the less likely will the effused sub- stance be to form cells and nuclei, vessels, nerves, and absorbents. Lymph is susceptible of absorption both in its fluid state and after it has been changed into blastema and fibro-cellular tissue. This, however, does not occur, at least not to any extent, during the height of the inflammation, by which it has been produced; on the contrary, there must always be a marked reduction of the morbid action before the absorbent vessels can be induced to take hold of it; but when this point has once been reached, the process often goes on very rapidly, as is witnessed in fractures, dislocations, wounds, and other injuries, in which the swelling, chiefly caused by fibrinous deposits, occasionally completely vanishes in a few days. The absorption will of course be more difficult when the lymph has become organized, when, in fact, it not unfrequently effectually resists all the efforts that the surgeon can employ to get rid of it. The opaque spot on the cornea often remains despite of the most protracted treatment. It is probable that lymph, before it can undergo absorption, even in its liquid state, is broken up and dissolved in the fluids of the affected parts; being thus brought more readily under the influence of the vessels. Moreover, lymph is susceptible of various kinds of degeneration, both in its early and in its more advanced stages, just like other deposits and forma- tions. When recently effused, it may be converted into pus, especially when it is aplastic and exposed to the air; under which circumstances it also fre- quently becomes hard, dry, and shrivelled, losing its vitality, and assuming the character of an effete substance. It also undergoes fatty degeneration, both before and after vascularization ; and, finally, there are cases in which it becomes the seat of pigmentary deposits. VOL. i.—9 Vessels in false membrane of the pleura. The vessels are large, numerous, 130 TERMINATIONS AND RESULTS OF INFLAMMATION. 1. USES OF PLASTIC MATTER. The uses of coagulating lymph in the repair of disease and injury were very imperfectly understood by the older surgeons, and hence it is not diffi- cult to account for their erroneous principles of treatment. A few only had any correct notions on the subject, which, however, strange as it may appear, they rarely applied in practice. Taliacotius, although he knew how to re- construct "mutilated parts, by the transplantation of integument from one region of the body to another, seems never to have thought of applying the knowledge thus acquired to the reunion of accidental wounds. Instead of approximating their edges and keeping them together for a certain period, to insure their adhesion, the older surgeons not only allowed them to gape, but took great pains to irritate and inflame them, thinking thereby to rid the part and system of noxious humors. No person with such an injury was deemed safe until the parts had passed through a process of mundification, suppuration, and incarnation. To treat them otherwise would, in their judgment, have subjected them to great hazard, on account of the supposed retention of peccant matter. An opportunity must be afforded for the escape of this matter, and the period consumed in this delusive treatment often extended through several months even in the most insignificant cases. Wounds which, if properly managed, would have healed in a few days, were thus often kept open for an incredible length of time. This practice, so pre- judicial to the true progress of surgery, and so utterly at variance with the best interests of humanity, continued in vogue until the time of John Hunter, towards the close of the last century. It remained for this illustrious man to point out the properties of plastic lymph, and to describe its many surgical uses. Through his influence a happy revolution has been effected in the treatment of wounds and other injuries, as well as in the various plastic operations, the beneficial effects of which cannot even yet be fully estimated. The modern practice in the treatment of wounds is, as soon as all oozing of blood has ceased, to approximate their edges by appropriate dressings, and to retain them in this position for a sufficient length of time to insure their reunion by the organization of the plasma that is effused between them. But little inflammation is required for the process, and hence the chief duty of the surgeon consists in keeping the parts cool, elevated, and at rest. The great danger is in doing too much, thereby thwarting nature's efforts at repair. All heating and stimulating applications are out of the question, as so many impediments to the desired action ; the mind and body are kept free from excitement, and the strictest attention is paid to the bowels, diet, and secretions; under this management the wound generally heals in a few days, the bond of union becoming hourly firmer and firmer until it is as per- fect as nature can make it by the conversion of the plasma into fibro-cellular matter, of which, however, very little is ordinarily left when the process is completed. Parts completely separated from each other, and immediately replaced, will, if judiciously managed, often reunite, and be nearly, if not quite, as use- ful as before.' Numerous cases, of a well-authenticated character, are upoD record of bits of fingers, the nose, and the ear having been successfully treated in this wise. It was upon a knowledge of the plastic properties of coagulating lymph that Taliacotius founded his world renowned operation, which is now univer- sally known by his name, of repairing mutilated noses, lips, and ears. His attention was originally directed to the subject by watching the effects of the grafting of trees; he observed that the transplanted portion not only con- tracted firm adhesions in its new situation, but that it generally grew with USES OF PLASTIC MATTER. 131 great vigor, and ere long produced most excellent fruit, altogether superior to, and different from that of the parent stock. Possessed of a profoundly inventive genius, he was led to believe that a similar operation might be per- formed upon man, and it was not long before he put his reasoning to the test of experiment. His success was complete, and the result was that he became the great rhinoplastic surgeon of his day. His method consisted in raising a flap of integument from the arm, and after having thoroughly pared the mutilated organ, in sewing the raw edges accurately together, care being afterwards taken to maintain the parts in contact with each other until they had become closely and inseparably united. The Indian method, as it is termed, differs from that of Taliacotius mainly in this, that the flap of skiu is generally borrowed from the immediate vicinity of the deformed organ, its pedicle being twisted upon itself in such a manner as not to interfere injuri- ously with its circulation. Du Hamel, near the middle of the eighteenth century, executed some curious experiments, which, as having a direct bearing upon the present subject, deserve passing notice, notwithstanding they are old and trite. They consisted in ingrafting the spur of a cock upon the comb of the same animal, where, especially if the spur was a young one, it generally promptly united. In one instance he found that the spur, although not larger than a hemp-seed when the operation was performed, acquired in the course of from three to four years a length of several inches. The experiment was subsequently repeated by John Hunter with similar results. He ascertained not only that what Du Hamel had said was perfectly true, but that, if the testicle of a cock be transplanted into the abdomen of a hen, such complete union will occur between them as to permit minute injecting matter readily to pass from the vessels of the one into those of the other. The fact that a tooth, extracted by mistake, will, if immediately replaced in its socket, speedily reunite, and ultimately regain its former hold, has long been familiar to dentists. It was formerly supposed that the adhesion was always imperfect, but that this is not so is shown by the circumstance that the vascular connection between the tooth and the socket may be demonstrated by injection. The knowledge of this fact led to the painful and disgusting practice, so much in vogue in the last century, of transplanting teeth from the mouth of one person into that of another, and which was finally abolished only when it was discovered that it was fraught with danger, on account of its liability to transmit disease. Finally, there is, as an additional illustration of this interesting subject, the singular experiment of John Hunter of inserting afresh human tooth into the comb of a cock, where it took root, and became firmly fixed, new vessels extending up into the cavity of the fang, as was ascertained by injection after the death of the animal. Curious and instructive as the above experiments are, they hardly equal, in point of interest, many of those that have been performed by the modern surgeon upon the human subject for the relief of mutilated structures. Whether science has attained its highest triumphs in the department of plastic surgery, or whether it is capable of still further achievements, time alone can determine. The good effects of plasma are exhibited in various other processes, as in the suppression of hemorrhage, and the radical cure of hernia. In the former, the patient would inevitably bleed to death if it were not for the agency of lymph in sealing up the mouth of the vessel by attaching the in- ternal clot firmly to its surface. In hernia a radical cure can only be effected through the intervention of plastic matter, thrown out in consequence either of the pressure of a well-adjusted truss, or the injection of some irritating fluid, causing inflammatory action in the parts around. 132 TERMINATIONS AND RESULTS OF INFLAMMATION. Plastic matter is often of service in circumscribing morbid action, and in inclosing foreign bodies. In abscess a wall of lymph is generally formed around the pus, effectually preventing its diffusion among the surrounding tissues. Occasionally the fluid is inclosed by a distinct membrane, derived from the fibrin of the blood, and possessed of a high degree of organization. In carbuncle and erysipelas the lymph is usually of an aplastic nature, and therefore incompetent to prevent the extension of the disease. Balls, needles, pins, and various other foreign bodies are occasionally inclosed in a manner similar to pus, and, in consequence, often remain harmless tenants of the body for many years. Again, plasma is of service in obviating accidents. Thus, in abscess of the lung, if it were not for the intervention of the fibrin of the blood, the mat- ter would often break into the cavity of the chest, and destroy life in a few days, if not in a few hours. How then is this untoward occurrence pre- vented ? Simply by the development of inflammation in the pulmonary pleura, followed by a deposit of lymph, which thus becomes the bond of ad- hesion between this membrane and the costal pleura ; so that by the time the matter reaches the surface an effectual barrier is opposed to its effusion, in consequence of which it generally discharges itself through a contiguous bronchial tube. A similar occurrence takes place in abscess of the liver in relation to the peritoneum and intestinal tube. In typhoid fever the glands of Peyer are often perforated, and yet it seldom happens that the contents of the bowel escape into the abdominal cavity, simply because of this wise provision of nature in gluing together the contiguous serous surfaces. Finally, lymph is of use in obliterating serous cavities. In the radical cure of hydrocele, a disease which has its seat in the vaginal tunic of the testicle, an operation is performed which has for its object the establishment of a certain degree of inflammation, followed by a deposit of fibrin, just suf- ficient to cover the opposing surfaces, and to insure their permanent aggluti- nation. Serous cysts are treated upon similar principles; and modern sur- gery has been emboldened to inject even some of the movable joints, the abdomen, and ovarian tumors with irritating fluids, for the radical cure of dropsical diseases of these parts. 2. INJURIOUS EFFECTS OF PLASTIC MATTER. But lymph is capable of producing injurious effects as well as beneficial; nature's operations cannot always be controlled by art, and it is therefore not surprising that she should often overleap the bounds of discretion when she is depleting the inflamed structures by effusion of plastic matter. Immense mis- chief is frequently done in this manner, within a few hours after the commence- ment of the morbid action ; mischief which it may require months of the most judicious and persevering efforts of the surgeon to eradicate. Examples of this occurrence are daily met with in practice, and serve as mortifying illus- trations of the impotency and imperfection of our art, as well as of the per- verseness of disease. Among the more common and obvious effects of this description are the following: 1. Mechanical obstruction of the natural outlets of the body. 2. Change of structure by interstitial deposits. 3. Abnormal adhesions. 4. Induration and enlargement. a. An example of mechanical obstruction from a deposit of lymph is afforded by what occurs in the windpipe in plastic croup, the principal anatomical character of which is the formation of a false membrane, which often moulds itself accurately to the shape of the tube, and which, especially when it ex- tends high up into the larynx, may become a source of suffocation by imped- ing the entrance of the air into the lungs. In rare cases the membrane is INJURIOUS EFFECTS OF PLASTIC MATTER. 133 detached and expectorated; but generally it remains in spite of our remedies, and speedily destroys the patient. Not even an artificial opening into the trachea will usually avert this event. In some of the mucous canals this matter is poured out beneath the lining membrane instead of upon its free surface, where, becoming organized, it leads to permanent contraction of the tube. It is in this manner that stric- ture is formed ; when the case is a very bad one, lymph may also be effused into the substance of the lining membrane, and even upon its free surface, as is seen in what is called the bridle-stricture of the urethra, which, however, is exceedingly rare. b. Change of structure by interstitial deposit of lymph occurs in almost all cases of inflammation, however slight or however situated. In pneumonitis, it closes up the air-cells and minute bronchial tubes, as well as the cells of the connective areolar tissue, producing what is called hepatization of the lungs. Opacity of the cornea, acting obstructingly to the rays of light, is the invariable result of a deposit of plastic matter either beneath its conjunctival covering or in its inter-lamellar structure. c. Abnormal adhesions, wherever found, are occasioned by this substance, thrown out as a consequence of inflammatory action. The effects of such ad- hesions are always more or less prejudicial. In the thoracic cavity, they confine and restrain the play of the heart and lungs; in the abdomen, they often become a source of internal strangulation; in the mucous outlets, as in the vagina and uterus, they may produce complete occlusion of their orifices; and in the vessels, especially the arteries, they sometimes induce obliteration of the largest sized trunks. Abnormal adhesions between the bowel and the sac in hernia are sometimes a cause of its irreducibility. Great mischief is often done by deposits of lymph into the joints. If the matter be not promptly removed by the absorbents, nature makes an effort to organize it, and to convert it into an adventitious structure, which, under- going various mutations, at length assumes the properties of the osseous tissue, at the same time that it effectually destroys the motions of the articu- lation. The case, in fact, is one of bony anchylosis, and no treatment that can be brought to bear upon it will be of any avail in regaining the functions of the part. d. Among the more frequent and distressing evils of plastic deposits are induration and enlargement, or hardening and thickening of the organs and tissues. Such occurrences are generally exceedingly annoying, often severely taxing the patience of the sufferer and the skill of the professional attendant. They are the direct result of interstitial deposits, which often manifest an early tendency to organization and transformation, and which none but the most determined perseverance in the use of remedies can enable us ultimately to overcome. The stiff and thickened joint, the indurated and enlarged testicle, the hypertrophied spleen, liver, and lymphatic gland, the hardened and enlarged tonsil, are literally living witnesses to the truth of this statement. TREATMENT. The treatment of lymphization is to be conducted upon general antiphlo- gistic principles; undue action is to be repressed, and the absorption of effused matter is to be promoted. To accomplish the first of these objects, the ordinary local and constitutional measures are employed; for the second, sorbefacients are necessary, as mercury and iodide of potassium internally, and the tincture of iodine, liniments, and embrocations externally. In the acute stage of the disease, while secretion is still active, purgatives and anti- raonials, with the liberal exhibition of calomel, constitute the chief means of 134 TERMINATIONS AND RESULTS OF INFLAMMATION. relief; but the tendency to deposit having ceased, their use is dispensed with, all except the mercury, which is now given in minute doses, and with a view strictly to its alterative effect; it is often carried to slight ptyalism, the mouth and gums being maintained in a tender condition for perhaps several weeks consecutively; or, with an occasional interval, for even a much longer period. In the latter event, the bichloride frequently, if not generally, forms a valuable substitute for the calomel; less likely to act hurtfully, and yet, at the same time, very effectually stimulating the absorbents. In such cases, too, small doses of tartar emetic often produce a most salutary influence ; its action being hardly inferior to that of mercury itself, with which it may fre- quently be advantageously combined. When the inflammatory action has pretty much subsided, its products, especially the serous and plastic, are generally easily gotten rid of by hydrochlorate of ammonia, or iodide of potassium, administered in doses varying from three to twenty grains, in aqueous solution, three times in the twenty-four hours ; strict attention being paid, meanwhile, to the diet and bowels. When the case is obstinate, an occasional mercurial will constitute a valuable addition. Among the more beneficial topical means are, the dilute tincture of iodine, applied twice in the twenty-four hours; inunctions with mercurial and other unguents, particularly that of the iodide of lead; stimulating embrocations; and steady, uniform support with the bandage. Various kinds of plasters, as the common mercurial, the compound galbanum, and others of a kindred nature, are also frequently serviceable. Washing the part well, when acces- sible, twice a day with hot water and Castile soap, and then using dry fric- tion upon it, often do more good than anything else. In some cases, again, cold, especially in the form of the douche, acts very beneficially, affording relief when everything else seems to fail. In the case of the joints passive motion must be carefully performed, at first once, and then twice a day, to prevent anchylosis from the organization of the fibrinous bands which are so liable to form during the progress of synovitis. When the object is simply to assist nature in her efforts at repairing injury, as a wound or fracture, care should be taken, on the one hand, that the attendant action is not too low, and, on the other, that it does not transcend the fibrinizing limits. By over-officiousness the system may be so exhausted as to render the proper supply of lymph in the part a matter of impossibility, or such a state of the constitution may be brought about by the effects of previous disease, intemperance, or inadequate nutrition from the want of proper food. However induced, it should claim prompt attention, every effort being made, by the use of tonics, stimulants, and other invigorating measures, to supply the blood with the requisite material for the deposition of fibrin ; all debilitating topical applications being at the same time dis- continued. Over-action, on the contrary, is met by the usual antiphlogistic means, carefully and warily applied, lest harm should result from the too rapid reduction of the vital powers. The management of the reparative process always demands great judgment and vigilance. SECT. IV.—SUPPURATION AND ABSCESS. Suppuration is the process by which pus is formed, and is one of the most frequent, as it is certainly one of the most important, of the results, events, or conditions of inflammation. Its presence, as a general rule, is denotive of a higher grade of excitement than a mere deposition of serum and plastic matter, which, however, are nearly always associated with it. But it must not be supposed that the reverse of this proposition is true ; for inflammation often exists in a severe degree, with an abundant effusion of the watery and SUPPURATION AND ABSCESS. 135 fibrinous elements of the blood, and yet there is not the slightest evidence of suppuration. It was formerly supposed that suppuration might occur without the agency of inflammation, and there seems to be still a lingering disposition on the part of some pathologists to adhere to this doctrine, if not by direct advocacy, at least by implication. The opinion doubtless had its origin in the fact that there are occasionally cases of suppuration in which large quantities of pus are thrown off, without any evidence of the ordinary phenomena of inflamma- tion, such, especially, as pain, heat, and discoloration of the structures in which the matter is formed, or any constitutional disorder ; the whole process being apparently conducted as if both the part and system were unconscious of what is going on. Such cases are by no means infrequent, and yet if they be carefully investigated, or traced through the various stages of their pro- gress up to the dissection of the affected tissues, the most satisfactory proof will be afforded of their phlogistic nature. In a cold, strumous or scrofulous abscess, for example, which has so often served as the basis for this, now nearly exploded idea, and the formation of which is sometimes the work of several months, inflammation is just as much concerned in the production of its contents, as in a phlegmonous boil that is developed in three or four days The only difference is, that in the one the morbid process moves on slowly and almost imperceptibly, while in the other it proceeds very rapidly, and is accompanied by such well-marked symptoms as to render it impossible to mistake their character. Pus may be formed, as is well known, without any breach of continuity of the affected parts. This mode of suppuration is, in fact, very common, not only in the serous cavities, but throughout nearly the whole of the mucous system. It is not, however, confined to these textures. In the cellular sub- stance, lungs, brain, liver, and other viscera, nothing is more frequent than suppuration, without any ulceration whatever in the inceptive stages of the morbid action. The formation of purulent matter does not take place with equal facility in all the organs and textures. Of the viscera, those which are most prone to take on suppurative action are the liver, lungs, and brain ; of the tissues, the cellular, cutaneous, mucous, and serous. In the fibrous, cartilaginous, tendinous, and osseous textures, this fluid forms with difficulty, and is seldom of a thick, consistent nature. Of the mucous system some portions are more liable to be affected with suppuration than others. Thus, it is much more common to find pus in the colon than in the stomach or ileum, in the vagina than in the uterus, in the urethra than in the urinary bladder, in the nose than in the mouth, in the fauces than in the oesophagus, in the bronchia than in the larynx. So, likewise, in the serous system, suppuration is more fre- quent in some situations than in others ; as, for example, in the pleura, the vaginal tunic of the testicle, and the lining membrane of the larger joints In the subcutaneous cellular texture, pus is most readily formed in those parts which are remote from the central organ of the circulation. The blood- vessels do not often suppurate, except when wounded; and the same, so far as we know, is the case with the absorbents. The lymphatic ganglions, how- ever, are very frequently affected in this way, especially those of the axilla, the groin, the mesentery, and the base of the lower-jaw, particularly in per- sons who are predisposed to scrofulous disease. The nervous tissue seldom suppurates, and the muscular still more rarely. From all these facts we may deduce the axiom, that those structures are most prone to form matter which contain the largest amount of loose cellular substance, and, conversely, that those which possess this tissue sparingly always suppurate with difficulty, requiring in general a much longer period, and elaborating a less perfect fluid. 136 TERMINATIONS AND RESULTS OF INFLAMMATION. The period at which suppuration may occur after the establishment of inflammation varies, on an average, from twenty-four hours to three or four days, depending upon the nature and situation of the affected tissues, the intensity of the morbid action, and also, and that in a material manner, upon the condition of the system, and the character of the exciting cause. Mucous membranes, especially if exposed to the air, generally suppurate very readily, having, as it were, a" predisposition to take on this kind of action ; serous membranes, on the contrary, suppurate with difficulty, one reason of which is that, being arranged in the form of shut sacs, they do not feel the stimulus of the atmosphere ; another, doubtless, is the fact that such structures, when irritated, are naturally inclined to furnish lymph rather than pus, their organization peculiarly fitting them for that office. The same difference exists between the veins and arteries, and it is practically fortunate that it does ; otherwise the danger of wounds, whether the result of accident or design, requiring the ligation of the principal arteries, would be much greater than experience has shown it to be. No surgeon likes to tie a large vein, well knowing that the operation may be followed by fatal suppuration of its lining membrane. In some of the internal viscera, as the brain and liver, pus sometimes forms with great rapidity, as is seen in cases of injuries of these organs. Matter, other things being equal, forms more rapidly when the inflammation is very intense than when it is comparatively mild. A wound inflicted upon an unhealthy or intemperate person will be more likely to run speedily into suppuration than one of a similar character occurring in an individual of sound constitution and regular habits. A phlegmonous boil will usually begin to deposit pus in from twenty-four to thirty-six hours, whereas a chancre does not furnish any, so far as we are able to judge, until the beginning of the fourth day. In variola, the suppurative process is generally not fully established until about the ninth day. Exposure of an inflamed surface to the air greatly promotes suppurative action, and is, consequently, directly hostile to adhesion. The more nicely the edges of a wound are approximated, the greater, all other things being equal, will be the probability of speedy and permanent reunion, and con- versely. Serous membranes, as already stated, have naturally a disposition, when inflamed, to pour out lymph, and become glued together; but whenever they lose the character of closed sacs, as they necessarily do when they are accidentally opened, the morbid action, consequent upon the injury, is certain to be followed by the formation of pus, especially if the air is permitted to have free access to them for any length of time. Pus originally appears in the form of distinct globules, which are dispersed through the affected structures, and can be easily recognized by their pale yellowish color. As the purulent particles increase in number, they gradually become confluent by the removal of the parts concerned, and in this way the matter is at length collected into an abscess. The symptoms which characterize the suppurative process will claim special attention when we come to speak of abscesses. Meanwhile, it will suffice to observe, in general terms, that they are such as denote the existence of ordi- nary inflammation, with an increase, more or less considerable, of the local and constitutional disturbance. Pus, the product of suppuration, has been an object of anxious study from the earliest ages of the profession down to the present time; but it has only been within a comparatively recent period that any real and reliable light has been thrown upon its physical, chemical, and microscopical properties. When genuine, or, as it is not unaptly termed, good, healthy, or laudable, pus is of a white, yellowish tint, opaque, homogeneous, of a sweetish taste' without any particular smell, and of the consistence of thin cream. It is heavier than water, in which it is partly dissolved, emits a faint, mawkish odor SUPPURATION AND ABSCESS. 137 on being heated to the natural temperature of the body, resists putrefaction with remarkable pertinacity, and is coagulated by heat, alcohol, and hydro- chlorate of ammonia. Pus freezes less rapidly than water, and when thawed does not regain its original properties. The specific gravity of pus is liable to considerable variation. It is less than that of blood, and greater than that of serum. According to Gueter- bock, it ranges from 1030 to 1033. In seven distinct examinations of pus, taken from abscesses in different situations—as the thigh, arm, axilla, back, pleura, and the lung in pulmonary phthisis—Dr. John Davy found the specific gravity as low in one as 1021, and in another as high as 1042. This great disparity is mainly attributable to two circumstances, the unusual quantity of the solid ingredients, and the variable density of the liquid part. The chemical constitution of pus has been examined by a great number of experimentalists, and the results of their investigations tend to show that it contains most of the elements of the blood. The following analysis is by Gueterbock, from the pus of an abscess in the human breast. Water ........ Fat, soluble only in boiling alcohol .... Fat and osmazome, soluble in cold alcohol Albumen, pyine, pus globules and granules, soluble neither in hot nor in cold alcohol ..... Loss ........ 86.1 1.6 4.3 7.4 0.6 100.0 Lehmann has investigated the chemical composition of the different ele- ments of pus with great care. Normal pus he found to contain from 14 to 16g of solid constituents, of which from 5-6§ belonged to mineral or inor- ganic substances. The most usual insoluble salts of pus are the phosphates of lime and magnesia, and the sulphate of lime; the principal part of the soluble salts is furnished by chloride of sodium. The quantity of fat was found to vary from 2-6§; the quantity of albumen in the serum from 1.2 to 3.7£. Casein and the coloring matter of the blood do not occur in normal pus. A substance which usually enters into the composition of pus is pyine. Gueterbock, who discovered it, considers it as a peculiar animal principle. Its exact nature is not understood. It is supposed by some to be an oxide of protein, by others a form of fibrin. It can be precipitated from pus by acetic acid, or by alum. It is soluble in water, but insoluble in alcohol. Pus occasionally contains a peculiar substance, denominated pyocyanine; it imparts a bluish or greenish hue to the contents of certain abscesses, and to the discharges of certain ulcers, but its real nature is not well understood. With regard to the composition of the com- pound part of the pus globules we possess no positive knowledge. The cell walls, contents, and nuclei, react like protein bodies, and are probably of an albuminous nature. The cell walls are dissolved by acids, but resist the action of alkalies. Pus, microscopically examined, is found to be composed of numerous small corpuscles suspended in a thin, transparent fluid, called the pus-liquor. These little bodies, which have received the name of pus globules, are generally of a spherical form, and vary in size from the s thor's collection. supply of vessels, as I have satis- fied myself by dissection, and as is evinced also by the rapid develop- ment of the morbid growth, and the great bulk which it occasion- ally attains. In one case in par- ticular I had no difficulty in tracing several large, straggling arteries into a tumor of this kind, showing that it had a very active circula- tion. The manner, however, in which the vascular system of the morbid product is arranged is not determined ; nor is it ascertained whether it is of new formation, or derived solely from the surrounding and included healthy structures. Of the character of its nerves and absorbents, we are equally uninformed. The other element of colloid is an unorganizable product, of a whitish, greenish, or yellowish color, and of the consistence of ordinary jelly, whence the name by which the disease is usually known. In the older cells the mat- ter is sometimes as firm as moist cheese, or the white of a hard-boiled egg, opaque, and of a white pearly or yellowish hue, interspersed with minute dark points. Sometimes, again, it resembles currant jelly, half dissolved glue, or a solution of gum shellac. However this may be, it never adheres to the walls of the cells, and is, therefore, easily enucleated, or pressed out. When perfect clearance has been effected of the cells of a mass of colloid, the fibrous structure exhibits very much the appearance of a piece of sponge, the alveolar arrangement being then particularly conspicuous, hundreds°of cells being often visible upon a surface less than an inch in diameter. Although the soft matter of colloid looks so much like jelly, chemical analysis has shown that it is entirely destitute of this substance, its principal COLLOID — MELANOSIS. 273 constituents being albumen, casein, and osmazome, in varying proportions. Destructive analysis has yielded, in the 100 parts, 48.09 of carbon, 7.47 of hydrogen, 37.44 of oxygen, and 7.00 of nitrogen. Under the microscope colloid appears as a homogeneous substance, with now and then a slightly granular arrangement, or large irregular plates. In this basis-structure are seen nucleated corpuscles, and large parent cells, in- closing several smaller ones. Cancer cells, such as occur in scirrhus and en- cephaloid, are occasionally found in it, but not as a necessary constituent, since in some specimens they are entirely absent. Moreover, it is worthy of notice that corpuscles, very similar to those of colloid, sometimes occur in gelatinoid infiltrations of the spleen, heart, and thymus. The stroma of col- loid is essentially composed of fibrin. It is impossible, in the existing state of our knowledge, to determine the precise nature of colloid, or to assign to it its proper position in the scale of the heterologous formations. It is certainly destitute of many of the pro- perties of carcinomatous disease, and yet its career, so far as I have had occasion to watch it in my own practice, is not the less positively fatal espe- cially when it occurs in the internal organs. In the osseous structures, it may occasionally be removed without relapse, and the same thing may probably be true in regard to colloid in some other situations; but upon this subject we are in need of further light. It has less disposition to ulcerate, and to contaminate the surrounding lymphatic ganglions, than the other heterologous formations. 5. MELANOSIS. Melanosis, sometimes called black cancer, occurs most commonly in the cellulo-adipose tissue beneath the skin, in the folds of the mesentery and omentum, around the kidneys, in the mediastinal cavities, the lymphatic ganglions, the eye, liver, lungs, and parotid glands. It is also met with, though more rarely, in the serous and fibrous membranes, the bones, ovaries, heart, pancreas, and spleen. Occurring usually alone, it occasionally coexists with some of the other heterologous deposits, especially the scirrhous and encephaloid, and may attack quite a considerable number of organs either simultaneously or successively. It takes place in both sexes, and at all periods of life, but is most frequent in adults and middle-aged subjects. An instance in which the melanotic diathesis prevailed to a remarkable extent came under my observation in 1855, in a man, aged fifty-eight years, who, after a confinement of nearly twelve months, finally died in a state of extreme exhaustion, the prominent symptoms having been harassing cough, occasional discharges of blood from the bowels, irritability of the bladder, frequency of the pulse, and copious night-sweats. Melanotic tubercles ex- isted in the subcutaneous cellular tissue in various regions, the lymphatic ganglions of the groin, axilla, and bronchia, the omentum and peritoneum, stomach, large and small bowels, pancreas, liver and gall-bladder, kidneys and supra-renal capsules, urinary bladder, prostate gland, seminal vesicles, lungs and pleura, heart, and thyroid body. The spleen and large vessels were sound. The brain, bones, and muscles were not examined. A remarkable feature in the case was the existence of numerous white and grayish tubercles in the midst of the black, showing that the former were in a nascent condi- tion, having not yet undergone the melanotic transformation. The melanotic matter is deposited in several varieties of form, of which the tuberoid is the most common. It occurs in small masses, of a rounded, ovoidal, or irregular shape, with or without a cyst, and from the size of a pin-head to that of a walnut. Of a dull sooty, brownish, or black color, they are generally invested by a distinct capsule, formed out of the cellular tissue VOL. i__18 274 TUMORS, OR MORBID GROWTHS. in their immediate vicinity, which thus serves to separate and protect them. Fibrous bands generally intersect their interior, and vessels are often seen ramifying over their surface, none of them, however, dipping into the proper melanotic matter. It is by the union of several of these smaller masses that large tumors are sometimes formed, reaching, now and then, the volume of a fist or even of a foetal head. Cases occur in which this matter presents itself in small points, or in irregular patches, generally beneath some serous membrane. Finally, it is sometimes found in a liquid form. Melanotic matter, in a pure state, is of a sooty black, dark brown, or dull bistre color, its consistence varying from the fluidity of ink to that of fibro- cartilage. Its chemical constituents are albumen, fibrin, and a dark, highly carbonized substance, not unlike the cruor of the blood, with a minute quantity of iron, soda, magnesia, lime, and potassa. It is opaque, without odor or taste, and miscible with water and alcohol ; it imparts a characteris- tic stain to linen, resists decomposition, and emits an empyreumatic smell when burned. Examined microscopically, melanotic matter is found to consist of a fibrous network, inclosing numerous meshes, which are filled with free, unadherent pigment cells, of a pale yellowish, dark, or dark brown hue, and of a rounded, oval, or irregular figure; they are of great Fig. 55. delicacy, and are occupied by colored granules, a few of the larger or older ones sometimes containing a nucleus with its nucleolus. These appearances are well represented in fig. 55. Pigment cells are not present in all cases, and their granules are occasionally seen in other structures, f ^A-' both healthy and morbid, as in the lung ;A:;'.©.£■ i pigment and in the elements of carcino- X&|!V;- matous growths. ,:i■;■■:/.' The precise nature of melanosis is unde- termined. I am, however, inclined to be- lieve that it is merely a modification of Microscopic structure of melanosis. encephaloid, the chief difference consisting in the superaddition of black pigment. What corroborates this view is that tumors partaking of the character of both these formations, occasionally co-exist, either in the same, or in different parts of the body ; and also, that they exhibit similar histological elements. Of the causes of this deposit nothing is known. It is always effused in a liquid form, and is wholly unorganizable, receiving neither vessels nor nerves; though these are freely distributed through its fibrous stroma. It has been supposed that black cancer might be communicated by inoculation, or imme- diate contact, but experiments upon the inferior animals have refuted this conjecture. After having remained stationary for an indefinite period, this matter manifests a disposition to disintegration, the softening process generally be- ginning at some superficial point, and thence gradually extending to the skin, which, giving way, leads to the establishment of a foul, non-granulating, unhealthy ulcer, which no skill can cure. The discharge is generally of a sanious character, mixed with and discolored by the heteroclite secretion. Its progress is usually more tardy than that of scirrhus and encephaloid, except when it exists simultaneously in a great number of organs, as in the case above described, where it terminated fatally in a little over a year The general health often suffers long before ulcerative action sets in, the patient becoming thin, haggard, and sallow. LOCAL ORIGIN. 275 Having thus described each malignant tumor separately, I shall, in the next place, offer some remarks on the origin of this class of affections, their diagnosis, and treatment. Local Origin.—It has been supposed that all malignant diseases are occa- sionally of a purely local character, having their origin in causes entirely independent of the general system; or, what amounts to the same thing, that they may be developed under the influence of local injury. But such an opinion, it seems to me, is hardly tenable ; at all events, it admits of great doubt whether such a result really ever follows such a cause; it certainly could not, one would suppose, unless there is a predisposition, a readiness, as it were, on the part of the system, to generate cancer cells, or to take on malignant action ; else why is it that external violence, as a blow or bruise, so seldom gives rise to this horrible and unmanageable complaint ? Why, in other words, is it that a blow will produce cancer in one person and not in another; or, still farther, why will one individual suffer and a thousand escape ? Cancer of the lip has often been attributed to the irritation produced by the hot and filthy stem of the earthen pipe in smoking. But it may well be asked whether the use of the pipe and the occurrence of this frightful disease should not be viewed rather in the light of a coincidence than in that of cause and effect ? Be this as it may, it is unquestionable that thousands of persons smoke and yet never suffer from cancer of the lip. So in regard to many of the other circumstances alleged to be capable of inducing malignant disease, as grief, mental anxiety, loss of rest, unwholesome food, and disorder of the menstrual function, which are so often accused of provoking carcinoma in the mamma and uterus. Unless, therefore, a predisposition exists in the system to the development of these affections, it admits of great doubt whether it is possible for any local irritation to originate them. It is far more probable that they take their rise in the blood, but how, or in what particular element of this fluid, we are of course totally ignorant. It has been asserted that cancer cells have been detected in the blood, but if this has been the fact it is certain that they were not formed there, but that they were simply introduced through the agency of the vessels during the progress of carcinomatous disease. To arrive at any other conclusion would be absurd. Can a tumor of an innocent, benign, or non-cancerous character, in its progress, become malignant ? in other words, is such a growth capable of what has been termed the carcinomatous degeneration ? It seems to me that it is not difficult to give a correct answer to this question. If the term " degeneration" is restricted to its true and legitimate signification we must reply in the negative, for no tumor, whatever be its structure, can, by a mere conversion or transformation, pass into a malignant condition. Such a change can be effected only under the influence of a vital process, involving the development and actual existence of the cancer cell; and I cannot, for my own part, see any good reason why a new growth, tumor, or deposit should be more exempt from such a disease than a primitive, original, or pre-exist- ing tissue, whatever be its structure. Nay, indeed, may it not be supposed that the more feebly a part is organized, the more prone will it be to take on such a process ? That this change does sometimes occur, may be inferred from the circumstance that tumors, believed to be cancerous, but which can- not be positively proved to be so, remain, occasionally, in a state of latency for ten, fifteen, twenty, and even thirty years, and then, all of a sudden, mani- fest a malignant and destructive action, generally followed by the worst consequences. It would be of great practical utility if we knew the origin of cancer, or if we were acquainted with the causes, local and constitutional, under the in- fluence of which malignant diseases, properly so called, are developed. But 276 TUMORS, OR MORBID GROWTHS. upon this subject, unfortunately, we are entirely ignorant, nor is it likely that our inquiries concerning it will lead to a satisfactory solution of a question which has occupied so much attention. Carcinoma is sometimes hereditary; not, however, so frequently as is generally supposed. Besides, it should be remembered that there is a differ- ence, and that a very wide one, between the transmissibility of this disease from the parent to the offspring, and its coexistence, or successive develop- ment, in different members of the same family. The latter occurrence, although also very infrequent, is much more common than the former, of which my own experience has supplied me with only a few examples. Lately, I saw a lady with a well-marked cancer of the mammary gland, whose mother and maternal aunt had died of the same disease. In the summer of 1850, I prescribed for an aged female with a cancer of the lip, whose mother had perished from cancer of the breast, and the father from cancer of the tongue. But the most remarkable and instructive instance of this kind, probably, upon record, is that related by Dr. Warren, in his work on Tumors. A man died of cancer of the lip ; his son had a similar disease in the breast, from which, after having undergone an operation at the age of sixty, he finally lost his life. Two of his sisters had cancer of the mammary gland; they were operated upon, but ultimately died from a relapse of the malady. A daughter of one of the ladies had a cancer of the breast, which was removed at an early period; she recovered, but perished some years after from disease of the uterus. A daughter of the gentleman had a cancer of the breast, and there was reason to believe that other members of the family were affected by the same malady. A case, almost equally remarkable, of this hereditary tendency to cancer, has been communicated to me by Dr. J. M. Warren. In this instance, a man who died of cancer of the penis, lost his father, grandfather, and great- grandfather from the same disease. More frequently, as has been already stated, the disease occurs, either simultaneously or successively, in several members of the same family. My own practice has afforded me a number of instances of this kind, and there is not a writer on carcinoma that does not narrate examples of it. In one re- markable case, four out of six members of one family have died of the dis- ease ; one from cancer of the uterus ; another from cancer of the mammary gland; a third from a malignant polyp of the nose ; and the fourth from car- cinoma of the thoracic viscera. Professor Gibson gives an instance of cancer of the breast in four sisters. Diagnosis.—Epithelial cancer is usually sufficiently easy of recognition. Its situation at the junction of the skin and mucous membranes, or upon either of these structures; its origin in a crack, fissure, or wart-like excres- cence; its extraordinary firmness, the part feeling like a mass of fibro- cartilage ; its slow growth ; its small size; and the absence, for a long time, of severe pain and constitutional taint; are features that cannot be mistaken. The only characteristic sign of melanosis is the peculiarity of the color of the tumor; hence, when it is situated superficially, as when it occupies the skin, eye, parotid gland, or lymphatic ganglions, it is quite impossible to mistake the nature of the disease. Colloid tumors are liable to be confounded with fibrous and enchondro- matous formations; but a careful consideration of the history of the case, and a thorough examination of the morbid mass will generally serve to clear up any doubt that may arise in regard to the diagnosis. Colloid growths are usually situated in the peritoneal cavity, in the ovary, or in the bones; they are slow in their progress, smooth or rough on the surface, of uniform con- sistence throughout, and free from pain, their bulk being usually enormous, and the general health greatly disordered. Fibrous tumors advance slowly, DIAGNOSIS. 277 seldom attain a great bulk, and do not usually seriously undermine the con- stitution. The enchondromatous growth is harder and less elastic than the colloid; its progress is rather rapid, and its outlines are always well defined, which is seldom the case with alveolar cancer. Almost the only disease with which encephaloid is liable to be confounded is scirrhus, and it will therefore be necessary to point out their differential diagnosis. For this purpose I give the subjoined table of the characteristics of the two affections. ENCEPHALOID. 1. The tumor is soft and elastic, not uni- formly, but more so at some points than at others. 2. It grows rapidly and soon acquires a large bulk, perhaps ultimately attaining the volume of an adult's head. 3. The pain is slight, and erratic, until ulceration begins, when it becomes more severe and fixed. 4. There is always marked enlargement of the subcutaneous veins. 5. The ulcer is foul and fungous, with thin, undermined, and livid edges, and is subject to frequent and copious hemor- rhage. 6. There is generally early lymphatic in- volvement. 7. Occurs at all periods of life. 8. Is most frequent in the eye, testicle, mamma, lymphatic ganglions, bones, and cellular tissue. 9. The disease usually terminates fatally in from nine to twelve months. 1. Uniformly hard and inelastic, feeling like a marble beneath the skin. 2. Growth is slow, and bulk comparatively small; the tumor rarely, even in the worst cases, exceeding the volume of a double fist. 3. The pain begins early, is distinctly localized, and is of a sharp, darting, burning, or lancinating character. 4. In scirrhus these vessels retain their natural size, or are only slightly en- larged. 5. The ulcer is incrusted with spoiled lymph, and has steep, abrupt edges, looking as if it had been punched in the part; bleeding little, and seldom. 6. Usually not until late, or just before ulceration is about to occur. 7. Seldom before the age of forty-five. 8. Never occurs in the eye and testicle, and seldom in the bones and lymphatic ganglions. 9. Seldom sooner than eighteen months or two years. It is not improbable that an encephaloid tumor might be confounded with a chronic abscess, or an aneurism, especially when it is so situated as to re- ceive an impulse from a neighboring artery. The very mention of the possi- bility of such an occurrence will be sufficient to put the young and inex- perienced practitioner upon his guard, and serve to point out to him the absolute necessity of the most profound caution in every case of a suspicious character. It has been proposed, in cases of doubt, to solve the difficulty by means of the exploring needle, or, rather, of an instrument so constructed as to admit of the removal of a portion of the morbid growth just sufficient to answer the purposes of a microscopic examination. I must confess, however, that I have a great aversion to all such procedures, believing that they gene- rally prove prejudicial to the part, by provoking an increase of the morbid deposit, the puncture, unless very small, serving as a new centre of action. I have witnessed in at least two instances great harm from the operation, and have therefore of late years uniformly discountenanced it, except when the tumor is seated in an extremity, so as to admit, if found to be cancerous, of prompt removal by amputation. The microscope is certainly not infallible as a means of diagnosis. It is often a valuable auxiliary, but nothing more. The practical surgeon must indeed be dull who cannot, as a general rule, determine the character of a morbid growth before he attempts its removal. The merest tyro in the pro- fession has no difficulty in discriminating between a gelatinoid and a fibrous polyp of the nose, a scirrhous and an encephaloid tumor of the breast, or a common hypertrophied ganglion of the neck and a malignant growth of the 278 TUMORS, OR MORBID GROWTHS. same part. Every new growth, whether benign or malignant, has its pecu- liar features, not less than every pre-existing one. I believe that, with proper care, and a reasonable knowledge of morbid structure, such as every cultivated surgeon ought to possess, it is, in general, as easy to determine the difference between a malignant and a non-raalignant tumor as it is to determine the difference between a muscle and a tendon. In making these remarks I have no desire to underrate microscopical researches; on the con- trary, I only wish to state that they have not, in my judgment, effected all the good that has been claimed for them, especially in this particular depart- ment of pathology and practice, and that, therefore, their results should be received with some degree of allowance. In fact, the whole subject of morbid growths, benign and malignant, should be revised and re-examined. When there is so much dispute as there confessedly is at present respecting the real nature of the cancer-cell, or, whether indeed there is such a cell at all, it well becomes the practitioner to look with distrust upon many of the alleged discoveries of the microscope. Besides, he should not lose sight of the value of his unassisted senses, nor cease to cultivate them in the highest possible degree. After a malignant disease, whatever may be its character, has made con- siderable progress, so as to impress itself upon the constitution, the diagnosis, however obscure it may have been in the early stages of the affection, is no longer doubtful. The worn and haggard features, the sallow complexion, and the emaciated and exsanguine condition of the system, are characters which it is impossible to mistake. The countenance bears the impress of the disease, looking as if it had been stamped with the seal of malignancy. TREATMENT. The treatment of the various forms of malignant growths may very pro- perly be discussed under one general head, since they are evidently all governed by the same laws, both as it respects their origin, progress, tend- ency, and termination. All internal remedies, of whatever kind and cha- racter, have proved unavailing in arresting their march, or in modifying them in such a manner as to render the surrounding structures tolerant of their presence. The vaunted specific of the empiric, and the enchanted draught of the honest but misguided enthusiast, have alike failed in perform- ing a solitary cure; and the science of the nineteenth century must confess, with shame and confusion, its utter inability to offer even any rational sug- gestions for the relief of this class of affections. But, although this is the case, yet it by no means follows that the subjects of these complaints may not be benefited by general and local treatment, if its application be directed by common sense and sound judgment. Every practitioner of experience knows how much ordinary local diseases are influenced by constitutional measures; and if this be true of these lesions, how much more must it be true of the malignant, in the production of which both the solids and fluids play such an important part. The attention of the surgeon should be particularly directed to the patient's diet, bowels, and secretions, and to the avoidance of all sources of local irritation, calculated to favor the morbid growth and hasten the fatal issue. ' The diet should, in general, be of a bland and unirritant character, but at the same time sufficiently nutritious to preserve a sound condition of the blood, and maintain the tone of the muscular system. All condiments, coffee, strong tea, pastry, hot bread, and the coarser kinds of vegetables and meats shou d be abstained from. Eggs, fish, oysters, and the white kinds of meat may be used once a day in moderate quantity, but ofteuer than this TREATMENT. 279 they should not be indulged in, unless there is some special reason for it, founded upon the state of the general health. Frequently a purely fari- naceous and milk diet is found to answer better than any other, the patient not only thriving under it, but the disease being apparently kept in check by it. The bowels should be maintained in a soluble condition, but all active purgation must be carefully avoided. The most suitable aperient, when a tendency to constipation exists, is a blue pill, with one grain of ipecacuanha, or equal parts of blue mass and jalap, at bedtime, followed, if necessary, by a Seidlitz powder in the morning. If evidence of gastro-intestinal irritation arise, the blue mass may be advantageously replaced by a small portion of calomel. In this way, while the bowels are maintained in a tolerably free state, the secretions are also duly preserved ; a matter of no little moment in the treatment of all malignant diseases without exception, especially when they are attended with marked constitutional disturbance. Sleep is procured and pain allayed by anodynes, the constipating effects of which are counteracted by the conjoined use of ipecacuanha or tartar emetic, in suitable doses. When the suffering is of a neuralgic character, the ano- dynes may be combined with arsenic or arsenic and strychnine. If marked debility exists, recourse must be had to tonics, as quinine and iron, aided by a nutritious diet and the use of brandy, wine, ale, or porter. Night-sweats are best controlled by aromatic sulphuric acid. Great care should be taken to keep the affected part perfectly at rest, and free from pressure and excitement. If it be the breast or testicle that is diseased, the organ must be well suspended, the dress worn loose, and all manipulation studiously abstained from. If the surface is tender, hot, and swollen, or oedematous, some mildly astringent and anodyne lotion will be of service, or the part may be painted several times a day with a weak solution of iodine. When the local inflammation is unusually severe, as is evinced by the discoloration and pain, nothing, according to my observation, will afford such prompt and decided relief as the application of from four to six leeches, unless it be a small blister, kept on until there is pretty free vesica- tion. Some cases are greatly benefited by the use of an opium, belladonna, or cicuta plaster, renewed every ten or twelve days. All caustic applications are to be carefully avoided, inasmuch as they can never do any good, but may do a great deal of harm by establishing sores which it will afterwards be impossible to heal. When the parts take on ulcerative action, the resulting sore must be kept constantly clean by frequent ablutions; while the excessive fetor which so generally attends must be allayed by the free use of the chlorides. The best dressing will be an emollient poultice, particularly that made of powdered elm bark, sprinkled, if there be much pain, with a little morphia, pulverized opium, or laudanum. If the ulcer be very sensitive, it should occasionally be touched, very lightly, with the solid nitrate of silver, or it should be kept constantly covered with the dilute ointment of the nitrate of mercury. When the discharge is very profuse, sanious, and offensive, a lotion composed of from two to four drops of nitric acid to the ounce of mucilage of gum arabic will be found exceedingly beneficial in diminishing its quantity and changing its character. The affected glands in the neighborhood of the diseased organ often require attention, especially when they are very painful and bulky. The remedies should be of an anodyne and antiphlogistic character, especially leeches, iodine, and saturnine lotions. The treatment of carcinomatous diseases by compression was introduced to the notice of the profession early in the present century by Sir Charles Bell, and, after having been alternately eulogized and condemned, has at 2S0 TUMORS, OR MORBID GROWTHS. length fallen into merited disrepute. Some years ago Mr. Arnott, of London, made an attempt to revive this mode of treatment, especially in cancer of the mammary gland, by the invention of a cup-shaped apparatus furnished with an elastic air-cushion, in order to apply the pressure in a more gentle and equable manner. The suggestion, emanating from so eminent an authority, attracted much attention at the time, and led to numerous trials, both in Europe and in this country, but with results so discouraging as to have caused its entire abandonment. In regard to extirpation, all experience has proved that it cannot be relied upon as a means of permanent cure. The only benefit which it can confer is temporary relief for a few months, or, at most, for a year or two ; and this is true no matter in how masterly and thorough a manner the operation may be executed. Hence not a few surgeons of the present day have expressed themselves as altogether averse to such a procedure, believing that it will only serve, in the great majority of instances, to hurry on the case to a fatal crisis. ~S\y own conviction is that interference with the knife is, as a general rule, only productive of harm, and that the patient will live quite as long without as with it, and, on the whole, in a state of greater comfort. Never- theless, there are cases, although it is difficult to define their character, where we occasionally see an operation followed by highly beneficial results, not only ameliorating pain, but apparently preventing an extension of the dis- ease, and relieving the mind of that terrible feeling of anxiety which is so sure to attend the more severe forms of carcinoma. The cases which have done best in ray own hands, after operation, were females with scirrhous breasts, which, after having been long in a quiescent state, at length assumed a threatening ulcerative tendency, or which had actually, in a slight degree, yielded to this process. Epithelial cancer is less liable to recur after extirpation than scirrhus, encephaloid, or melanosis. Removed in its earlier stages, there is occasion- ally a strong probability that there will be either no relapse at all, or only after a considerable period. One reason probably of this is the fact that the disease is more of a local character than the ordinary forms of carcinoma. General Rules for conducting Excision of Malignant Diseases.—When excision is determined upon, it is a matter of paramount importance that it should be performed in the most thorough and complete manner, in order that the parts may be effectually guarded against relapse. The slightest atom of the new tissue, the most minute cancer cell, nay, possibly, the smallest particle of cancer juice, may, if left behind, endanger a reproduction of the malady. 1st. To accomplish this object, it is necessary that the incisions should be carried through the healthy tissues at some distance from the morbid deposit. Should any part have escaped the knife in the first instance, it should be traced out immediately after the extirpation of the main mass, and be excised with the most scrupulous exactness. Free use should be made, in this stage of the operation, of the sponge and finger; of the former, for clearing away the blood, and of the latter, for ascertaining the consistence of the surface of the wound. The sight alone should never be trusted in a case of this kind, inasmuch as it is a great deal more deceptive than the sense of touch. Not a particle of the least suspicious substance should be left behind. Skin, muscle, glands, vessels, nerves, and bone should all be sacrificed, if necessary to the success of the operation. Nay, the very atmosphere of the disease should be destroyed ; and, with this view, the surgeon should always remove a considerable amount of healthy substance. 2dly. The operator should endeavor to preserve as much of the common integument as possible, in order to afford a complete covering to the surface of the wound. This rule is one of great importance, and should never be TREATMENT. 281 departed from. Another precept, of nearly equal consequence, but one which is not generally sufficiently iusisted upon, is to preserve as large a quantity as practicable of the subcutaneous cellulo-adipose tissue, with a view of maintaining, unimpaired, the circulation of the skin. Whenever this is much interrupted, as it necessarily must be by a very close dissection, there is addi- tional danger of a speedy return of the abnormal action, and also greater risk of erysipelas immediately after the operation. 3dly. When only a portion of an organ is involved by the heteromorphous matter, the rule is to remove, not a part, but the whole of it. Thus, in cancer of the mammary gland, the practice invariably is to extirpate the entire organ, no matter how small a portion may be implicated in the disease. Upon this point, surgeons have long been agreed. When the disease is seated in an ex- tremity, especially the distal portion, the proper operation is amputation, not excision. 4thly. In removing a malignant tumor we should always endeavor to avoid loss of blood. This is a good rule, even when the patient is tolerably ple- thoric; but its observance is especially important in lean and fat subjects, the latter of whom, in particular, generally bear the loss of this fluid very badly. I deem it a matter of great moment to guard against hemorrhage in every operation of this kind, not so much on account of the immediate recovery of the patient, as on account of the danger of relapse, which, I confidently be- lieve, is frequently very much increased by this accident. 5thly. It is a matter of great consequence, in reference to the question of relapse, that the whole of the wound left by the operation should be healed by the first intention. For this purpose, the parts should always be approxi- mated as nicely as possible, not only at their edges, but also over the surface of the wound, that there may be no cavities or pouches for the lodgment of matter, but that the restorative process may proceed in the best and most rapid manner at every point. The most suitable dressings are a light com- press and bandage, aided by adhesive strips or collodion plaster. Sutures are objectionable, because the tract made by them occasionally serves as a point of departure for new deposits, thereby promoting relapse. They cau- not, however, always be dispensed with, especially when there is a scarcity of integument. 6thly. When the integument is defective, it is sometimes practicable to borrow the requisite amount from the surrounding parts; an operation first suggested, I believe, by Martinet, who imagined that we could thereby gene- rally, if not always, effectually prevent a return of the disease. He thought we might thus change the functions of the parts in such a manner as to re- store their healthy nutrition, and so counteract the tendency to the produc- tion of cancer. I have had recourse to this procedure in a number of instances, in different regions of the body, especially in epithelial cancer of the lips and eyelids ; but in none with any permanent or even protracted benefit. For a time the transplanted parts retained their healthy character; but at the end of a few months they gradually became hard and rigid, and soon thereafter exhibited all the evidences of carcinomatous disease. 7thly. When a sufficiency of integument cannot be obtained, and the wound is obliged to heal by the granulating process, it is worthy of consideration whether the whole of the raw surface should not be effectually cauterized with the nitrate of silver, or the acid nitrate of mercury, so as to form a superficial eschar. The practice certainly derives support from the beneficial effects which are said to follow the treatment of cancer by cauterization in the hands of the empirics, as well as in the hands of some scientific practi- tioners. Finally, considerable diversity of opinion has existed among surgeons as 282 TUMORS, OR MORBID GROWTHS. to the time when the operation should be undertaken with the best prospect of ultimate success. The preponderance of professional sentiment, however, has always been in favor of early interference, on the ground that the longer the disease is permitted to remain, the greater, all other things being equal, will be the risk of contamination. The advocates of this measure, indeed, never countenance a resort to the knife when there is positive evidence that the disease has invaded the adjacent parts, or the system at large. Some, it is true, employ it with a view of prolonging life, or alleviating suffering, but never with the hope of effecting a radical cure. Treatment after Operation.—The treatment after removal of the affected structures must be conducted upon general principles. Everything should be done calculated to insure union by the first intention. When the patient has recovered from the immediate effects of the operation, he should be put upon a general course of treatment intended to maintain his health as near as possible at the normal standard. Above all, strict and constant attention should be bestowed upon the diet. Of the propriety and importance of attention to the patient's diet, after excision, no one can entertain any doubt. The force of this remark will appear the more evident when it is recollected that the progress of cancer has occasionally been stayed for months, and even years, by a regular and per- sistent system of starvation, barely allowing a sufficient quantity of food, and that of the most bland and unirritant character, to maintain the due play of the vital functions, without too great a reduction of the heart's action. The kind of diet is, doubtless, a matter of no little moment. As a general rule, it may be stated that meats, soups, and the coarser varieties of vegetables should be proscribed, on account of their heating and indigestible character. For the same reason, condiments, wine, spirits, and fermented liquors are to be eschewed. Among the more suitable articles may be mentioned stale bread, toast, and soda biscuit, hominy, rice, sweet and Irish potatoes, mush, maccaroni, baked apples, figs, and ripe fruits. Not only should the food be perfectly simple and easy of digestion, but great care should be taken that it is always thoroughly masticated, and that the quantity at each meal is never so great as to crowd and oppress the stomach. As drinks, the best articles are water, milk, and weak tea. Coffee is too stimulating, and must be avoided. Of late years almost an exclusive milk diet has been used in several re- markable cases after this operation, and with effects so encouraging as to deserve farther trial. The facts published upon this subject by Dr. Pierce, Dr. Bowditch, and several others, are exceedingly interesting and instructive, and should receive attentive consideration. As there are no remedies which will eradicate the cancerous poison from the system before operation, so are there none which will prevent its repro- duction after. Of the numerous articles that have been employed for this purpose there is not one that can be viewed in the light of a specific, or as a counteragent to the morbid action. Some of the older surgeons, and, indeed, quite a number also of the modern, strongly insist upon the establishment of a kind of perpetual drain in the neighborhood of the original disease, as a means of preventing relapse after extirpation. The principal measures that have been suggested for this pur- pose are the issue and seton ; but with this mode of treatment I have no ex- perience. Should relapse ensue, and the patient become debilitated, recourse must be had to supporting measures, as quinine, iron, brandy, and nutritious food, aided by gentle exercise in the open air. Pain must be allayed by the free use of anodynes, and night-sweats by elixir of vitriol, or oxide of zinc, given in as large doses as the stomach will tolerate. Constant attention must be TREATMENT. 283 paid to cleanliness; fetor must be destroyed by the chlorides ; and the utmost care must be taken to protect the parts from the pressure of the clothes and rude contact of every description. The most suitable local remedies are leeches, the dilute tincture of iodine, emollient cataplasms, medicated with anodynes, and opiate plasters. Contra-indications to Surgical Interference.—The following circumstances may be enumerated as contra-indicating the removal of malignant tumors :__ 1st. No operation should be performed when the disease is congenital, or when it manifests itself soon after birth. Under such circumstances, a resort to the knife is almost certain to be followed by relapse, and that, too, in a very short time, owing, probably, to the fact that the system is, as it were, saturated with the cancerous poison. Cases of this kind are peculiarly viru- lent and intractable, resisting all attempts at cure, frequently, indeed, even at palliation, and rapidly tending to a fatal termination. The occurrence of the disease in several members of the same family may also be regarded as contra-indicating ablation, inasmuch as it is denotive of a constitutional pro- clivity to malignant action. 2dly. Interference should be avoided when the disease exists in several parts of the body; as, for instance, when it affects the mamma and the uterus. or the testicle and the eye. Although all these organs are accessible to the knife, yet a resort to it under such circumstances would be highly injudicious, inasmuch as it could not possibly eventuate in any permanent good, but, on the contrary, be almost sure to hasten the patient's destruction. No surgeon, however reckless, would think of operating when the external disease is asso- ciated with carcinoma of an internal part. 3dly. Operation is never resorted to, at least not as a curative agent, when the morbid growth has attained unusual magnitude : when there is serious local involvement; or, lastly; when there is marked evidence of the car- cinomatous cachexia. Thus, in cancer of the mamma, no surgeon who values his reputation, or who has any regard for the welfare of his patient, thinks of interfering when there is great bulk of the tumor, or firm adhesion of the organ to the surrounding parts; when the skin is changed in structure, ulcerated, indurated, or dimpled; when there is enlargement of the axillary, subclavicular, or sternal lymphatic ganglions; when there is oedema, with numbness and loss of function in the corresponding limb ; and, finally, when, in addition to some of the symptoms just mentioned, the features exhibit all the evidences of the cancerous cachexy. The same circumstances guide the surgeon in carcinoma of the testicle, eye, lip, penis, and extremities. If the knife is ever employed when the malady has made such progress and such inroads, it is with a view solely to palliation, not to cure. Of the propriety of such a course, every surgeon must be his own judge. 4thly. When the disease advances very rapidly, as it not unfrequently does in encephaloid, breaking through its original boundaries, and leaping, as it were, suddenly into the surrounding tissues, it may be assumed, as a general rule, that ablation will be improper; or that, if had recourse to, speedy repullulation will be the consequence. Rapid growth, constituting what has sometimes been denominated the acute form of malignant action, always implies a bad state of the constitution, and imperatively forbids surgical interference. There is another symptora which is equally portentous, but which has not, I think, engaged sufficient attention. I allude to the cedema- tous appearance of the parts immediately around the morbid deposit, or at a distance more or less remote from it. This condition, which is seldom absent in external carcinoma in its latter stages, is not unfrequently present at an early period in encephaloid, especially the hematoid variety of this affection, and always denotes the very worst state of things, both local and constitutional. The immediate cause of this symptom is obstruction of the 284 TUMORS, OR MORBID GROWTHS. lymphatic vessels and ganglions. Observation shows that nothing but mis- chief is to be expected from interference when the malady has attained this crisis. 5thly. A quickened state of the pulse, occasioned by the local irritation, augurs unfavorably. Excision, performed under such circumstances, is nearly always followed by speedy relapse; and it is, therefore, the duty of the sur- geon to discountenance it. 6thly. Latent cancers should not be tampered with. Cases constantly occur iu which, from neglect of this precaution, the patient loses his life, within a very short period after operation, from a return of the disease in its worst form. The reproductive powers of the part, if not of the system generally, usually manifest an astonishing activity under such circumstances, and the consequence is that the malady soon accomplishes its work of destruc- tion. 7thly. It is not necessary here to insist upon the propriety of refraining from operation when there is serious disease of an important internal organ. Such a complication could hardly fail to predispose to relapse, if not to the speedy destruction of the patient. Reproductive Tendency of Malignant Diseases after Operation.—Of the reproductive tendency of carcinomatous diseases, after extirpation, or de- struction by the actual or potential cautery, writers have made mention from the earliest periods of medical science to the present time. Hippocrates was fully aware of the fact; and he entered his protest against all operative pro- ceedings, under the conviction that, however early or well executed, they could not possibly afford any permanent relief, or guard the patient against a return of his malady. Similar views have been advanced by nearly all succeeding writers. If a different sentiment has occasionally been expressed, it has been by men who have had a very imperfect knowledge of the disease, who have been poor observers, or who have wilfully concealed the truth, from interested and dishonest motives. The period at which relapse occurs varies from a few weeks to a number of years. On an average, it may be stated to be from four to six months. Occasionally it takes place within an almost incredibly short period. In one of my cases, the malady returned in less than three weeks. The original dis- ease, which exhibited all the marks of genuine scirrhus, was of eight months' standing, and was seated in the left mammary gland, which it involved nearly in its whole extent; the nipple was somewhat retracted, and there was a slight enlargement of one of the lymphatic ganglions, which was removed in the operation. The dissection was performed with much care, and every particle of the morbid structure was apparently cut away; the greater portion of the wound united by the first intention, but a part of the centre remained open and became the starting-point of the new growth. The woman, who was forty-six years of age, died three months after the operation, having en- dured the most horrible torments. Sometimes a relapse does not take place until the end of the first year- and in a few instances it is postponed to a later period, as the expiration of the second, third, and even fourth year. But, although such cases are extremely interesting, yet they are altogether of an exceptional character; for, where one instance of this kind occurs hundreds take place where the disease proves fatal within the first six months after the operation In the exceptional cases, the affection is probably more localized than under ordinary circumstances; the malignant action, while it has a tendency to reappear at the cicatrice, or in the immediate vicinity of the original disease, having apparently no disposition to invade the general system. ° All malignant diseases possess this tendency to relapse after ablation, but TREATMENT. 285 not in an equal degree. Encephaloid undoubtedly enjoys it to a far greater extent than scirrhus, and scirrhus than colloid. Melanosis also relapses with great frequency and promptness, and may be placed next to encephaloid in this respect. Again, it must be borne in mind that a genuine cancer is more certain to return than a cancroid affection, and, also, that it is more apt to prove rapidly fatal. The reproductive tendency of malignant diease, after operation, is well illustrated by the following case:—A man, aged thirty-two, consulted me in April, 1851, on account of an epulis of the lower jaw, first noticed three months previously; it was firm, elastic, free from pain, of a pale-red color, and attached to the gum and jaw, extending from the ramus to the first bicuspid tooth. Two operations had already been performed upon it, each being followed by rapid relapse. On the 27th of April I removed the parts, along with the corresponding portion of the jaw. On the 24th of September I operated upon him a second time, removing the whole of the new growth, which was about the size of a pullet's egg, and about three-quarters of an inch of the anterior extremity of the ramus of the bone, from which the dis- eased structure seemed to spring. On the 31st of August, 1852, I excised the ramus at the articulation, the disease having attacked its inferior ex- tremity. The man remained well until the winter of 1853, when the disease broke out in front of the ear, and soon formed a tumor of the size of a small fist, from the effects of which he rapidly sank. It is worthy of remark that the general health had been all along pretty good, and that the wound always healed well after each operation. In a case of cancer of the lip, the particulars of which have been communi- cated to me by Dr. Barclay, of New York, also five operations were per- formed, the patient having survived the first excision a little more than seven years. In a case of encephaloid of the thigh, reported to me by Dr. C. S. Tripler, of the Army, the man did not die until five years after the first operation. I am acquainted with the history of a number of other examples nearly equally remarkable. With the renovative tendency of melanosis every one is familiar. Hardly an example of permanent cure by operation is upon record. I recollect a remarkable instance of this recurring action which occurred, many years ago, in the practice of the late Professor McClellan, of this city. The disease seemed to have begun in several small subcutaneous tubercles of the abdomen, about the size and appearance of shot, which soon became exquisitely painful, and gradually bursting through the skin, were at length converted into foul, fungous sores, attended with a highly fetid, sanious discharge. Many of these tumors were extirpated, some in their crude, others in their open state; but, although the wound generally readily healed, they were always promptly succeeded by a new growth in the immediate vicinity of the original. The man became much emaciated, and finally died completely exhausted, with all the evidences of the melanotic diathesis. The most interesting and extraordinary example of recurring encephaloid, of which I have any knowledge, is one which has been for nearly three years under my personal observation. The patient is an unmarried woman, aged forty-four, who in March, 1857, perceived in the left breast a small tumor, which was excised the following October. During the next sixteen months two more operations were performed, but as the mammary gland had been only partially removed, I extirpated the whole of it, along with a fourth tumor, in May, 1859, when the case was placed under my charge by Dr. Russell, of this city. The disease soon reappeared in the cicatrice, and in three months and a half again required the use of the knife. After four operations by myself the case fell into the hands of my former clinical assistant, Dr. Asch, who attended her until May, 1861, when I performed the twenty- 286 TUMORS, OR MORBID GROWTHS. second operation, the number of tumors removed, from first to last, being fifty-one, varying in size from a small almond to a pullet's egg. The ence- phaloid character of all was unmistakable. They generally recur at or near the cicatrice within a few weeks after extirpation, and speedily assume a fun- gating appearance. They are of a soft, vascular, brain-like structure, inclosed in a distinct capsule, and the seat of a thin, fetid discharge with little or no disposition to bleed. Occasionally she complains of sharp, shooting pains in the tumors, extending to the shoulder. Her general health has all along been excellent; there is no lymphatic in- volvement in the axilla or elsewhere; menstruation has been going on well; and she has always rapidly recovered from the effects of the operations. The records of surgery may be challenged for a parallel case of this disease. When malignant disease returns after extirpation, its tendency, as a general rule, is to assume the encephaloid type. This is true of all the different forms of these affections, whether they reappear at the site of the original disease, in the neighboring lymphatic ganglions, or in the internal organs. Hence the reason why the secondary disease is usually so rapidly fatal. SCROFULA. 287 CHAPTER VIII. SCROFULA. The term scrofula had formerly a far more limited application than is ac- corded to it in modern times. It was originally employed to designate a glandular swelling of the neck, strikingly resembling the neck of the swine, whence its derivation. At present, however, it has a much wider signification, being made to include within its range quite a variety of diseases apparently of the most opposite character, yet in reality essentially alike in every parti- cular. As meaning the same thing, the words struma and tubercular disease are frequently used. The affections which may be comprised under this term are pulmonary phthisis, chronic enlargement of the ganglions of the neck and other parts of the body, hip-joint disease, psoas, lumbar, and chronic abscesses, Pott's disease of the spine, certain forms of follicular ulceration of the mucous membranes, arachnitis, otorrhcea, ozsena, ophthalmia, eczema, and ulceration of the bones. The fact is, the class of scrofulous maladies is almost endless, affecting as they do almost every part of the body, and assuming as they do almost every form of morbid action. Scrofula consists essentially in the deposition of a peculiar morbid product long known by the name of tubercle. An attempt has lately been made to draw a distinction between the matter of tubercle and the state of the system which predisposes to its occurrence. It is difficult altogether to deny the propriety of this distinction; for there are unquestionably cases which we are in the habit of designating as strumous, where, nevertheless, there is not, so far as we are able to determine, the slightest strumous deposit. There would seem to be merely a strumous irritation in the part, without the part being in a condition to furnish any specific secretion, such as that to which we apply the term strumous, tubercular, or scrofulous. There is another distinction, which, however, is fast losing ground, which it is mofe difficult to reconcile than that just mentioned. I allude to the alleged difference between phthisis and scrofula. It would be easy, if a work on surgery were the proper place to discuss the subject, to adduce argument upon argument to show the utter fallacy of this opinion. I have long taught the identity of these diseases, and endeavored to prove that the only real difference beween them depends, not upon any difference in the morbid ac- tion, but solely upon the difference of structure, tubercular disease sharing the same fate, in this respect, as ordinary inflammation and as the other hete- rologous deposits. A tubercle in the lung is essentially the same disease as a tubercle in a bone or a lymphatic ganglion, having the same origin, running the same course, and producing the same results. Why then consider them as different? Tubercular disease occurs at all periods of life. Sometimes, indeed, it exists as an intra-uterine affection, thus leading to the conviction that it is occasionally hereditary, or that it is transmitted in the very act of impregna- tion. When it occurs as phthisis, it is most common between the twentieth and fortieth year, and it is remarkable that after the age of puberty it exists rarely in any part of the body without involving the lungs. In children, the 288 SCROFULA. disease, considered in a general point of view, is most liable to happen be- tween the third and tenth year. A vast majority of the cases of scrofulous disease that are met with in practice, in the form of coxalgia, Pott's disease, caries of the short bones of the extremities, arachnitis, ophthalmia, otorrhcea, tonsillitis, and chronic enlargement of the lymphatic ganglions, occur at this period of life, and constitute an immense source of mortality. It is a remark- able fact that adults seldom suffer from external scrofula; and, on the other hand, it is equally remarkable that children suffer comparatively little from consumption, so common among persons after the age of twenty. In old age the disease rarely occurs in any form. Struma is frequently hereditary. The children of consumptive parents are often cut off by the same disease, or they suffer in various parts of the body, as the bones and joints, the lymphatic ganglions, the eye, ear, and serous membranes. Whole families are sometimes destroyed by it. Occasionally the disease skips one generation, and reappears in another, owing, doubtless, to some temporary improvement in the intermediate offspring. The tubercular deposit has been observed in nearly every structure of the body. The only parts, perhaps, in which it does not occur, are the skin, vessels, nerves, ligaments, aponeuroses, tendons, and voluntary muscles. Of the organs, properly so called, there is not one which is not, at times, its seat. Experience, however, has shown that it manifests a decided preference for certain organs and parts of organs. Thus, it occurs most frequently in the lungs, particularly their summits, then in the lymphatic ganglions, next in the spleen, serous membranes, and mucous follicles of the alimentary canal, then the bones and joints, and finally the liver, kidneys, testes, and false mem- branes of the serous cavities. Its coexistence in various parts of the body, or its almost universal diffusion, is sufficiently frequent, and constitutes the so-called strumous diathesis. The deposit being a direct product of the blood, occurs both in the inter- stices and upon the free surfaces of the organs. Hence it exhibits itself in various/orms, of which the tubercular is by far the most common, the stratiform and infiltrated being, indeed, exceedingly rare. The tubercular variety occurs in little masses, from the size of a millet-seed to that of a pea, of a pale yellowish or grayish color, and of a consistence ranging from that of curds or soft putty to fibro-cartilage, hundreds and even thousands often existing in a very small compass. When very numerous and closely grouped together, they sometimes coalesce, so as to form a considerable sized tumor. The stratiform variety of the deposit is most common upon mucous surfaces, while the infiltrated is met with chiefly in the lungs, around tubercular exca- vations, and in the lymphatic ganglions. Whatever shape it may assume, it is always deposited in a fluid state, from which, however, it passes speedily into the solid form, which it retains for a certain period—generally from six to twelve months—when, becoming softened and disintegrated, the part makes an effort to rid itself of it. These changes are followed by the formation of a cavity, named a strumous abscess, of which the best examples occur in the lungs, bones, and lymphatic ganglions. The matter is peculiar; being gene- rally of a yellow-greenish color, of a cream-like consistence, and intermixed with small whitish flakes, very similar to broken-down grains of boiled rice. Microscopically examined, it is observed to consist of a transparent matrix, inclosing granules, nuclei, cells, and oil-globules, the relative proportions of which vary in different specimens, and even in different portions of the same mass, the chief circumstances which influence its minute structure being the age of the deposit, the nature of the affected organ, and the general condi- tion of the subject. Most of the granules are very minute, and afford an albuminous reaction ; they exist in great numbers in yellow tubercle, and often contain so much fatty matter as to be completely dissolved by ether. SCROFULA. 289 The free nuclei, or true tubercle corpuscles, are round, ovoidal, oblong, or almost shapeless, and vary in size from ^s^o to ^gVo- of an inch in diameter. They constitute a large proportion of the morbid product, and are generally intermixed with epithelial cells, oil globules, and crystals of cholesterine. The adjoining cut, fig. 56, from a drawing by Dr. Da Costa, conveys a good Fig. 56. Fig. 57. Tubercle corpuscles. Tubercles in enlarged mesenteric glands from a scrofulous patient. idea of the microscopical characters of tubercle as it occurs in different parts of the body. In fig. 57, it is seen as it is deposited in the lymphatic glands. Tubercular matter, in its crude state, consists almost entirely of albumen, with a small quantity of earthy salts, particularly phosphate and carbonate of lime. Some specimens also contain a little fibrin, casein, extractive mat- ter, and pyine ; but the great and pervading substance is albumen, or protein matter. The microscopical and chemical examinations of this matter are extremely valuable, inasmuch as they go to show the low grade of its vitality, and its consequent inability to maintain, for any length of time, its parasitic exist- ence. Certain authors, founding their opinion upon these facts, look upon it as an unorganizable product, very much of the same nature as that of colloid and melanosis. In this view, however, I cannot concur; for I have investi- gated tubercular matter too often, and under too many varying circumstances, not to be convinced that it is susceptible of organization, although certainly in a less degree than scirrhus and encephaloid. It is, in point of vitality, a more humble substance than either of these ; it occupies a lower grade in the scale of cell development; and has a greater quantity of protein matter. Nevertheless, we must concede to it a certain degree of life-power, a certain form of organization, otherwise it would be impossible to explain the various changes which it undergoes, and the fact that it occasionally contains distinct vessels, clearly traceable into its interior, and intended to minister to its nourishment and protection. The matter of colloid is very different from that of tubercle, in having no attachment to the cells in which it is contained, in being alike in all stages of its existence, and in never experiencing any transformations. The same is true of melanosis. If this substance is occa- sionally very hard, it is because of its involvement with its fibrous matrix, or the surrounding tissues. Tubercle, on the contrary, is always firmly adherent to the parts with which it is in contact, except when it is effused upon mucous surfaces, acquires a firm consistence during its development, and often under- goes absorption, or the earthy transformation. Besides, the softening pro- cess frequently begins in the very centre of the morbid product, which could vol. 1.—19 290 SCROFULA. certainly not happen if it were an inorganic substance. Those who deny the vascularity of tubercle attempt to account for the occasional existence of vessels by supposing that they become imprisoned in its substance during the progress of its formation. That this view is sometimes true is highly proba- ble, but it is applicable only to certain parts of the body, and then only under certain circumstances. The explanation is undoubtedly not admissible in those cases where the tubercular matter is deposited upon the free surface of the serous membranes or in the substance of the adventitious, where its vascularity is so often observable. This matter, however, is not always organizable. Like coagulating lymph, it is sometimes deprived of its vitality almost in the very act of its secretion. This is particularly the case when it is effused upon the free surfaces of the raucous membranes, espe- cially those of the urinary passages, whose irritating contents speedily render it effete. Of the exciting causes of tubercular disease our knowledge is rather con- jectural than positive. It may be fairly inferred, however, from the numerous observations that have been made upon the subject, that, when the tendency to the disease exists, anything calculated to produce excessive debility, or an impoverished condition of the blood and solids, may provoke the morbid deposit. The causes which are most likely to bring about this effect may be thus stated : 1. Meagre and unwholesome diet, deficient in fibrinous, albu- minous, gelatinous, and fatty qualities. 2. Protracted disorder of the diges- tive organs, particularly the various forms of dyspepsia. 3. Exposure to cold, and confinement in damp, ill-ventilated, ill-lighted apartments. 4. Exhausting fevers. 5. Excessive and long-continued evacuations of blood. 6. Severe courses of mercury. 7. Stoppage of habitual discharges, as the menstrual and hemorrhoidal. 8. Protracted mental depression. 9. Tertiary syphilis. All these causes act by lowering the vital principle, and diminish- ing the plastic properties of the blood. The immediate cause of the disease is inflammation, which regulates, not only the quantity, but also the quality of the deposit. The inflammation is generally of a low grade, and is therefore not characterized by the ordinary phenomena, although it is not the less effective on that account. The rea- sons which may be adduced in support of this view are the following:__ 1. Irritation of the lung, mechanically excited, will frequently give rise to tubercle in that organ, as is occasionally seen in cases of foreign bodies, acci- dentally introduced through the larynx. In the inferior animals, as the dog and rabbit, mercury dropped into the trachea will often induce the disease in a short time. Miners, needle-grinders, and weavers, who are habitually exposed to the inhalation of gritty and irritating matter, are particularly prone to phthisis. 2. This view of the origin of the disease is countenanced by the composi- tion of the deposit; for we know of no substance which contains so much albumen, or albumen and fibrin, that is not the product of inflammation. 3. Tubercle bears a great resemblance to coagulating lymph, especially the more degraded forms of that substance, and this, as every pathologist is aware, is always the result of inflammatory action. 4. The disease is often developed under the immediate effects of cold, and various other causes which have a tendency to produce congestion of the internal viscera. Indeed, it is well known that dyspeptics and persons who live upon unwholesome food, or in damp and ill-ventilated apartments, are peculiarly liable to suffer from this disease. The duration of strumous disease is too variable to admit of any accurate general statement. Phthisis usually destroys life in from nine to eighteen months; tubercular arachnitis often terminates fatally in a few days; while external scrofula may last for years, and finally eventuate in recovery.' SCROFULA. 291 The symptoms vary, of course, according to the nature of the affected structure, but, whatever this may be, there are certain appearances which are hardly ever absent in any case. Thus, whether the disease be seated in the lungs, in a bone, a joint, or simply in the cellular tissue, in the form of a cold abscess, there is always, during the progress of the malady, excessive emaciation ; for, with the exception of the glandular viscera, the brain, nerves, and a few other structures, there is hardly an organ in the body that does not, in some degree, participate in the general atrophy. The fat gradually but surely disappears ; the muscles are pale, flabby, and attenuated ; the cellu- lar tissue is deprived of its moisture ; the skin is soft and blanched ; the hairs grow slowly, and many drop out; the nails are thin, and frequently incur- vated ; and the bones, although they retain their size, are unusually light. and saturated with sero-oleaginous fluid. The blood also is altered. It is impoverished, thin, pale, and deficient in globules. The clot is unnaturally small and dense, and, when the disease is fully established, with a tendency to suppuration, is almost always covered with a buffy coat. The fibrin is not materially changed until softening sets in, when it increases dispropor- tionably in quantity, and so continues until suppuration begins, when it attains its maximum. These changes are generally very conspicuous in phthisis, psoas abscess, and extensive disease of the lymphatic ganglions. Scrofula has been supposed to be contagious, and many experiments have been performed, both upon man and the inferior animals, with a view of de- ciding the question. In no instance, however, has the operation succeeded. Kortum applied scrofulous pus to sores and wounds in the necks of children, but always failed to induce the disease. Hebreard and Lepellitier performed similar experiments upon dogs and guinea-pigs with a like result. Finally, Goodlad and others attempted, with no better success, to create the disease in their own persons by inoculation. The idea of the contagious character of phthisis was formerly very prevalent, but is now obsolete. Persons who are affected with scrofula, or who are laboring under what is termed the strumous diathesis, exhibit certain peculiarities which may be considered as almost characteristic. These refer mainly to the state of the complexion, the digestive apparatus, and of the circulation. The complexion is generally brunette, and the hair, for the most part, dark, although in both these respects the greatest possible diversity exists. The eyelashes are drooping and of extraordinary length ; the pupils are habi- tually dilated ; the upper lip is tumid ; the face is pale and puffy ; the hands and feet are nearly always cold ; the body is unusually impressible by atmos- pheric vicissitudes ; the abdomen is hard and distended; there is a deficiency of muscular strength ; and the intellect is dull and sluggish, instead of being sprightly and precocious, as is usually represented. The digestive organs are subject to frequent derangemeut; the appetite is irregular and capricious ; the bowels are either constipated or relaxed, seldom entirely natural; diges- tion is feeble and imperfect; great annoyance is experienced from flatulence and acidity ; and the individual is often a martyr to dyspepsia. Children predisposed to struma are particularly prone to cutaneous eruptions about the scalp, to purulent discharges from the ears, and to chronic enlargement of the tonsils. There is another class of strumous subjects of a state of mind and body almost the opposite of that just described. The complexion is light and florid, the eye blue, the mind unusually active, and the cutaneous circulation quite vigorous. The parts of the body which are most liable to suffer, in this form of constitution, are the bones and joints, the eye, skin, and lym- phatic ganglions, particularly those of the neck, consumption being much more rare than in the dark variety. 292 SCROFULA. Scrofulous Ulcer.— Various scrofulous affections of the skin give rise to ulceration, but, perhaps, the most characteristic ulcer of this kind is that consequent upon suppuration of the lymphatic ganglions of the neck, groin, and axilla. Be this as it may, the features of the scrofulous ulcer are so pecu- liar as to require distinct notice. . The surface of the scrofulous ulcer is always unhealthy, being coated with rough, aplastic matter, of a pale yellowish or grayish color, hard, and firmly adherent to the subjacent structures. There is reason to believe that this matter, which possesses none of the characteristics of laudable pus, is often intermixed with disintegrated tubercular substance. In many cases the bottom of the ulcer is formed by altered lymphatic ganglions, of a reddish appearance, and so much softened as to break down under the slightest pres- sure ; sometimes, however, they are hard, almost of a fibrous consistence, and as if thev had been partially dissected from the surrounding parts. In some cases, in fact, they separate, or slough out, several perhaps coming away at the same time, or in more or less rapid succession. No healthy granulations exist upon such a sore, unless it is in a healing condition, and even then they form and maintain themselves with great difficulty. The edges of the ulcer are characteristic. They are of a bluish, purplish, or reddish hue, undermined, hard, jagged, thin and sharp at some points, thick and obtuse at others. Occasionally they look as if they were bent in towards the bottom of the ulcer. They are generally remarkably insensible, incapable of forming granulations, and deeply congested, the blood passing through the vessels in a very languid and imperfect manner. In fact, the skin, having lost its support, is excessively impoverished, and has great diffi- culty in maintaining its vitality. The parts around the scrofulous ulcer are generally hard, either from the presence of indurated and diseased ganglions, or from interstitial deposits; usually, in fact, from both. The skin is red and congested, and not unfre- quently also somewhat cedematous, pitting on pressure. The swelling is often great and disfiguring; in short, characteristic of that peculiar appear- ance from which the disease originally derived its name, the neck, when that is the affected region, strikingly resembling that of the swine. The scrofulous ulcer may be single, or there may be more than one; vari- able in shape and extent, and frequently communicating with considerable sinuses. The discharge is ichorous, or thin and whey-like ; sometimes thick and yellowish ; in either case, apt to be intermixed with the debris of disinte- grated ganglions, flakes of lymph, and broken-down tubercular matter. Treatment.—The treatment of scrofula, like that of cancer, has been ex- ceedingly diversified and empirical, for there is hardly a solitary article of the materia medica that has not, at one time or another, been called into requisi- tion. Even at the present day, when the pathology of the disease is so much better understood, the greatest uncertainty prevails in regard to our thera- peutic measures, and the consequence is that few practitioners approach the disease without doubt and misgiving as to the benefit they may be able to confer by their treatment. Strumous affections have always afforded a vast field for the charlatan, and his pretensions have never been more impudently paraded before the public than in our own day. One, if not the chief, reason of this is that so few practitioners really understand the nature of this class of diseases; they seem to forget, or not to know, that they occur in every possible form and under every variety of circumstances, and that, in order to meet them successfully, it is necessary constantly to vary our remedies ac- cording to the exigencies of every particular case. I am certain, from no little experience upon the subject, that the results of our treatment hinge most materially upon a just discrimination of the different states of the system under which these affections occur. To treat every case of scrofula alike, TREATMENT. 293 without regard to the state of the system which attends it, is the climax of absurdity. Let the practitioner remember that scrofula has no specifics, and he will soon cease to employ his remedies empirically. The indiscriminate use of iodine and cod-liver oil in this affection has done mankind and the profession an immense deal of harm. It will be sufficient, for practical purposes, to consider scrofulous subjects as being divisible into two great classes, the enfeebled, and the vigorous; that is, those who have but little constitutional stamina, and those who, although affected with a strumous taint, are comparatively stout and robust, possessing a ruddy complexion, and an active cutaneous circulation. The latter, undoubtedly, constitute the minority of the cases that come under our observation, but they are, nevertheless, sufficiently common, and so well marked as to be easily recognized by the most superficial observer. Now, to treat these two classes of subjects on the same principle, as is so generally done, is contrary to the dictates both of sound sense and daily experience. While cod-liver oil, iodine, and tonics will perform wonders in the naturally weak, they will be of little avail in dislodging and curing the disease in the naturally robust; and, conversely, while the lancet and tartar emetic will be of immense service in the latter, their employment can scarcely fail to be eminently prejudicial in the former. Let it not be imagined, however, that one mode of treatment is applicable to all cases of this form or that form of the disease; on the contrary, circumstances constantly arise during the pro- gress of each particular case which imperatively call for a change of remedies, and it is in the knowledge of this circumstance that the great art of curing the malady lies. It is well, as a general rule, to begin the treatment with some mild but efficient aperient, to clear out the bowels, and improve the secretions. Our course must then be shaped by the peculiarities of the case. If the patient be naturally very feeble, or has become so in consequence of protracted suf- fering, an alterative and tonic course must at once be instituted, as the most likely to meet the indications; but if, on the other hand, he is strong and plethoric, as denoted by the state of his pulse and complexion, much time will be gained, and structure saved, by the use of antiphlogistics, especially tartar emetic and Epsom salts, in the form of the saline and antimonial mix- ture, properly guarded with tincture of opium. The lancet must be employed with the greatest care; but I am satisfied that it is often of immense benefit in arresting the morbid action, and that it has fallen into too much neglect in the treatment of scrofulous diseases. In scrofulous inflammation of the eye, throat, and lymphatic ganglions, its effects are often marked and perma- nent. But there is a time when the employment of antiphlogistics ceases to be proper, and when they may be superseded by other remedies, similar to those generally applicable in the more common form of the disease. If the depletory system of treatment is carried too far, it cannot fail to do harm by exhausting the vital powers, and thus creating a disposition, in different parts of the body, to the deposition of tubercular deposits. Among the various remedies that have been employed from time to time for the cure of scrofula, iodine holds a prominent rank. This article was first introduced to the notice of the profession, as a therapeutic agent, in 1820, by Dr. Coindet, of Geneva, and since that time its efficacy in the treatment of this affection has received the most ample confirmation. Indeed, it may be regarded as the remedy par excellence in this disease. It may be employed alone, or in union with other substances, as potassa, iron, mercury, lead, qui- nine, barium, and ammonia, and hence much judgment is often required to determine what particular form of the remedy is best adapted to a particular case or form of the malady. As a general rule, it may be observed that, when a purely alterative effect is desired, it may be exhibited by itself, in substance, 294 SCROFULA. in tincture, or in the form of Lugol's concentrated solution, consisting of one scruple of iodine and double that quantity of iodide of potassium, dissolved in seven drachms of water. Of this the patient may take from five to ten drops every eight hours, in a wineglassful of sweetened water, the dose being gradually increased to fifteen, twenty, twenty-five, and even thirty drops, according to the tolerance of the system. With the same view the iodide of potassium is not unfrequently adminis- tered alone; and, when scrofula is associated with constitutional syphilis, rheumatism, or mercurial disease, it certainly constitutes one of the best forms in which iodine can be exhibited. With whatever view it may be employed, it is proper always to begin with small doses, as four or five grains, if the patient be an adult, and gradually to increase them to ten, twenty, and even thirty grains, three or four times a day. The most eligible way of giving it is in water, or in union with the fluid extract of sarsaparilla. Some patients take it very well in hop tea, and when there is much restlessness at night, or nervous irritation, this is perhaps the best form in which it can be exhibited. When the liver is at fault, or when there is a syphilitic taint of the system, or much disorder of the secretions, the protiodide of mercury may be advan- tageously prescribed, in doses varying from the fourth of a grain to half a grain, three or four times a day. The biniodide may be employed with the same view, but it should be recollected that it is much more potent, and that, therefore, greater caution should be observed in its administration. The dose, which at first should never exceed the one-twelfth or one-sixteenth of a grain, may be gradually augmented to a fourth or even half a grain, given in the form of pill, or dissolved in alcohol. When an alterant and tonic effect is indicated, nothing can be better than the iodide of iron, or the iodide of quinine. The former of these articles is one of the most valuable anti-scrofulous remedies that we possess, and one which rarely entirely disappoints expectation. In my own practice I have found it particularly beneficial in strumous disease of the cervical ganglions, of the upper lip, the eye, and joints. I often give it in solution, but more commonly in the form of pill, in combination with quinine and opium. If vascular action be present, a minute portion of tartrate of antimony and po- tassa may be added to each dose. In children, who cannot take pills well, the best mode of administering it is in combination with syrup of orange- peel, or syrup of sarsaparilla. The iodide of quinine has been advantageously employed in the treatment of scrofulous tumors, in cases where iodine and tonics are indicated, in doses from one to two grains every six or eight hours. In whatever form iodine be employed, whether as a simple or compound, it must be borne in mind that the system should be free from all vascular excitement, and that, after it has been exhibited for a fortnight, it should be pretermitted for several days, when it may be resumed, and given as before. Employed in this manner it exerts a much happier influence upon the pro- gress of the complaint, and is much less likely to disagree with the stomach and bowels, than when given uninterruptedly. In case it acts as an irritant, it must be exhibited in smaller doses, or be combined with opium or hyos- cyamus. Great mischief often results from neglect of this precaution. Another remedy of great value in the treatment of scrofulous disease is barium. It has repeatedly succeeded in my hands when other means have proved inefficient or entirely unavailing; it is particularly valuable in chronic enlargement of the cervical ganglions, both before and after the establishment of suppuration. It is chiefly adapted to patients with a languid circulation, a pale tallow-like complexion, a flabby tongue, indigestion, and cold extre- mities. Its use is contra-indicated when there is inflammatory excitement or congestion of any important organ. The best mode of administration is the TREATMENT. 295 officinal solution of the United States Pharmacopoeia, beginning with six or eight drops, and gradually but cautiously increasing the dose to ten, twelve, or fifteen drops, three times a day, in a wineglassful of hop tea, or half an ounce of the simple syrup of sarsaparilla. Exhibited in large quantities, it is liable to cause nausea, heartburn, diarrhoea, griping, headache, rigors, and profuse sweats; in a word, all the symptoms of mineral poisoning. There is an iodide of barium which is worthy of trial in scrofulous affec- tions. The dose is one-eighth of a grain three times a day, gradually in- creased to one, two, or even three grains. In some cases of scrofula bromine, in the form of iodide, answers a good purpose, although, as a general rule, it is very decidedly inferior to iodine. The average dose, for an adult, is from five to ten grains thrice a day. There is no medicine which has been more frequently or more extensively employed in the treatment of strumous diseases than mercury. The prepara- tions most commonly used are calomel, blue mass, corrosive sublimate, and the black sulphuret, or Ethiop's mineral. Of these the bichloride is the best. It should be given in minute alterative doses, as the one-sixteenth or one- twentieth of a grain, three times a day, either in the form of a pill, or along with sarsaparilla. Thus administered, it yields hardly in efficacy to iodine, and is probably superior to barium. In employing mercury, in any form, care should be taken that the system be properly prepared for its reception, and that it be not carried so far as to induce salivation. If it be found to act as an irritant or excitant in any way, it must be at once discontinued, or exhibited in smaller quantity. Whether mercury produces its beneficial effects merely by correcting the secretions, and thereby improving the general health, or by suspending or modifying the tubercular action, we have no means of knowing. When the disease has existed for a considerable length of time, and espe- cially when there is a decided tendency to emaciation, great benefit may be expected from the use of cod-liver oil, given in half ounce doses thrice in the twenty-four hours, in good ale, or along with a little brandy. The value of this remedy is no longer a matter of doubt, but rests upon the general testi- mony of the profession. Although it contains a minute quantity of iodine and bromine, it is probable that its good effects depend chiefly upon its nutritive qualities. However this may be, it unquestionably improves the condition of the digestive organs, and acts slightly upon the urinary and cutaneous secretions. To derive much benefit from it, its use must be con- tinued, steadily and persistently, for a long time. Whatever remedies may be employed, the closest attention should be paid to the bowels, diet, exercise, and dress. Constipation should be counter- acted by mild aperients, as blue mass and rhubarb, or, when there is much disorder of the secretions, by a few grains of calomel, followed by a little oil. Active purgation, however, must be studiously avoided, as it will ine- vitably do mischief by inducing debility. Torpor of the liver must be promptly met by mild mercurials, and acidity by alkalies, of which bicar- bonate of soda, either alone, or in union with a little ginger, is the most valuable. The alkalies were at one time much in vogue in the treatment of scrofula, in the belief that they possessed a kind of specific power, but their influence was evidently much overrated. Emetics are occasionally of service, especially when there is much nausea, depraved appetite, and headache. The diet of a scrofulous patient should be light, unirritant, and rather nutritious than otherwise. It should consist principally of the farinaceous articles, with milk or weak tea at breakfast and supper, the latter of which should always be very light, and taken at least three hours before retiring to bed. Coffee, fresh bread, pastry, and everything else of an indigestible nature must be proscribed. The food should be well masticated, amd never used in 296 SCROFULA. such quantity as to oppress the stomach. In the latter stages of the malady, or even earlier, if the strength seems to require it, some of the lighter meats, a little fresh fish, or a few oysters may be taken twice a day, along with a glass of porter, ale, sherry, port, or Madeira, or, what is better than all, of brandy and water. Sometimes an almost purely animal diet seems to agree best with the stomach. Many patients are greatly benefited by the free use of whiskey, rapidly becoming strong and fat under its influence. It should be taken repeatedly in the twenty-four hours, in quantities suited to the state of the stomach and system. As an important auxiliary exercise claims particular attention. It may be taken on foot, in a carriage, or on horseback, as may be most convenient or agreeable to the sufferer, and should be indulged in whenever the weather admits of it. Care is taken that it is never carried to fatigue. In bad weather, the patient may use dumb-bells, or amuse himself in sawing wood, planing, or anything else to which he may have access. Children should be carried about in their nurses' arms, or in handcarts. Particular attention must be paid to the patient's clothing. He must be warmly clad. Flannel should be worn next the surface, both in summer and winter, the feet should be protected with thick shoes and stockings, and the skin should be maintained in a healthy, perspirable condition by frequent ablutions with tepid water, impregnated with common salt, ground mustard, strong soap, or any other exciting substance. A change of air is sometimes of vast service, and has been known to be of itself almost sufficient to effect a cure in this disease. The locality selected should be as healthy as possible, and not liable to great or sudden variations of temperature. If the atmosphere be dry, it matters little whether it be cold or warm, provided it does not run into either extreme. A residence near the sea-shore is often of immense benefit. In the latter stages of the disease, when the patient is harassed with hectic fever and diarrhoea, the treatment must be of a tonic and stimulant character. The diet must be highly nutritious; porter, ale, wine, and milk-punch must be freely used; the bowels must be restrained with astringents; the excessive sweats must be controlled with quinine and elixir of vitriol; and sleep must be procured and pain allayed with anodynes. There is no doubt that the state of the mind is capable of exercising a powerful influence upon the cure of scrofula, especially when seated in the external parts of the body. We may assume this to be a fact from the astonishing benefit which so often followed the royal touch, a practice which is said to have originated in the time of Edward the Confessor, near the middle of the eleventh century, and which continued down to the reign of Queen Anne. The belief in the efficacy of the royal touch seems to have been a long time almost universal in Britain. It was particularly prevalent in the reign of Charles II., who, in one single year, touched nearly 100,000 persons, who flocked to him from all parts of England, Ireland, Scotland, Jersey, and Guernsey. The practice was generally accompanied by prayers and other religious ceremonies, and particular days and seasons were set apart for its observance. The effect of this singular remedy was variable; in some of the patients a cure followed almost immediately after they were touched; in others, the relief was more tardy, but in the end not the less effectual; occasionally the process was obliged to be repeated; and in some cases the treatment was entirely useless. Richard Wiseman, who was surgeon to Charles II., and a most sagacious observer, must have had great confi- dence in the efficacy of the royal touch; for he expressly declares that " His Majesty cured more persons of scrofula in one year than all the chirurgeons of London in an age." The local treatment of scrofula merits some attention, although it can be TREATMENT. 297 alluded to here only in a very general manner, as each affection comprised under this denomination requires a mode of management in some respects peculiar to itself. The most important topical remedies are leeches, blisters, issues, pustulation with croton oil, tincture of iodine, embrocations, and sorbefacient unguents, especially such as have iodine for their bases, as the iodides of mercury, lead, potassium, iron, barium, and zinc. Leeches are often of immense service; and, as to counter-irritants, they can rarely be dispensed with in any case. Of the various sorbefacient applications none holds a higher rank, in my opinion, than the tincture of iodine, either pure, or, as I generally prefer, considerably diluted with alcohol. It is used as in ordinary inflammation, and often exerts a powerful influence upon the pro- gress of external scrofula, especially of the joints and cervical ganglions. Blisters, too, are a valuable means of relieving local congestion, modifying capillary action, and removing morbid deposit. If the part affected be a joint, rest, long and faithfully continued, will be necessary, if, indeed, not indispensable. If abscesses form, they must be opened, with the precaution, if possible, of excluding the atmosphere, experience having shown that such ingress is highly prejudicial, not on account of anything noxious in itself, but because of its tendency to cause decomposition of the contents of the sac, and, consequently, violent reaction, or hectic irritation. The swelling is attacked in its most depending part, the knife being introduced in a valve- like manner, and the opening immediately closed with adhesive strips, sup- ported by a compress and roller. The practice of permitting such accumu- lations to continue until they have seriously impaired structure, or caused intense suffering, cannot be too pointedly condemned. When the enlarged glands obstinately resist treatment, they should be excised, provided that they are sufficiently accessible to the knife, and also that there is no serious internal disease forbidding interference. An opera- tion is particularly indicated when the morbid growths press upon important neighboring structures, or when they are a source of deformity, as when they are situated in the neck or about the angle of the jaw. The dissection is often tedious and bloody, especially when a large chain of glands has to be removed, and is then very liable to be followed by erysipelas and other bad consequences. The scrofulous ulcer must be treated rudely at first, and gently afterwards. The undermined edges are cut away with the knife or scissors, and the surface is thoroughly touched with dilute acid nitrate of mercury, the solid nitrate of silver, or sulphate of copper, the application being repeated every other day until there is an appearance of healthy granulations, when milder means, such as opiate cerate, or the dilute ointment of nitrate of mercury, take its place. If disintegrated ganglions are present they should be removed with the knife, or destroyed with the Vienna paste; for so long as they remain no substantial progress can be made towards a cure. Sinuses are traced out with the bistoury, unless they involve important structures, when stimulating injec- tions, or the seton, must be used instead. Valuable aid will often accrue in these cases from the daily application of the dilute tincture of iodine to the surface immediately around the ulcer. 298 WOUNDS. CHAPTER IX. WOUNDS. SECT. I.—GENERAL CONSIDERATIONS. The term wound is a generic one, being employed to designate all injuries attended with a division of tissue, inflicted by sharp, pointed, or blunt instru- ments and weapons of every description. The breach, or solution of con- tinuity, may be apparent or concealed ; that is, upon and in the skin, as well as in the more deep-seated structures, or the skin may retain its integrity, and the wound be strictly subcutaneous. Wounds are constantly made by surgeons in the legitimate exercise of their professional duties, as in the removal of limbs, tumors, and urinary calculi, and in the restoration of lost or mutilated parts. In general, how- ever, they are inflicted accidentally, and hence, as this may happen in a great variety of ways, they are very properly arranged under different heads, according to the manner in which they are produced. Thus, a wound is said to be incised when it is caused by a sharp instrument; lacerated or contused, when it is made by a blunt body; and punctured, when the weapon is narrow and somewhat pointed. A gunshot wound is a breach inflicted by a ball. In a poisoned wound the tissues are inoculated with some peculiar virus, either secreted by an appropriate apparatus in the bodies of certain-animals, as the bee or snake ; contained in the salivary fluid, as in the dog in hydro- phobia ; or developed after death, as in the human subject in the dead-house. The term penetrating is employed when the wound communicates with a cavity, as a joint, the chest, or the abdomen. Wounds are also generally named according to the region of the body which they occupy, or the particular tissues, organ, or cavity which they affect and interest. Thus we are accustomed, in common parlance, to speak of wounds of the head, neck, chest, abdomen, and extremities; of wounds of the skin, muscles, tendons, vessels, and nerves; of wounds of the stomach, heart, lungs, liver, and brain; and of wounds of the joints, pleura, pericar- dium, and peritoneum. Finally, wounds may be superficial or deep ; recent or old ; simple or com- plicated ; oblique, transverse, or longitudinal. The meaning of these terms is too obvious to require any particular explanation. The most common complications which attend their occurrence, or which arise during their progress, are, hemorrhage, the presence of foreign matter, abscesses, mortifi- cation, erysipelas, pyemia, and tetanus. These accidents, whether in their individual or combined capacity, often completely change the character of a wound, rendering complex what was originally perhaps perfectly simple, and dangerous what was, in the first instance, perhaps so insignificant as hardly to attract serious attention. The characteristic features of wounds will be pointed out in connection with the different classes of injuries to which they relate. The prognosis and treatment will also receive due attention. I shall therefore content myself here by stating, in general terms, that the great and leading iudica- MODE OF DRESSING WOUNDS. 299 tions, in every wound, whatever may be its nature, are, first, the stoppage of hemorrhage; secondly, the removal of extraneous matter; thirdly, accurate approximation and retention of the edges of the solution of continuity; and, lastly, the prevention of inflammation, tetanus, and other untoward occur- rences. In every case, the most prompt attention should be given; the parts should be bandied in the most cautious and gentle manner; and the dressings, which are never to be too officiously interfered with, should always be as light as possible. In short, whatever is done, should be done with a view to the most speedy and perfect restoration of the injured structures. 1. MODE OF DRESSING WOUNDS. The most important retentive means are adhesive plaster and sutures, aided, if necessary, by the bandage and attention to the position of the wounded parts. There are various substances which are endowed with adhesive properties, and which are therefore well adapted to retain the edges of a wound in con- tact with each other. Those, however, which are usually employed for this purpose are the common adhesive plaster, collodion, and isinglass plaster. The old adhesive plaster is composed of resin and lead plaster, in the pro- portion of one part by weight of the former to six parts of the latter, melted together over a gentle fire, and spread smoothly by machinery upon muslin, which is rolled up, and kept in the shops ready for use, care being taken to protect it from the heat. The addition of a little soap renders it more plia- ble, and prevents it from cracking in cold weather, without impairing its adhesiveness. To attain the same end, some pharmaceutists are in the habit of incorporating with it spirits of turpentine, but such an addition is highly objectionable, as the plaster, when thus prepared, is liable to irritate the skin, and thus induce a tendency to erysipelas and the development of small ulcers, to say nothing of the probability of its interfering with the adhesive action of the wound. The plaster, when intended to be used, is cut into suitable strips with a pair of scissors, carried in the direction of the length of the cloth, not in that of its breadth, as it is much more yielding in the latter than in the former, and therefore liable, when it becomes heated on the skin, to let the edges of the wound gape more or less. Trifling as this precept may appear, I consider it to be of great practical importance, and am satisfied that it is much less insisted upon than it should be. When the wound occupies a limb, each strip should be long enough to extend about three-fourths round it; on no account should it completely encircle it, lest it obstruct the return of venous blood, and at the same time cause pain and tension. The width of each strip should be uniform, and should vary, on an average, from half an inch to an inch, according to the exigencies of each particular case. Previously to applying the plaster, the surface of the skin should be divested of hair, and well wiped with a dry cloth, as the least moisture prevents it from adhering. The shaving of the parts is necessary to facilitate the removal of the plaster, which would otherwise be difficult and painful, and which might, by its traction, even seriously compromise the safety of the adhesive process. These important preliminaries being disposed of, bleeding having ceased, or nearly so, and the edges of the wound being carefully held together by an assistant, each strip is heated by holding its back against a pitcher or coffee-pot filled with boiling water, and then applied in such a manner as that its centre shall correspond with the wound, each extremity firmly grasping the opposite side. If the wound is very long and deep, the first strip should be stretched across its middle, which thus becomes the starting point of all the rest. The interval between each two strips should not, on an average, 300 WOUNDS. exceed the eighth of an inch, as this will afford ample space for the drainage of blood, serum, and lymph, of which there will generally be more or less after every injury of this description, especially if it be of considerable extent. Care must be taken that the adhesive strips are laid down in as smooth and even a manner as possible; hence, the parts should always be put in the position in which it is intended to keep them during the treatment. If the strips turn up in folds, or are partially detached, they should be immediately replaced by others, more skilfully applied. Finally, care must be taken, on the one hand, not to invert the edges of the wound or to draw them together too firmly, and, on the other, not to approximate them so loosely as to en- danger their partial separation. Iu short, everything must be done in a neat, accurate, workman-like manner. Much has been said of late years respecting the value of isinglass plaster; it is alleged that it is more bland than the common plaster, that it is quite as adhesive, and that it possesses the additional advantage of not provoking irritation, which the other undoubtedly sometimes does, especially in persons of a delicate, sensitive skin. Moreover, it is claimed that isinglass, when spread on gauze, will, by its transparency, admit of complete surveillance of the wound, thus enabling the surgeon to witness the changes going on in and around it. Notwithstanding these supposed advantages over common adhe- sive plaster, my conviction is that the latter, as prepared by the modern pharmaceutist, is decidedly superior to it, in every particular. The idea that common adhesive plaster is apt to cause erysipelas and ulceration of the skin is in great measure, if not wholly, chimerical; at all events, it has seldom fallen to my lot to meet with such occurrences. In the next place, it is much stronger than isinglass plaster, and therefore it affords better support to the parts. Thirdly, it is less liable to become prematurely detached ; and, lastly, although it is opaque, yet as there is always an interval left between each two strips for drainage, it is obvious that it cannot in the slightest degree inter- fere with the examination of the wound and its vicinity. I, therefore, as a general rule, limit the use of isinglass plaster to the dressing of small wounds or little cuts, and employ the common plaster for wounds of large size. The principles regulating its application do not differ from those already laid down. The strips should be of appropriate length and width, and moistened on the glazed surface with a sponge wet with hot water. The credit of having introduced collodion for surgical purposes is due to Dr. J. P. Maynard, of Boston, by whom it was first used in 1847. It is a solution of gun cotton in ether, assisted by a little alcohol, and is a transpa- rent, colorless fluid, of a syrupy consistence, which, when applied to a dry surface, allows of the rapid escape of the ether, leaving a thin, bluish film, possessed of remarkable adhesive and contractile properties. Being imper- vious to water, it is less liable to be prematurely detached than isinglass or common resin plaster. Put upon wounds or abraded surfaces, it produces sharp pain, which, however, speedily subsides, and does not afterwards return. It may be applied by means of a camel-hair pencil, or a small brush, directly to the affected parts, as in the case of small, superficial cuts; or upon strips of silk gauze, or patent lint, of suitable width and length, when the wound is so large and deep as to require firm support. As the ether evaporates very rapidly, the dressing should be applied with as much celerity as possible, everything being thoroughly arranged beforehand, and the edges of the wound well dried and supported by an assistant. Personal observation induces me to believe that collodion makes an excellent dressing in solutions of continuity about the neck and face, or in all the more movable regions of the body, and in those cases where it is particularly desirable to exclude the contact of the air. Within the last few years caoutchouc has been pressed into the service of MODE OF DRESSING WOUNDS. 301 the surgeon on account of its adhesive qualities; an excellent sticking plaster may be prepared from it by spreading a solution of it, with a stiff brush, upon gauze silk, or thin calico, after the fashion of collodion. One great advantage which it possesses over most other materials is that it is completely impermeable by water. Whatever substance be employed, it should be allowed to remain on so long as it seems to answer the object for which it was applied. The moment, however, it becomes a source of irritation, loses its hold, or interferes with drainage, it should be removed; but before this is done the new substitute should always be in full readiness, so that the parts may not be unduly exposed to the air, before the dressing is renewed. Surgeons, I think, often err in being too anxious to meddle with the adhesive plaster; too early interference has a tendency to interrupt the adhesive process, and may, in persons of bad, irritable constitutions, give rise to erysipelas and other accidents. I have, more than once, after severe operations, retained all the adhesive strips for upwards of a fortnight; until, in fact, complete cicatrization had taken place. Such good luck, however, is rare; and it more generally happens that the dressings, plaster and all, have to be changed at the end of the second, or, at farthest, the third day. Much, of course, will depend, in every case, upon the state of the weather, the size and situation of the wound, and the amount and character of the discharges. When the wound is extensive, only a few strips should be taken off at a time, otherwise we shall endanger the separation of its edges. Before the dressing is reapplied, the parts should be thoroughly cleansed with tepid water, pressed from a sponge held at some distance ; no wiping must be done, nor must the wound be roughly squeezed. If there is matter at its bottom or between its edges, it should be pressed out in the most gentle and careful manner; all rough manipulation being not only painful but injurious to repa- rative action. Sometimes the necessary cleanliness may be readily effected with a moist sponge or soft cloth passed lightly over the surface. Great skill is required in removing the plaster to the best advantage of the parts. Each strip should be raised by taking hold of one extremity with the thumb and finger of one hand, while the other hand is engaged in supporting the wound ; the other end being treated in a similar manner, the portion corre- sponding with the wound is lifted off last, and thus all danger of injury is effectually obviated. The principal sutures employed in surgery are the interrupted, twisted, con- tinued, and quilled. To these may be added the important modifications in- troduced by Professor Pancoast, namely, the plastic suture, as he terms it; the clamp suture of Dr. Sims ; and the button suture of Dr. Bozeman; all of which will receive proper attention, in connection with plastic operations and the treatment of vesico-vaginal fistule. The interrupted suture, which is more frequently employed than any other, is made with a needle, either straight, or slightly curved, and armed with a single, well-waxed ligature, either of silk or of linen, as may be found most convenient; for, in a practical point of view, it is really altogether immaterial which it is. The instrument, which should be very sharp, and spear-shaped, is introduced through the edge of the wound, from without inwards, at a suitable distance from its surface, and then pushed from within outwards at precisely the same point at the opposite side, leaving the thread in its track. A second stitch is then to be taken in a similar manner, and thus the opera- tion is continued until a sufficient number has been introduced, when the ends of each ligature are to be tied with a reef-knot, and cut off close. The dis- tance at which the needle should be inserted from the wound must of course vary in different cases and in different regions of the body; but, in general, it should not be less than half a line, nor more than a quarter of an inch. 302 WOUNDS. Fig. 5S. The depth at which it is passed should be such as to admit of accurate ap- proximation of the wound, about one-third of the thickness of the edge being behind and the rest in front of the needle. In no case of superficial wound should the instru- ment embrace muscular or aponeurotic sub- stance. The interval between each two stitches must also necessarily vary, according to cir- cumstances, from a few lines to an inch or more, and should be supported, after the sutures have been tied, with adhesive plaster, as seen in fig. 58. When the wound is very small, it may be sewed up with a common cambric needle, and a proportionately delicate thread. The twisted suture is made by introducing a needle through the edges of the wound, and passing a thread round it, so as to confine it in its place. It makes an admirable retentive ap- paratus, but it is of more limited application than the interrupted suture. From the fact that it is generally employed in the treatraent of hare-lip, it is often called by that name. Various instruments are employed for making the twisted suture. The one to which I give the preference is what is called the lady's toilet pin, consisting of a round steel pin, very sharp-pointed, and furnished with a glass head ; it readily penetrates the tissues, and creates less irritation than the common sewing needle, formerly so much employed for this purpose. Twenty-five years ago surgeons were in the habit of using a silver needle, with a movable steel point, as seen in fig. 59; a cumbersome, awkward in- Fig. 59. strument, now happily discarded. Dieffenbach recommended what is called the insect pin, which, however, has never come into general vogue, at least on this side of the Atlantic. In small wounds of the forehead, face, and neck, in which it is of so much importance to avoid a scar, I have been in the habit, ever since I entered the profession, of employing a very delicate gold pin, with a head of sealing-wax, and there is not, I am sure, any article better suited to fulfil such a purpose. Insusceptible of oxidation, it causes no irritation, and may therefore be retained an unusual length of time, with- out detriment to the parts. Whatever instrument may be employed, transfixion is effected in the same manner as in the common interrupted suture. The wrapping material is also similar, the thread varying in thick- ness according to the particular object to be attained. It is wound round the pin elliptically, as in fig. 60, as it ar- ranges itself much more evenly and smoothly when thus applied than when applied in the form of an 8, as in fig. 61, and as recommended in the books. As many pins or needles having been inserted as may be deemed advisable, the threads are passed from one to the other diagonally across the gap, so as to effect complete apposition there also, and so obviate the necessity for using adhesive plaster. Finally, the Fig. 60. Fig. 61. MODE OF DRESSING WOUNDS 303 ligatures being tied, the operation is completed by cutting off the points of the pins with a pair of forceps, delineated in the adjoining sketch, fig. 62, the object being to prevent them from hurting the patient, or being caught in his clothes. Fig. 62. Pin pliers. Instead of confining the pin with a thread, Mons. Rigal uses a thin nar- row ring of gum-elastic, which answers the purpose most admirably, drawing the parts firmly and evenly to- Fig. 63. gether. The only objection to it is that it may cause too much pressure in the event of there being unusual swelling in the lips of the wound. Dr. Washington L. Atlee, of this city, has employed this form of suture in quite a number of his ovariotomy cases, and thinks it possesses decided advantages over the ordinary con- trivance in that operation. The annexed cut, fig. 63, exhibits the shape and mode of application of the ring. The time during which the pins are retained varies from thirty-six hours to three or four days, according to the circumstances of the case. Their removal should be effected with great care, in a direction contrary to that of their introduction, the parts being well sup- ported at the time. The threads being generally firmly glued to the surface and edges of the wound, are al- india-rubber suture. lowed to remain until they drop off of their own accord, which usually happens in a day or two after. The support thus afforded is often of great service to the imperfectly organized bond of union, and its premature removal sometimes necessitates the employment of adhesive plaster, or the insertion of a new pin. The continued suture, fig. 64, is similar to that used by the glover, on which account it is generally known as the glover's suture. It is made with a needle armed with a suitable thread, which is passed diagonally from one side of the wound to the other, on the same principle as in the interrupted suture. Its use is almost exclusively restricted to the treatment of wounds of the intestines, where it will again be noticed. The quilled suture, fig. 65, so called from the fact that it was originally made with the assistance of two quills, is employed chiefly in the treatment of lacerations of the perineum, with a view of effecting more even and ac- curate contact of the opposed surfaces. The older surgeons were in the habit of using it in sewing up deep muscular wounds, as those of the thigh and abdomen. No one, however, thinks of resorting to it for such a pur- pose at the present day; for in the latter case, the object can be attained much more easily by the ordinary interrupted suture, extending down nearly to the peritoneum; and in the former by methodical support with the com- press and bandage. The quilled suture is made by passing a stout double thread through the sides of the wound, at intervals of an inch or an inch and a half, and tying 304 WOUNDS. its ends over a piece of bougie, quill, or wood, lying parallel with the cut, but about half an inch from it. Fig. 04. Fig. 65. The glover's, or continued suture. Quilled suture. Although sutures undoubtedly act as foreign bodies, necessarily exciting a certain degree of irritation in the tissues into which they are inserted, yet I have by no means that dread of them which they seem to have inspired in the minds of many practitioners. It has rarely happened to me to witness any ill effects from their employment, and in those cases in which this event did happen the fault, I am inclined to believe, was due more to the indiscre- tion of the surgeon, or the want of stamina on the part of the patient, than to any untoward operation of the sutures themselves. Provided the threads, or needles and threads, are clean, of suitable size, and properly inserted; the constitution of the patient in good condition ; and the wounded structures in a tolerably sound state; it is difficult to understand how they could be- come a source of serious irritation, much less of erysipelas or severe ulcera- tion, effects which have all been charged to their action. My rule has therefore always been to use them freely, and to allow them to remain as long as they seem to answer the purpose for which they were introduced. The moment this object is attained, or they are found to be productive of injury, they should be withdrawn. The best material for sutures is unquestionably metal, and it matters not, according to my experience, whether this is silver or iron, provided it is properly tempered, perfectly smooth, and sufficiently pliant and thin. This substance, although noticed in connection with this subject by different writers, was first introduced into regular practice by Dr. Sims, of New York, to whom too much credit cannot be awarded for what must be regarded by every surgeon as one of the greatest additions to our armamentarium of the present day. The advantages of the metallic suture over every other are now so well established, as to render it unnecessary to offer any comments in its favor. It is sufficient to say that it is entirely free from all irritating properties, and that it may be retained for weeks and even months without provoking sup- purative action, so common when silk or thread is employed. MODE OF DRESSING WOUNDS. 305 The wire is introduced in the same manner as the thread, the short end being firmly twisted round the long one, in order to prevent it from slipping out of the eye of the instrument. Quite a number of needles have been devised for facilitating the insertion of the wire, but it is questionable whether they possess any particular advantage over the one in common use. Perhaps the most unexceptionable is one with two holes, with a vertical groove between them on each side. It is hardly necessary to add that the ends of the suture instead of being tied should be simply twisted together. The annexed engravings will serve to convey an idea of some of the best forms of this kind of needles. Fig. 66 represents Mr. Price's instrument; Fig. 66. Price's needle for wire suture. it is grooved on both surfaces, and is pierced with two holes, nearly half an inch apart, the wire being passed from the lower to the upper, and then doubled and twisted at the end to hold it. Mr. Murray's needle, fig. 67, has a groove and open box end, while Mr. Lister's, fig. 68, has a single eye and Fig. 67. Fig. 68. Murray's needle. Lister's needle. a groove at the side. Ingenious contrivances of a similar kind have been constructed by Dr. Levis and Dr. Goddard, of this city. Some care must be taken in removing the wire suture, lest the edges of the wound should be forcibly separated. To prevent this the loop should be cut on one side very close to the edge of the wound, when the twist may be seized with the forceps, and the wire gently drawn out. The length of time during which the suture is retained must depend upon circumstances. From three to five days is a good average period. Rest and easy position are essential elements in the treatment of wounds. If the part be exercised, or subjected to motion, it will be difficult, if not impossible, to preserve apposition, and to limit inflammatory action. If the wound be transverse, and seated in an extremity, it will be impossible to prevent it from being torn open, unless the muscles which pass along it are maintained in a relaxed condition. Thus, if the wound involve the front of the thigh, the limb is extended, and flexed if it affect the posterior aspect. In each case, the muscles immediately concerned in the lesion are put in a state of perfect repose. In very large and deep wounds, it is hardly possible to keep the edges in contact, in their entire extent, without the aid of compresses and bandages. Let us suppose that the injury is seated in the thigh, and that it is accom- panied by extensive division of the muscles. In such a case, adhesive plas- ters and sutures, however skilfully applied, would scarcely be sufficient to give the wound the support which is necessary to keep the deep portion of vol. i.—20 306 WOUNDS. the edges in apposition with each other. More or less separation would almost be inevitable. To fulfil this indication, so important to the adhesive process, it is indispensable to lay a stout compress along each side of the limb, opposite the deep part of the wound, and to confine it with a roller, extending from the toes upwards as far nearly as the groin. In all wounds of this description, whether the result of accident or of operations, great care must be taken to prevent the retention of fluids, otherwise suppuration will take place instead of union by the first intention. Large intervals should be left between the adhesive strips, and holes should be cut in the bandage where it lies over the affected part; in some cases it will even be proper to leave a small tent at the bottom of the wound, bringing it out at the most dependent point, to drain off the discharges. The most suitable bandage for supporting the wounded parts is the com- mon roller, carried upwards from the distal portion of the limb to a short Fig. 69. Fig. 70. Invaginated bandage for longitudinal wounds. distance above the seat of the injury. The invaginated bandage, represented in figs. 69, 70, and formerly so much in vogue, is a dangerous contrivance, unworthy of scientific surgery. 2. MODE OF HEALINO OF WOUNDS. The parts having been properly adjusted, the duty of the surgeon, as far as manipulation is concerned, is temporarily at an end. Nature, the phy- sician of wounds, as she was called by Paracelsus, must do the rest. " Warily," says this eccentric man, in his "Great Surgery," published in 1536, "warily must the surgeon take heed not to remove or interfere with Nature's balsam, but protect and defend it in its working and virtue. It is the nature of flesh to possess in itself an innate balsam which healeth wounds. Every limb has its own healing in itself; Nature has her own doctor in every limb; wherefore every chirurgeon should know that it is not he, but Nature, who heals. What do wounds need ? Nothing. Inasmuch as the flesh grows from within outwards, and not from without inwards ; so the surgery of wounds is a mere defensive, to prevent Nature from suffering any accident from with- out, in order that she may proceed unchecked in her operations." If these sentiments, uttered more than three centuries ago, could only be firmly im- pressed upon the mind of the modern surgeon, there would be much less meddlesome practice of every kind than there is now, notwithstanding our boasted knowledge, and our contempt for the fathers of the profession. Modern surgeons have described five distinct modes according to which wounds are supposed to heal. The first is by immediate union, or the direct growing together of the raw surfaces; the second, by scabbing, or the for- mation of a crust of blood covering over the wound; the third, by the effusion MODE OF HEALING WOUNDS. 307 of lymph, and the conversion of this into fibro-cellular tissue ; the fourth, by granulation, and the development of epithelial matter; and the last, by the junction or inosculation of the granulations with each other. The old doc- trine, so ably advocated by Hunter, and so long entertained by practitioners generally, assumes that there are but two modes of cure; the one consisting in union by the first intention, or primary adhesion, and the second in the formation of granulations, filling up the gap, and thus repairing the injury, the last stage of the process being the development of new skin. This latter mode of repair constituted what was so long known in the schools as union by the second intention, or union by granulation. The idea that immediate union of a wound may take place was first advanced by Dr. Macartney, of Dublin, and is now prominently taught in all the British schools of surgery, if not also in those of this country It assumes that two raw surfaces, laid closely and evenly together, will promptly coalesce with each other, independently of inflammation and effusion of lymph or blood, vessel inosculating, as it were, with vessel, muscular fibre uniting with muscular fibre, skin adhering to skin, and nerve becoming again con- tinuous with nerve. It is alleged, it is true, that this occurrence is uncom- mon, and that it requires for its production a good constitution, an entire absence of local inflammation, and the greatest possible caution in respect to the management of the parts. When these conditions are present, it is asserted that even large wounds are capable of this kind of union ; and a case, observed by Mr. Paget, is usually referred to as an illustration and proof of the possibility of such an occurrence. This case is briefly as follows: A female, aged thirty-three, had had her breast and several axillary glands removed on account of cancer. The flaps, which were very large, were care- fully approximated, and kept in place with isinglass plaster; the general health seemed to be excellent, and union took place in the ordinary way, the whole line of incision having firmly closed by the end of the third week, except at one narrow spot, at which granulations arose from the pectoral muscle. Erysipelas and phlebitis now set in, and carried off the patient in four or five days. " I cut off," says Mr. Paget, "the edges of the wound with the subjacent parts, expecting to find evidence of union by organized lymph, or, possibly, blood. But neither existed; and the state of the parts cannot be better described than by saying that scarcely the least indication remained of either the place where the flap of skin was laid on the fascia, or the means by which they were united. It was not possible to distinguish the relation which these parts held to each other from that which naturally exists between the subcu- taneous fat and the fascia beneath it. There was no unnatural adhesion ; but as the specimen, which is in the Museum of St. Bartholomew's, will still show, the subcutaneous fat which did lie over the mammary gland was now connected with the fascia over the pectoral muscle, just as, for example, the corresponding fat below the clavicle is naturally connected to the portion of the same fascia that lies there. The parts were altered in their relations, but not in their structure. I could find small points of induration where, I suspect, ligatures had been tied, or where, possibly, some slight inflammation had been otherwise excited; and one small abscess existed under the lower flap. But with the most careful microscopic examination, I could discover no lymph, or exudation corpuscles, and only small quantities of what looked like the debris of such oil particles or corpuscles of blood as might have been between the cut surfaces when the flaps were laid down. In short, we cannot otherwise or more minutely describe this healing than by the term "immediate union;" it is immediate, at once in respect of the absence of any intermediate substance placed between the wounded surfaces, and in respect of the speed with which it is accomplished." 308 WOUNDS. No one, it seems to me, can examine the history of this case without being struck with the fact that it was just such an one as must, of necessity, have been followed by inflammation and a deposit of fibrin; the operation was evidently a severe one, the dissection was extensive, the relations of the parts were completely changed, and it is impossible to conceive that the flaps, although carefully laid down and confined by isinglass plaster, could have united without the intervention of plastic matter. If the use of the knife is ever productive of inflammation, it surely ought to be under such circum- stances. That inflammation was present, is proved by the circumstances, referred to by the reporter, that there were several little points of induration apparently corresponding with the site where ligatures had been applied, and mention is also made of the existence of a small abscess, clearly denotive of the same fact. Thus, then, it is perfectly certain that both inflammation and deposit of lymph had occurred at several places, and it may be imagined, without any stretch of the imagination, that nature had treated the rest of the wound in a similar manner, with this difference only that less lymph was effused there than elsewhere. The union, too, was more prompt and effect- ual. Hence, long before the woman expired, the plastic matter, poured out as a consequence of the amputation of the breast, was completely absorbed, having fulfilled its purpose as a bond of connection between the opposed surfaces; so that, when the parts were examined with the microscope, not the slightest trace of it could anywhere be discovered. Different textures, it is well known, possess different faculties of furnishing plastic matter, as well as of removing it after it has been deposited. Thus, in amputation of the leg, when the flap is exposed to the air, we observe that muscles, fibrous membrane, skin, and cellular tissue are much more rapidly glazed with lymph than adipose substance, vessels, or bone, the latter of which, in fact, rarely exhibits any evidence of its presence until the end of the first week, and then it always shows itself first on the medullary membrane, then on the cancellated structure, and lastly on the outer compact substance. Now, if we take into consideration all the circumstances that can be brought to bear upon this question ; the fact that all injuries whatever are followed by inflammation, if the patient survives their effects long enough, as well as by more or less effusion of lymph ; that some structures take on this action more readily than others; that inflammation is often slight in one part and severe in another; and that lymph, when no longer of any use, is invariably absorbed, nature abhorring a substance which she does not need, as in the case of a wound after the completion of the solidifying process; taking, I say, all these circumstances into account, I am satisfied that it is impossible for any wound, however induced, situated, or treated, to heal by immediate union, or without the intervention of inflammation and effusion of lymph. The only case, it seems to me, in which such a mode of union would be at all possible, is where the edges of a wound, as, for instance, one of the hand, are carefully approximated immediately after the receipt of the injury, thus affording the vessels and other structures an opportunity of promptly regain- ing their natural relations. But even here it is more rational to conclude that the vessels, irritated and fretted by the injury which they have sustained, would pour out a thin film of lymph, serving as a bond of reunion between the divided parts. The second mode in which a wound is said to be capable of healing is by the process of scabbing, and here also, it is alleged, the cure is effected with- out the intervention of inflammation, or the deposition of plastic matter. An injury of this kind being inflicted, the blood coagulates upon its surface, where it soon forms a hard, solid crust, which thus protects it from the contact of the air and other injurious influences until it is covered over with new skin, MODE OF HEALING WOUNDS. 309 when nature's shield, now no longer required, is cast off as an effete substance. This mode of healing is rare in man, but sufficiently common in the inferior animals, as the horse and cow, owing to their being so much less liable to active inflammation and its consequences. It is occasionally imitated by the surgeon's dressing, consisting of lint dipped in blood, or smeared over with collodion, so as to protect the raw surface from the contact of air and dirt. The principal proof deduced by the advocates of this mode of cure rests upon the supposed fact that inflammatory deposits occurring in a case of this kind would effectually destroy the process by prematurely detaching the scab, and so leading to the development of granulations, or union by the second intention. No one, however, has ever demonstrated that there is no inflam- mation when a wound is incrusted in this way; on the contrary, the whole theory is a mere speculation, unsupported by a single proof. The difference between such a wound and an ordinary open one, is simply this, that, in the former, there is very little inflammation, whereas in the latter, there is a good deal, but in neither is it wholly absent. With regard to the third mode of cure, or union by adhesive inflammation, all pathologists stand upon the same ground, none disputing the possibility of its occurrence. The only conditions which it demands for its speedy and successful accomplishment are, first, that no coagulated blood shall intervene between the contiguous surfaces, and, secondly, that the part and system shall be maintained in such a state as not to permit the inflammation to transcend the limits of lymphization. According to this doctrine, union cannot take place without more or less inflammation and the effusion of a certain amount of plastic matter, serving as a bond of connection between the opposed sur- faces, glazing and gluing them together, and ultimately, after having enjoyed the properties of nucleated blastema, assuming the character of cellulo-fibrous tissue. Now, if the views which it has been my object all along here to in- culcate be correct, it follows that all union is the result of adhesive action ; that is, of a certain degree of inflammation just sufficient, and no more, to pour out the requisite amount of coagulating lymph for effecting the cohesion of the raw surfaces. If the quantity of this substance is very small, or its vitality greatly impaired, no union will occur; nor will such an event take place if the effusion be attended with high excitement; for under such cir- cumstances the lymph that is poured out will be aplastic and associated with suppuration, causing the parts to gap and compelling them to heal by granu- lation or union by the second intention. In the more favorable cases of ad- hesive inflammation, the intervening substance is soon removed by absorption, without being transformed into cellulo-fibrous tissue, which can only be needed when the union is tardy, or when it is effected through the medium of an in- ordinate quantity of plastic material; when, in short, the apposition has been somewhat imperfect, and yet not sufficiently so as to offer any serious obstacle to cohesion, or to cause suppuration. In general, when the process of reunion goes on kindly, the merest conceivable film of lymph is sufficient for the pur- pose ; the vessels, nerves and absorbents soon extend from one side to the other across the intervening substance, and as soon as coalescence has occurred, and complete interchange has been established, the new matter, now no longer needed, is speedily removed, precisely in the same manner and for the same reason that the callus is removed after the union of a broken bone ; nature, as already stated, being averse to letting anything remain that is not needed if she can get rid of it. The fourth mode according to which wounds may heal is by the granulating process, or union by the second intention. This occurs in all cases where the adhesive inflammation is thwarted, whether in consequence of defective action, mismanagement, or any other cause whatsoever. The surface of the wound gaping, it gradually becomes covered with granulations, by which the cavity 310 WOUNDS. is ultimately filled up, cicatrization constituting the last act of the process. The manner in which these bodies are formed, as well as their structure and functions, having already been considered under another head, nothing further need here be said respecting them. Finally, the new doctrine teaches that a wound may heal by the direct con- junction of granulations, or by a kind of secondary adhesion. This mode of cure, it is alleged, may occur whenever we place in contact the edges of an open wound, thereby bringing the granulations more closely in apposition, and so favoring their coalescence, coherence, or direct growing together. To my mind this mode of union does not differ from the ordinary process which we notice during the development, aggregation, and adhesion of granulations upon the surface of wounds and ulcers; hence, if this opinion be correct, such a distinction is as unnecessary as it is unscientific. I question, however, whether there is, in either case, anything like a direct adhesion ; on the con- trary, it seems more probable that whenever granulations unite they cohere through the medium of a thin film of plastic matter, as is the case with the raw surfaces of a recent wound, as previously described, and which is rapidly transformed into nucleated blastema, or germ cells, which thus form the basis of new tissue. If what has now been said be correct, it follows, as a necessary corollary, that there are only two modes in which wounds unite, long recognized by- surgeons, easily comprehended, and in perfect harmony with the results of observation and experience. These two modes are, as was previously stated, adhesive inflammation, or union by the first intention, and repair by granula- tions, or union by the second intention; in other words, there is no form of union without inflammation and lymph ; and the only difference in the two processes here mentioned is that in the one the plastic matter serves as a direct bond of connection between the opposed surfaces, while in the other it is converted into a series of elaborately organized bodies which, by their coalescence, ultimately fill up the gap left by the retracted edges of the wound. A subcutaneous wound heals on the same principle as an open one, only that, the contact of the atmosphere being prevented, there is less inflamma- tion. Inflammation, however, is never, as some have asserted, entirely ab- sent ; for we always find after the operation of tenotomy, an operation which supplies us with one of the best examples of this class of lesions, that the parts continue to be sore and tender for some time afterwards, and that, as when the tendo-achillis has been divided, the person walks with great diffi- culty, or, as more generally happens, is altogether disinclined, if not actually unable, to move about. The lymph that is poured out here is highly organ- izable, and is therefore readily transformed, at first, into nucleated blastema, then into cellulo-fibrous matter, and ultimately into tendinous tissue, closely resembling that which it serves to unite. SECT. II.—INCISED WOUNDS. An incised wound is one inflicted with any sharp cutting instrument, as a knife, a sword, or an axe. It may vary in extent from the slightest possible incision to a gap of frightful length and depth. The largest lesions of this description are generally made designedly by the surgeon in the extirpation of tumors, in the amputation of the limbs, and in the resection of joints. In general, they are open, and therefore in contact with the air; but in some instances they are subcutaneous, and therefore exempt from such exposure. Every incised wound, however simple, is characterized by three phenomena, deserving of special consideration ; 1st, by an effusion of blood; 2dly, by INCISED WOUNDS. 311 more or less pain ; and 3dly, by a retraction of the edges of the divided structures. 1st. The hemorrhage varies in quantity, from a few drops to several ounces, or even quarts, .according to the extent of the injury, and, above all, the vas- cularity of the affected tissues. When the capillaries alone are involved, the blood oozes rather than flows away, whereas the reverse is the case when a tolerably large vessel is divided. The hemorrhage may be strictly arterial, but in general it is both arterial and venous. In the former case the fluid is of a scarlet color, and spirts out in jets, synchronously with the contrac- tion of the heart; in the latter, on the contrary, it is of a dark modena, or purple complexion, and issues in a continuous stream, as in bleeding at the arm. Some parts of the body being more vascular than others, are natu- rally inclined to bleed more when divided. Thus, a wound of the cheek bleeds more freely than one of the leg, and both less than one of the lip. Again, a part that has been habitually irritated for a long time will, when divided, emit a much greater amount of blood than it will if it be in a healthy state. A familiar example of this occurs in excision of the tonsils, an ope- ration which is sometimes attended with profuse hemorrhage, in consequence of the enlargement of the vessels, and their inability to retract on account of inflammatory effusions. 2dly. The pain, like the hemorrhage, attendant on an incised wound, is influenced in its extent, by the size of the lesion, the nature of the affected textures, and the temperament of the individual. In general, it very soon subsides, and does not afterwards return, unless there is an undue amount of inflammatory action. When a large nerve has been implicated in the injury, there is usually, in addition, some degree of numbness in the surrounding tissues, and occasionally, also, partial paralysis in the distal parts. 3dly. The retraction of the edges of the wound is dependent upon the natural resiliency of the cutaneous and muscular tissues. It is very mate- rially influenced, however, in its degree, by the depth of the wound, by its situation, and also by the amount of motion to which it may be subjected immediately after the receipt of the injury. Thus, a wound of the hairy scalp, extending down to the bone, will scarcely gape any, while one on the forehead, arm, or leg will exhibit a frightful cavity, in consequence simply of the muscular contraction of the part, or, in the case of the two latter, on account of the change of posture. The treatment of such an injury is perfectly simple. The first object is to arrest the hemorrhage, provided this has not been already done by the natu- ral efforts. In all cases where it is of a capillary character it soon ceases spontaneously; or, when this does not happen, it may be promptly stopped by exposing the surface of the wound to the cold air, or by pressing upon it a sponge wet with cold water. When, on the other hand, it proceeds from a vessel of considerable size, the more prudent course will be to apply the ligature; for, although it may be temporarily suppressed, yet it will be very liable to break out again upon the slightest exertion ; or, at all events, as soon as reaction takes place. The manner of performing this operation will be pointed out under its appropriate head. The hemorrhage having been arrested, the next thing to be attended to is the cleansing of the wound. Every foreign substance, no matter how deli- cate or minute, must be carefully picked away with the forceps, removed with the fingers, or dislodged with a stream of water, squeezed from a sponge. The finest hair, if allowed to remain, would act as an irritant, and impede the adhesive process. The same remark is applicable to the blood that may cover the wound, or incrust its edges. It is just as necessary to remove this as it is to remove dirt or any extraneous substance whatever. Even the slightest possible layer of blood is likely to prove a barrier to immediate re- 312 WOUNDS. union; for although it is unquestionable that this fluid may occasionally become organized, yet such an event is never expected or wished for under such circumstances. HenCe the whole surface of the wound should be tho- roughly freed of blood, not roughly, of course, but as gently as possible, before we attempt the approximation of its edges. If the blood has coagu- lated and become adherent to the wound, it may readily be detached with the fingers, forceps, or handle of the scalpel. Finally, the circumjacent parts, if covered with hair, are carefully shaved and washed. The object of these preliminaries is to place the wound in the best possible condition for union by the first intention, or the establishment of the adhesive process. To insure this, the edges must be carefully approximated in their entire extent, and retained in contact for a certain period, by appropriate means, aided by rest and proper position of the part. If the wound be of small extent, nothing will be required beyond a strip or two of adhesive plaster. If, on the other hand, it is long and deep, it will probably be neces- sary to use, in addition, a few sutures, if not, also, a compress and bandage. The wound being dressed, and the parts concerned placed at rest in a relaxed, and, if possible, also in an elevated position, little remains to be done by the surgeon, except to watch and assist nature in her reparative efforts. Within a short time after the edges of the wound have been approxi- mated, inflammation is set up, and this is speedily followed by an effusion of plastic lymph, not only upon their surface, but also into the surrounding tissues. The interposed layer, hardly as thick as the most delicate spider's web, soon becomes organized, by an interchange of vessels and nerves be- tween the opposite sides, and thus forms the bond of union between the divided structures. In the meantime the inflammation gradually subsides, the surrounding tissues regain their accustomed functions, and the consoli- dation is completely established. The resulting cicatrice remains rough for some time, but by degrees it becomes polished, and finally assimilates itself to the natural skin, except that it is whiter, free from hair and sebaceous follicles, and less capable of resisting the effects of disease. But it is not always that the healing process advances so favorably as it has just been described. In many cases, indeed, it is materially retarded, interrupted, or even entirely prevented. Various causes may contribute to bring about this untoward result; of which the most common are the pre- sence of some foreign body in the wound, or the want of accurate apposition of its edges, too much motion in the part, improper applications, or an undue amount of morbid action. It is the duty, therefore, of the practitioner not only to attend well to every case of the kind in the first instance, but to watch it most sedulously throughout its entire progress, inciting action when it is deficient, and repressing it when it is too high. If the symptoms assume an untoward tendency, the adhesive action threat- ening to pass into the suppurative, the sutures and plasters should immediately be slackened, and recourse be had to the water-dressing, either warm or cold, simple or medicated, according to the tolerance of the part and system. In general, simple water will be found to answer better than anything else, and may often be advantageously employed from the very commencement, espe- cially if the wound be very large, in anticipation of inordinate action. The diet, bowels, and secretions must be properly regulated; and if suppuration be inevitable, the most agreeable and soothing application will generally be a light emollient cataplasm. Gaping of the wound should be counteracted by the use of adhesive strips, aided by position, and, if necessary, by a few loose stitches and the bandage. LACERATED WOUNDS. 313 SECT. III.—LACERATED WOUNDS. A lacerated wound is a lesion in which the tissues, instead of being smoothly divided by a sharp cutting instrument, are torn rudely and forcibly asunder. The edges are ragged and irregular, there is little pain or hemorrhage, and the surrounding parts, frequently bruised and discolored, are cold and be- numbed. The injury most commonly occurs in factories, grist-mills, and steamboats, from the clothes and limbs being accidentally caught in the machinery. Extensive lacerations are often caused by weapons of war; by the teeth of the inferior animals, as the shark, dog, and bear; by the passage of the wheel of a cart or carriage; and by falls from a considerable height, in which the body strikes against a hard and projecting object, as a stone, a post, or an iron-railing. A lacerated wound differs from an incised one, 1st, in the slightness of the attendant pain; 2dly, in its indisposition to bleed ; 3dly, in its tendency to suppurate and slough; and, 4thly, in its liability to be followed by tetanus and other nervous symptoms. The pain in lacerated wounds is generally very trifling; indeed, instances are frequently met with in which it is entirely absent, the patient being uncon- scious at the moment and for some time afterwards of having received any serious injury. Thus in the case of Wood, the miller, as detailed by Cheselden, the arm was torn off at the shoulder, and yet so slight was the pain that the man was not aware of what had occurred until he observed the limb moving round on the wheel. I have seen several instances in which the tendons of the fingers, along with a portion of their muscular bellies, were pulled out with such velocity as not to be productive of the least local distress, the patient not being conscious of having been injured until a short time after the accident. When the lesion is very grave and extensive, as when a limb is suddenly severed from the trunk, the attendant shock must necessarily be so severe as to obliterate, in great measure, all local sensation. Upon the occur- rence, however, of reaction, the pain becomes frequently very violent, requiring large doses of anodynes for its suppression. The absence of hemorrhage in a lacerated wound forms a very striking fea- ture, and is the direct consequence of injury done to the vessels. In an incised wound there is no impediment to the flow of blood, because the vessels are divided evenly; in a lacerated one, on the contrary, they are torn into shreds and fragments, which readily intercept the fluid as it sweeps over them, and thus promote the formation of a coagulum, often extending high up into the tube. The vessels, moreover, are partially paralyzed, from the injury sus- tained by the nervous filaments of the affected parts; hence they are incapable of contracting upon their contents and of propelling them onwards. In addition to these circumstances, there is frequently, especially in severe lace- rations, excessive prostration of the system, which powerfully contributes to the coagulation of the blood, and the formation of an internal clot. This indisposition to hemorrhage is present even when very large vessels are wounded. In the celebrated case of Wood, above alluded to, the arm was torn off along with the scapula, and yet there was no hemorrhage. Many instances of a similar kind have been published, among the more remarkable of which are those related by La Motte, Morand, Carmichael, Mussey, Gib- son, and Allan. Lacerated wounds are frequently deceptive in their appearance, the amount of injury being much greater than the surgeon is at first led to suppose. The skin, for example, may be affected very slightly, perhaps, indeed, hardly at all, while the muscles, aponeuroses, vessels, and even the nerves may be exten- 314 WOUNDS. sively severed, or torn up. In many cases the bones are crushed, large joints laid open, and the soft structures completely pulpified. Hence too much cau- tion cannot be observed in our examinations, as well as in our prognosis. The treatment of a lacerated wound is to be conducted upon the same general principles as that of an incised one. All extraneous matter is re- moved, the vessels, if necessary, are tied, the parts are neatly approximated, and every precaution is used to moderate the resulting inflammation. In applying the ligature, care is taken to select a sound portion of the artery, otherwise secondary hemorrhage will almost be certain to follow the sloughing process. When the hemorrhage is venous, it may, in general, be promptly and effectually arrested by the compress and roller, which should be so arranged as not to impede the return of the blood to the heart. All undue constriction must be avoided. Ligation is rarely called for, even when the largest veins are torn across. Although it is not probable, from the ragged character of the wound, that much of it will heal by the adhesive process, yet it is always best to treat the case with reference to this object. For this purpose the edges, after having been neatly trimmed, are lightly approximated, and main- tained by adhesive strips, supported by a bandage; all tension is carefully avoided ; and large interspaces are left between the plasters for the purpose of drainage. Sutures may usually be dispensed with, although I have not the same dread of them that some surgeons have ; for I have, in many cases, derived the greatest benefit from their employment, while I have rarely seen them do any harm. They should never be retained longer than forty-eight hours, and they may be removed even earlier, if they appear to act injuriously. If any parts are entirely deprived of vitality, they raay at once be cut away, but as there must generally be some uncertainty on the subject, it is a good rule to let them alone, and intrust their separation to the efforts of nature; or, at any rate, to wait until it is perfectly certain that they have perished. To moderate the inflammation, the water-dressing is used, either warm or cold, as may best comport with the comfort of the patient. On the appear- ance of suppuration it may, unless acting very kindly, give way to the linseed cataplasm, which, in its turn, is superseded as soon as the granulating process is fairly established, by the opiate cerate. If the inflammation run very high, threatening to terminate in gangrene, purgatives and nauseants are freely used, and leeches applied to the parts immediately around the wound. The lancet is rarely required, except in very robust and plethoric subjects, in whom, under such circumstances, it cannot be resorted to too early or hardly too vigorously. Mercury is frequently indicated at the very commencement of the treatment, on account of the concomitant derangement of the biliary and digestive ap- paratus, produced by the shock of the injury. It should be administered in moderate doses, either alone or in combination with opium, Dover's powder, or morphia and antimony. Anodynes must be freely given to allay pain and insure sleep. Much judgment is required not to carry the depletion too far. In all cases due allowance must be made for the waste which must necessarily attend a wound of this description, as well as for the depression which the system experiences in the first instance, and which often continues to exert its baneful influence for days and weeks together. Secondary hemorrhage may arise as soon as reaction takes place, or it may be postponed until the sloughs begin to separate. In the latter case, it will not be likely to occur before the fifth or sixth day. When there is reason to expect such an event, as there will be when a considerable sized artery is im- plicated, the patient should be most sedulously watched until the crisis is past, a tourniquet being placed loosely around the limb, and the nurse instructed in its use, so as to be fully prepared to meet the emergency the moment it arises. For the want of such precaution life might be destroyed in a few minutes, before it is possible for the attendant to reach the bedside. CONTUSED WOUNDS. 315 Tetanus is most frequently met with in nervous, irritable subjects during the prevalence of hot, or damp, chilly weather, and often arises without any obvious cause, either as it respects the wounded part or the system. Large doses of anodynes, especially of opium and assafoetida, will usually promptly arrest it in its earlier stages, but when fully developed it almost always proves fatal, no matter what treatment may be employed. When the laceration is seated in an extremity and involves important ves- sels and nerves, or when it is accompanied by a comminuted fracture, a com- pound dislocation, or a disorganized state of the soft parts, the probability is that amputation will be required. Should this be decided upon, the proper period for performing the operation is as soon as reaction is fully established. If it be undertaken while the patient is pale, faint, and nearly pulseless, he will be almost certain to die from the immediate shock of the operation, or, at all events, withiu a few hours after, from an inability to recover from the effects of it. On the other hand, the amputation should never be postponed until the system has been assailed by inflammation, since this would equally compromise the result. The time for interfering, then, is when the heart has resumed its wonted action, the pulse reappeared at the wrist, the color re- turned to the face, and the warmth been re-established in the extremities; then, but not until then, do we operate. SECT. IV.—CONTUSED WOUNDS. A wound is said to be contused when the parts, instead of being neatly divided by a sharp instrument, are bruised and severed by an obtuse body, its edges being ragged and shreddy. The injury may happen in a great variety of ways, as from a blow with a heavy bludgeon, the kick of a horse, the passage of the wheel of a carriage, the contact of a partially spent ball, or the explosion of a gun, shell, or rocket. An ugly contused wound is occa- sionally received by a fall from a considerable height, in which the person alights among sharp and disjointed stone, upon a pile of timber, or upon a mass of rubbish. The most severe accident, however, of this kind is that which follows the passage of the wheel of a railroad car, in which the body is often mangled in the most frightful manner, the soft parts being literally pulpified and the bones ground to pieces. The effects of a contused wound are various. When the injury is very severe life may be destroyed on the spot, just as in a gunshot wound, from shock or loss of blood, and without any attempt whatever at reaction. In the milder forms, however, the consequences may be very trifling. From the manner in which the structures are bruised there is generally but little pain in the first instance and for some time afterwards ; the part feels merely stiff and benumbed, perhaps somewhat sore and tender; by and by, however, when in- flammation arises, the pain is often considerable, while in some instances it is extremely severe. When the injury is extensive, there is always great shock to the whole system ; the patient is deadly pale, and almost bereft of con- sciousness, with hardly any pulse at the wrist, and great coldness of the ex- tremities. When he recovers from this state he is apt to suffer from vomiting and various nervous disorders. If the weather be hot, or the constitution unusually irritable, he may be seized with locked jaw. Neuralgia is also liable to occur as a sequel of such accidents. Another peculiarity of the contused wound is the trifling hemorrhage which usually attends it; resembling, in this particular, the lacerated and punctured wound. The vessels being bruised and paralyzed, are unable to propel their contents, which, in consequence, almost instantly coagulate, thus opposing an effectual barrier to the effusion of blood, which is also, at the same time, in 316 WOUNDS. many cases, if not generally, deprived of its vitality in the midst of the in- jured and perhaps pulpified tissues. When, however, the lesion is very slight, the vessels are sure to throw out more or less blood, although the flow is never copious, except when a considerable sized artery has been laid open, when it may be so great as to prove fatal in a few minutes. Much, then, will depend, in every case, as far as bleeding is concerned, upon the extent and particular character of the lesion sustained by the coats of the vessels, and also, but in a minor degree, upon the injury inflicted upon the blood itself. Although there is frequently little or no bleeding in a wound of this kind immediately after its occurrence, yet there is generally, if the injury be at all extensive, great danger of secondary hemorrhage. The period at which this will be likely to happen is when the sloughs begin to separate, which, on an average, will be from the fifth to the tenth day, according to the size of the breach and the amount of the concomitant contusion. Hence, as in lacerated and gunshot wounds, the patient should always be diligently watched during this period, lest, hemorrhage coming on unexpectedly, he should perish before he can obtain assistance. Contused wounds rarely heal by the first intention ; the parts are too much bruised to enable their vessels to pour out plastic matter; the inflammation is often extremely severe, and the surgeon is fortunate if he can restrain it within the limits of suppuration, and prevent the occurrence of gangrene. The latter event is by no means uncommon when the lesion is at all severe, and there are few cases of the kind in which more or less tissue is not deprived of vitality during the infliction of the injury. Under such circumstances sloughing will of course be inevitable. Lesions of this kind are often followed by large abscesses, particularly when they occur upon the scalp, on the hands and feet, and deep among the muscles of the thigh, abdomen, back, and shoulders. The pus is sometimes exten- sively diffused beneath the muscles, and is frequently preceded by erysipela- tous inflammation, especially in nervous, irritable, and intemperate individ- uals. Serious injury is occasionally inflicted upon the trunk or upon a limb, without any outward evidence whatever of the fact, perhaps not even the slightest bruise, scratch, or discoloration of the surface. Such accidents are most fre- quently caused by the passage of the wheel of a carriage, the kick of a horse, machinery in rapid motion, or the blow of a cannon ball, and are easily accounted for by the elasticity of the common integuments, which enables them to glide out of the way of the vulnerating body, while the other and deeper-seated structures, which are destitute of this property, are sometimes completely destroyed by its contact, the vessels and nerves being cut to pieces, the muscles torn into shreds, the bones mashed, and the largest joints laid open. The scalp is sometimes extensively detached from the cranium by a fall upon the head without any external wound, and a partially spent cannon ball, strik- ing the belly obliquely, has been known to tear open the bowels, spleen, and liver, without leaving any mark or trace whatever upon the skin. Such in- juries, which are, to all intents and purposes, subcutaneous wounds, are pecu- liarly severe, and are liable to be followed by the worst consequences; often proving fatal on the instant, or, subsequently, from the effects of inflamma- tion. Differing from the lesions now described are what may be called, in the strict sense of the term, contusions, that is, injuries of the organs and textures without any actual division of substance, except upon a small scale, implicat- ing chiefly the more minute vessels and nerves, along with the connective tissues. Of this form of accident the " black eye," the result of pugilistic rencontre, affords an excellent illustration ; as does also the bruise upon the scalp from a blow with a stick. The immediate effect of such an injury is an CONTUSED WOUNDS. 317 extravasation of blood from the rupture of the smaller vessels of the part, and more or less discoloration of the surface, usually of a reddish, bluish, or purplish tint, with a sense of numbness and a dull, heavy pain. The quan- tity of blood poured out varies from a few drops to many ounces, according to the extent of the lesion, the size of the vessels, and the nature of the affected structures ; it is seldom considerable, unless there is an abundance of cellular substance, when it may be very great, as well as widely diffused. When the fluid presents itself as an infiltration, it constitutes what is technically called an ecchymosis, of which a good example is afforded in the extravasation which occurs in the submucous cellular tissue of the conjunctiva after a blow upon the eye in an ordinary fight. If, on the other hand, the blood is collected in a small circumscribed spot, the affection takes the name of "thrombus," while the term "depot" is employed to designate it when it is large and concen- trated. This distinction is not without its practical value, and therefore de- serves to be borne in mind. The accumulations of blood which occur on the child's head, and in the labium of the mother, during severe and protracted labor, are good illustrations of a sanguineous depot, which is often met with upon a large scale in severe contusions, both with and without wound. When the extravasation is copious, it is to be assumed, whatever may be its form, that it has been caused by the rupture of some of the larger vessels, and hence such an occurrence should always be regarded as one of a serious character, often placing limb and life in jeopardy. In the treatment of contused wounds three leading objects are to be kept in view ; the first is to arrest hemorrhage, the second to limit inflammation, and the last to promote the absorption of effused blood. The hemorrhage is to be controlled in the usual manner; by compression and cold applications, if it be slight, or venous, and by ligature, if it be co- pious and arterial. When the bleeding vessel is concealed, as when the wound is subcutaneous, it may be extremely difficult to find it, owing to the bruised and injected state of the parts, which often renders the search one of great labor and annoyance ; still, it is our only resource, and the sooner, therefore, the operation is performed the better, for it will certainly not at all facilitate the undertaking, if we wait until the supervention of inflamma- tion. If the obstacles be unusually great, or if, in our attempt to tie the artery at the seat of injury, we should be compelled to interfere with import- ant structures, it will be well to secure the vessel at some distance above the wound; trusting that the recurrent bleeding will cease spontaneously, or under the influence of systematic and persistent compression. Although we can hardly expect to obtain much, if any, union by the first intention in a contused wound, still it will do no harm to try; for such an attempt will certainly not make matters any worse. We should, therefore, always proceed as if such an occurrence were not only practicable but pro- bable ; with this view the edges of the wound should be as nicely approxi- mated as possible, care being taken of course not to draw them together at all tightly ; for due allowance must be made for swelling and drainage, which will always be more or less considerable in this class of lesions. No fear need be entertained respecting the use of sutures, provided they be intro- duced loosely, and not too numerously. I never hesitate to employ them in such cases, with the restrictions here specified, and am not aware that I have ever seen any ill effects from them. It is only when they produce tension, or when they are made to embrace improper tissues, that they are likely to prove prejudicial. The same remarks are applicable to adhesive strips ; they can- not be dispensed with, but it is plainly our duty to apply them with great care, and in such a manner as to leave free room for the escape of fluids. Some authors advise that the edges of the wound should be neatly trimmed prior to their approximation, but such a procedure is never justifiable, un- 318 WOUNDS. less it is perfectly clear that the tissues are dead, or unless they are so rag- ged and irregular as to render it impossible to effect accurate apposition. It will generally be well to intrust this matter to nature, permitting her to do as she may consider best. A few sutures and adhesive strips are usually the only dressings that will be required. The parts, having been properly arranged, should be kept con- stantly wet with evaporating lotions, of which alcohol and water, in the pro- portion of one part of the former to five of the latter, will generally be the best. Weak solutions of acetate of lead or Goulard's extract will also be serviceable. Such cases are generally benefited by slightly stimulating ap- plications, which seem to have the power of giving tone to the weakened vessels, and thus warding off erysipelas, which is so frequent a result of this lesion when treated in the ordinary manner. Leeches and iodine may be- come necessary when the inflammation is very active, and in this case too a poultice will generally be found to be more grateful than cold water or astringent lotions. The bowels must be maintained in a soluble state; but the greatest care must be taken to guard against severe purgation, and, in fact, against all active depletion. Due allowance must be made, in every case, for the profuse discharges which are so liable to follow contused wounds. If mortification should occur, the treatment will not differ from that conse- quent upon ordinary inflammation. Pain and nervous symptoms are con- trolled by anodynes and antispasmodics. When granulations begin to spring up, the milder ointments will come in play, and will advantageously super- sede the warm and cold applications ; the former proving now too relaxing, and the latter too repressing. The removal of extravasated blood is best promoted by the tincture of arnica, in the proportion of three ounces to the pint of water, diligently applied with patent lint; and by cold astringent lotions, such as acetate of lead, Goulard's extract, alum, and hydrochlorate of ammonia. After the lapse of a few days, the part may be frequently bathed with spirits of cam- phor, or soap liniment; painted with the dilute tincture of iodine ; or covered with a poultice made of crumbs of bread and common salt, or of the bruised roots of briony. Under this treatment an ordinary ecchymosis will often vanish in a few days; in the more severe cases a much longer time may be required. When the extravasated blood appears in the form of a depot, or as a con- centrated collection, attended with marked tension of the integuments, the speediest way of getting rid of it is to make a small opening, just sufficient to permit the blood to drain off, if it be fluid, or to be squeezed out, if it be coagulated. The walls of the sac are then approximated by a compress and bandage, and irritation is kept down by the ordinary antiphlogistic means. Cavalry-men and grooms are exposed to a severe form of contusion of the tibia, from the kick of the horse. The accident is liable to be followed by violent inflammation, with a tendency to erysipelas and diffused abscess. Recovery is often slow, and suffering great, especially if there has been much concussion of the bone, or extensive injury of the periosteum. The treat- raent is conducted upon general principles, with the addition of free incisions to liberate the soft parts, the knife grating against the surface of the bone, as in the operation for whitlow. SECT. V.—PUNCTURED WOUNDS. A punctured wound is a peculiar injury, deriving its name from the nature of the instrument with which it is inflicted, and the manner in which the tissues are divided. It comprehends all those lesions which are produced PUNCTURED WOUNDS. 319 by nails, splinters of wood, thorns, pins, needles, pieces of bone, or fragments of glass: or by the thrust of a dirk, bayonet, lance, sword, or any other sharp-pointed weapon. The operation of tapping affords a familiar instance of such a wound. The sting of the bee, wasp, and other insects, and the bite of the snake, dog, rat, and other animals are all examples of this class of injuries, with this difference, however, that most of them are inoculated with the peculiar poison secreted by these creatures, and hence they naturally come to be considered separately. In common, every-day life, punctured wounds are most frequently met with in the hands and feet of the working classes. In dissecting and sewing up dead bodies the physician often punc- tures his fingers, and sometimes suffers severely in consequence, apparently, from the introduction of a peculiar septic virus, generated either during the act of dying or shortly after death. Punctured wounds vary much in their extent, direction, and character; thus, they may be superficial or deep, narrow or wide, straight or crooked, simple or complicated; circumstances which will necessarily exert more or less influence upon their prognosis, treatment, and termination. Their depth is usually much greater than their width ; hence it is often extremely difficult to determine the amount of injury done to the parts in which they are situated. A punctured wound is peculiar, not only as it respects the mode of its production, but also in regard to its effects. The tissues are forcibly pressed asunder, and, consequently, more or less contused, if not also a good deal lacerated. The wound made by the bite of man and the inferior animals is usually both a punctured and a lacerated wound; so also when a splinter of wood, or a similar body, is violently driven into the flesh during an engage- ment on shipboard, or when a person is suspended by a hook or impaled upon a railing. A needle, nail, or bone, on the contrary, usually makes a purely punctured wound. The pain attendant upon such an injury is frequently most excruciating, depending evidently, not so much upon the extent of the lesion, as upon the injury sustained by the nerves of the part, and the bruised and condensed state of the tissues. Hence the suffering, which is often immediate, is sure to be immensely increased if the resulting inflammation is at all severe. It is always greatest, other things being equal, in persons of a nervous, irritable temperament. Much also will depend, in this respect, upon the nature of the vulnerating body. The puncture, for example, made in the operation of tapping the abdomen with a trocar generally causes but little uneasiness, while that of a nail, penetrating the sole of the foot, deep down among the muscles, usually produces the most intense agony. Violent nervous symp- toms often supervene upon such accidents, and in hot climates, as well as in the hot seasons in the colder latitudes, they are liable to be followed by tetanus, especially among negroes and the more intemperate classes of whites. Punctured wounds are rarely attended with much hemorrhage, indeed fre- quently hardly any at all; if a large artery, however, has been penetrated, then the bleeding may not only be copious, but fatal, and that perhaps on the instant. The thrust of a sword, lance, dirk, or bayonet into the chest, abdomen, neck, or thigh, often literally taps the vessels, destroying the pa- tient in a few minutes. The shock of such a lesion, too, may prove to be of consequence; even a slight puncture is sometimes followed by excessive prostration, and it has been found that soldiers, during engagements, are seldom able to continue the fight beyond a few minutes after they have been deeply pricked by the point of any of these weapons. The shock of the sys- tem is excessive, and the patient soon falls into a fatal syncope. Another peculiarity of punctured wounds is their liability to be followed 320 WOUNDS. by erysipelas, angeioleucitis, abscess, contraction of the limbs, and wasting of the muscles. Mortification will not be likely to ensue unless the main artery or nerve of an extremity has been severed, or the system at the time of the injury is in a bad condition. Punctured wounds of the scalp, hands, and feet are particularly prone to be followed by severe nervous and inflam- matory symptoms, and also by erysipelas, the latter generally coming on within less than thirty hours after the infliction of the injury. When the lymphatic vessels become involved, as they often do, the disease is indicated by a red line extending from the seat of the injury towards the nearest lym- phatic ganglions. A similar phenomenon, along with more or less indura- tion, is witnessed when the veins participate in the mischief; an occurrence by no means uncommon. The secondary effects of punctured wounds are often very serious, entailing much suffering, with occasional deformity and loss of limb, and demanding much care on the part of the practitioner. Needles, pins, fragments of glass, and pieces of bone sometimes enter the tendons, ligaments, and aponeuroses, and causing severe and protracted irritation, ultimately lead to irremediable contraction. The treatment of punctured wounds consists, first, in the extraction of the foreign body, in case it has not been already dislodged ; secondly, in check- ing hemorrhage; and thirdly, in moderating inflammation and preventing the development of nervous symptoms. To determine whether any extraneous matter remains in the wound, all that is necessary, in most cases, is simply to inspect the vulnerating body. If this exhibit marks of fracture, the probability is that a part of it has been left behind, if so, the probe and finger will assist in detecting it. Should the wound, however, be very deep and narrow, it may be necessary, before this can be done, to make an incision, the extent of which must depend upon the circumstances of each particular case, the only care to be observed being the avoidance of important structures, especially vessels, nerves, and tendons. When a needle or other slender substance is imbedded in the flesh, or buried in the cellular tissue, we may often succeed in detecting it by folding up the skin over it, or making gentle and systematic pressure with the ends of the forefingers at its supposed site, which is generally indicated, at least in recent cases, by a little puncture, perhaps not as large as a flea-bite, upon the surface. Sometimes the local pain or tenderness affords valuable infor- mation as to the precise spot where the needle is lodged. I never hesitate, when there is reason to believe that the foreign body has been retained, to make, if necessary, a free incision for the purpose of extracting it; it is much better to do this at once than to temporize with the case, and to wait until bad symptoms arise, when such a procedure becomes inevitable, although it may now be too late to prevent altogether its bad effects. In the sole of the foot pieces of bone, glass, and other small bodies are sometimes buried deeply beneath the plantar aponeurosis, where it is often quite impossible to detect their presence, however carefully searched for. I well remember a case of this kind which fell under my observation many years ago, in a most interesting boy, nine years old, who lost his life from this cause. As he was running about barefoot one morning, he trod upon a chicken bone, a fragment of which, nearly an inch long, entered the sole of the foot, lodging deeply in the substance of the flexor muscles, in contact with the metatarsal bones. Pain and swelling followed, but still the boy walked about for upwards of a fortnight, limping of course ; the weather, in the meantime, being excessively hot. Suddenly symptoms of tetanus came on ; Professor Willard Parker, then my colleague, and I now saw the case, and, although we made every effort to discover the foreign body, yet such was the swelling of the part and the depth at which it was situated that we PUNCTURED WOUNDS. 321 could not detect it. Death followed in a few days, when we found it so completely buried that it required a very elaborate dissection to remove it. The bleeding in punctured wounds generally ceases spontaneously ; if a large artery has been laid open, or divided, it must be exposed, and tied at each extremity, in the usual manner. If this cannot be done, compression may be tried, as in the treatment of aneurism ; or, this failing, or not being deemed admissible, the main trunk of the vessel is tied at some distance from the injury. To prevent the occurrence of severe pain and nervous distress a full ano- dyne should always be given, if the case be at all severe, immediately after the accident, and the part wrapped up in flannels, wrung out of warm water and laudanum and frequently renewed. If the general health suffer, a dose of calomel should be administered, followed by oil or senna. If fever arise, the antimonial and saline mixture with morphia may be required, to act on the skin and bowels, and to allay pain and induce sleep. If matter threaten to form, as indicated by the tension and throbbing of the part, free incisions must be made; erysipelas, angeioleucitis, and phlebitis must be treated in the usual manner. Nervous symptoms must be met with the liberal use of morphia and tartar emetic. Along our Indian borders very severe wounds, of a punctured character, or partly of a punctured, and partly of an incised nature, are often inflicted with the arrow, which, as is well known, is capable of being projected, with extraordinary precision, to a great distance. Being usually made of the young willow, or other suitable wood, it varies in length from two feet to two feet and a half, and is feathered in the greater part of its extent, in order to facilitate its movements and increase its speed through the air. The head is generally furnished with a spear-shaped piece of flint, obsidian, or iron. This, which is technically termed the point of the weapon, is of a flattened conical figure, its length from base to apex ranging from three-quarters of an inch to an inch and a half; the corners, or angles, project in a line with the side of the free extremity, and are usually upwards of an inch in width, the whole arrangement being such as to enable the instrument to operate on the principle of the barb of a fish-hook. Thus constructed, the point is securely fixed in a notch on the head of the arrow by means of the tendinous shreds of the deer, coated over with the resin of the fir-tree. It is supposed that many of our Indian tribes poison their arrows, so as to inflict a more deadly wound; but I am informed by an old pupil, Dr. William F Edgar, of the army, that this practice is peculiar to the savages inhabiting the mountainous regions watered by Pitt River, one of the northern branches of the Sacramento. These people, it is said, use the poison of the rattle- snake, by grinding the dried head of that reptile into an impalpable powder, which is then applied by means of the putrid blood and flesh of the dog to the point of the weapon, the wound of which proves speedily mortal. Dr. T. C. Henry, an army surgeon, writes me that wounds made by arrows often partake of the nature of incised wounds, or of those caused by the thrust of the small sword. The iron heads of these weapons are exceed- ingly thin, and being propelled with great force, make a clean cut, a portion of which not unfrequently unites by the first intention. Unless an important vessel is laid open, such wounds seldom bleed much. Sometimes the head of the arrow is broken off deep in the flesh, thus requiring a tedious dissec- tion for its removal. vol. I.—21 322 WOUNDS. SECT. VI.—TOOTH WOUNDS. Wounds inflicted by the bite of the human subject and of the inferior animals, as the dog, cat, or rat, partake of the nature of contused, lacerated, and punctured wounds. Such lesions are by no means uncommon, and, from the danger which so often attends them, are worthy of more attention than they have hitherto received. I have seen quite a number of cases of severe suffering occasioned by wounds received upon the fingers in the act of strik- ing persons upon the mouth. The inflammation consequent upon such injuries is prone to assume an erysipelatous character, especially if, at the time of the accident, the constitution happened to be in a deranged state, and it is sometimes so violent as to be followed by mortification. In 1851, a distinguished jurist struck a man upon the mouth, wounding his finger slightly against his teeth. Erysipelas promptly supervened, and the hand had to be amputated; subsequently the disease reappeared in the stump, and necessitated the removal of the arm. The following cases will serve as illustrations of this class of injuries, of which I believe no account has yet appeared in any of our systematic treatises on surgery. Mary Jackson, aged 47, always in good health, struck the back of her hand against the tooth of a servant girl, producing the merest scratch of the skin over the knuckle of the right index-finger; the part bled only a few drops, and caused hardly any pain at the time. Within two hours afterwards, however, it began to throb and ache, the pain extending up the hand, and thence gradually up the limb as far as the axilla, where considerable enlarge- ment of the lymphatic ganglions soon took place. The forefinger swelled rapidly, and to an enormous degree; the hand and arm were also much tumefied, and a deep red line was seen passing along the limb. Great con- stitutional disturbance came on, attended with loss of sleep and appetite; and a large abscess formed in the theca of the finger, followed by necrosis of the last phalanx and anchylosis of the other joints. The whole limb remained for a long time sore, tender, and swollen, and upwards of a year elapsed be- fore the re-establishment of the general health. James Black, aged 36, farmer, eight weeks ago struck a man upon the mouth, receiving a superficial abrasion over the knuckle of the little finger of the right hand. Violent erysipelas of the whole limb followed; the finger became enormously swollen, and a large abscess formed in it, eventuating in the death of its phalanges. The general health suffered greatly, and a fresh attack of erysipelas broke out after the amputation of the finger. Many months elapsed before final recovery occurred. A medical gentleman, upwards of seventy years of age, received a small wound upon the left index-finger by striking a negro lad upon the front teeth. Erysipelas soon showed itself, attended with exquisite pain, and extending up the limb beyond the elbow. After much suffering, in which the constitution seriously participated, the inflammation at length disappeared, leaving the finger stiff, crooked, withered, cold, and benumbed. Thomas Clark, aged 47, farmer, in good health, struck a man on his mouth, on the 24th of December, 1851, the knuckle of the metacarpal bone of the right ring finger coming in contact with the incisor teeth ; the skin was slightly broken, but he experienced no pain at the time. The same evening, however, the hand and finger became painful and stiff, and the next day they began to swell and to present an erysipelatous appearance. Excessive suffer- ing ensued, producing profound constitutional disturbance; and finally, in about three weeks, a large abscess formed in the hand, requiring the lancet. GUNSHOT WOUNDS. 323 When I first saw the case, at the end of this time, the thumb and all the fingers were stiff and immovable ; the wrist-joint was also much affected, and, in fact, the whole limb was sore and painful. In August, 1852, the thumb and fingers were still rigid and useless; much colder than natural, benumbed, and considerably attenuated. Every attempt to bend the fingers was attended with severe suffering. The right ring-finger was anchylosed at the metacarpo- phalangeal joint. There was still much uneasiness in the palm of the hand. The whole limb had an atrophied appearance. The bite of the human subject is often followed by violent symptoms, com- ing on soon after the infliction of the injury. I have witnessed quite a num- ber of such cases, and in several have experienced much trouble in saving limb and life. I do not presume that the saliva has anything to do, in this class of wounds, with the production of the bad effects by which they are so liable to be succeeded; the parts are badly bruised, or bruised, lacerated, and punctured, and we well know how prone such injuries, however induced, always are to be followed by erysipelas and other serious consequences, especially when they occur in persons of intemperate habits, or disordered health. The bite of the inferior animals, particularly when they are much enraged, is often succeeded by a very bad form of erysipelas. Many years ago I attended, along with Dr. Trimble, of Ohio, a child, about three years of age, who had been bitten in one of his fingers a short time previously by a rat. A severe attack of erysipelas soon came on, involving the whole hand and forearm, and causing the most violent local and constitutional suffering. The bitten part was converted into a large unhealthy ulcer, discharging a thin, sanious fluid, and was a long time in healing. Recovery finally took place, but not without permanent anchylosis of the finger, and partial atrophy of the hand and forearm. The bite of the dog, cat, and horse is liable to be followed by similar results. In India the slightest bite of the camel is said frequently to occasion severe inflammation and great general disturbance. The treatment of tooth wounds and abrasions must be conducted upon the same general principles as ordinary contused and punctured wounds. I would strongly advise, however, that the part should always be well cleansed and bathed with warm salt water, to get rid of any saliva and other matter that may have been deposited by the teeth; after this the best application will be a lead and laudanum poultice, followed, if necessary, by leeches, and, if matter form, by early and free incisions. The dilute tincture of iodine, pencilled over the inflamed surface around the wound, will also be useful. The best internal remedies will be calomel and opium, with an active purge at the commencement of the treatment. When the case is obstinate, altera- tives and tonics with change of air may be required. SECT. VII.—GUNSHOT WOUNDS. Gunshot wounds are injuries inflicted by fire-arms, as pistols, muskets, rifles, carbines, cannons, shells, and rockets ; and are dangerous or otherwise according to their extent, the nature of the affected structures, and the state of the system at the time of their receipt. Occurring in all parts of the body, they may, in one case, be so slight as hardly to attract serious attention, while in another they may be so severe as to cause death upon the spot, either in consequence of shock or loss of blood, or, secondarily, from the violence of the resulting inflammation. Even when the person is so fortunate as to escape with his life, he often remains miserable ever afterwards on account of his mutilated condition, the repeated formation of abscesses, or the occurrence of neuralgic pains, which, hardly leaving him any respite from 324 WOUNDS. suffering, keep his mind and body in a state of constant irritation, and utterly incapacitate him for enjoyment and useful exertion. The wounding missiles which are generally employed in civil life, in this country, are pistol, rifle, and musket balls, varying in their volume from that of a body but little larger than a swanshot to that of a small marble. Until recently the ball in use in the American army was the round musket ball, which, with a view to greater efficiency, has been superseded by what is called the new rifle-musket ball, the weight of which is 500 grains. It is of a coni- cal shape with a square hollow base and three grooves ; and when fired with a charge of sixty grains of powder, at a distance of 200 yards, penetrates eleven one inch pine planks, placed one inch and a half apart. At the dis- tance of 1000 yards it penetrates three and one-fourth of such planks. The British, French, and Russians employ a considerable variety of balls adapted to the peculiarities of their respective services. The Enfield ball, used by the English since 1853, is rapidly superseding all other missiles of that description. It is a long conical ball, hollow in the base, weighing 3j and 9ij. The French Minie ball weighs 5j, 3'j and 9ij. The Russian ball, also conical, weighs 3j and 3vj. It has been found in military operations that the conical ball, while it meets with much less resistance from the atmosphere than the round ball, passes to a much greater distance, and does more terrific execution upon entering the body, generally passing in a straight line, and fracturing and comminuting the bones in a most fearful manner; thus causing a much greater mortality, as well as a more frequent necessity for amputation. The conical ball, moreover, is less liable to become flattened and divided than the round ball, and the aperture of exit is nearly always opposite to that of entrance, which was not so often the case formerly. It is alleged that much of the gravity of gunshot wounds in the Crimean war arose from the substi- tution of the conical bullet. To show with what power the Minie ball occa- sionally does its work, it may be stated that it has been known to pass through the bodies of two men and to lodge in that of a third standing some distance behind. Sometimes two balls are united by a piece of lead, and put in a cartridge, thus producing, when fired, a terrible wound, as often happened in the Schles- wig-Holstein war. The Russians in the Crimea also caused great mischief by this expedient. In the naval action off Camperdown, in 1797, great de- struction was wrought by the Dutch, by firing bags of nails and pieces of old iron. Cannon balls are made of cast iron, and range in weight, on an average, from one to sixty-four pounds, the larger being chiefly used at sea and in beating down batteries, and the smaller in field-service. Grape-shot are small balls, confined in a canvas bag, arranged round a wooden spindle by means of a cord, the whole bearing a faint resemblance to a bunch of grapes, whence the name. From this the canister-shot differs principally in being contained in a cylindrical tin-case, closed at each extremity with a piece of wood. Both these classes of missiles are accurately fitted to the caliber of the guns from which they are intended to be discharged. " Shells are large hol- low spheres of iron loaded with gunpowder, which may act either in their entire form as solid balls, or subsequently by the explosion of their contents, and their subdivision into numerous splinters, by which their ravages are greatly extended. Shrapnell shells, so named from their inventor, are hollow spheres, loaded partly with gunpowder, partly with balls." A pistol ball, if fired near, inflicts quite as deadly a wound as a musket or rifle ball. This missile is now generally of a conical shape, and operates with great effect, both upon the soft and hard structures. GUNSHOT WOUNDS. 325 A buck-shot wound is at present of rare occurrence. During the late war with Great Britain it was sufficiently common. Buck-shot are sometimes in- closed in wire cartridges, and are then very effective, carrying close for twenty yards, diverging somewhat at fifty, and entering separately at one hundred and fifty, readily penetrating a yellow pine board an inch thick. Small shot, striking the body in a concentrated form, are capable of pro- ducing the same effect as a large bullet; if they are scattered, the injury will be less grave, unless they happen to hit an important organ, as the heart, brain, or spinal cord, when death may ensue in a few minutes, or, more re- motely, from the resulting inflammation, as in several instances which have fallen under my own observation. Lachese has ascertained by, numerous ex- periments that a load of small shot discharged at a dead body, at a distance of ten inches, will make a clean round opening; at from twelve to eighteen inches the opening will be very irregular and ragged ; whereas, at thirty-six inches, the shot will be scattered in such a manner as to enter separately, not making a common opening at all. Grave injury is sometimes inflicted by the explosion of percussion-caps. Such accidents are sufficiently common among sportsmen, whose pleasures of the chase are often requited by the loss of an eye, and by the most excruci- ating suffering, from the lodgment of a piece of the foreign body in one of the chambers of that organ, or in the substance of the iris. Persons are occasionally killed with wadding discharged from an ordinary fowling-piece. An instance occurred, some years ago, in one of our theatres where a man lost his life from this cause in a sham-fight upon the stage. The wadding, which was a common cartridge, struck the side of the head, fractur- ing the temporal bone, and passing across the brain, lodged against the falx of the dura mater, from which it was extracted by Dr. John Rhea Barton after death, which happened in an hour after the accident. In 1838, a girl was killed in England by the discharge of a gun loaded with paper pellets, some of which penetrated the body and lodged in the lungs and liver. In two other cases life was destroyed by a single pellet; in one, by laying open the fifth intercostal artery, and in the other by breaking the orbitar plate of the frontal bone, and injuring the brain. A case is recorded of a man being fatally wounded by a kid-glove with a button attached to it; it was discharged from a blunderbuss, loaded with powder, and struck the person, who was standing ten feet off, upon his abdomen, in the cavity of which it was found on dissec- tion. It is well known that gunpowder alone, without any wadding, may, when discharged near the body from a gun, pistol, or fowling-piece, cause fatal in- jury. From the experiments of Lachese it appears that, when the distance does not exceed six inches, and the weapon is large and strongly charged, the wound thus made will bear some resemblance to that produced by small shot, each particle which escapes combustion acting like a pellet. The fact that the mere explosion of powder near the body is capable of causing severe bruises, contusions, lacerations, and even death, has long been familiar to observers. The instances are quite numerous of great suffering, mutilation, and disfigurement having been produced by the lodgment of grains of powder in the eyes, face, neck, and other parts of the body. Stone quarriers are par- ticularly liable to such accidents. In its character, a gunshot wound partakes of the nature of a contused and lacerated wound; at the opening of entrance and for some distance around, the tissues are bruised, but as the ball passes onward it tears the parts, and at the opening of exit they often look as if they had been cut with a sharp knife. The effects of the transit of the missile upon the soft tex- tures may be explained, as was first suggested by Sir Charles Bell, by a re- 326 WOUNDS. ference to a diagram consisting of three concentric rings, as in fig. 71. The first, including the tubular wound, is bounded by tissues Fig. 71. which are so compacted, condensed, or contused as to de- ^----. prive them, to some extent, of their vitality, or, at any rate, /O—-\\ t0 P'ace tnem *n sucn a condition as inevitably to lead to / //-~C\ \ suppuration; consequently this portion of the-wound sel- ( ( ( J J dom unites by the first intention. The structures between V Va^-^a/ / the first and second rings, having sustained less injury, will V ^---J also inflame, but only, as a general rule, in such a manner ----- as to give rise to a deposit of lymph, or lymph and pus; while those beyond the last circle will either retain their natural properties, or, becoming excited, will merely experience some slight serous infiltration. The above phenomena may generally be studied to the greatest advantage in deep flesh wounds, as those of the thigh. In such cases there is often a considerable slough of the bruised tissues, upon the separation of which the parts are seen to suppurate and to form granulations, while farther on they are hard, next cedematous, and beyond this natural. These phenomena, how- ever, do not generally pervade the entire length of the wound ; for it fre- quently happens that a considerable portion of the track unites by adhesive action, the tissues being lacerated instead of contused, as they are in the early stage of the passage, and consequently favorable to restoration. The precise point where the tubular wound loses the character of a contusion and assumes that of a laceration cannot generally be ascertained; it will of course vary very much in different cases, and under different circumstances. The preceding remarks in regard to the injury inflicted by the projectile are chiefly applicable to the smaller kinds of balls, such as the pistol and rifle; the larger ones are generally productive of more serious mischief, and hence it often happens that the wound sloughs in its entire length, from the opening of entrance to that of exit; there being afterwards, when the dead parts have separated, extensive and tedious suppuration, the matter, perhaps, burrowing deeply among the soft structures, and thus greatly retarding the process of repair. Disposition of the Projectile.—The manner in which the projectile is dis- posed of varies; sometimes it lodges, and then, of course, it makes but one opening; at other times it passes completely through the part, and so leaves two apertures, one of entrance, and the other of exit. Cases occur where one ball may make three, four, or even more holes. Thus, if it should hap- pen to encounter a sharp edge of bone, as the crest of the tibia, it may be cut into two or more pieces, each of which may afterwards issue at a sepa- rate point. Dupuytren met with a case in which a ball, cut into fragments, made five orifices; and at Antwerp the younger Larrey saw six holes made in a similar manner. Again, a ball piercing the surface, just above the wrist, may be unable to penetrate the aponeurosis of the forearm, but, travelling along for some distance under the integument, may emerge below the elbow; then, the limb being considerably flexed at the moment, it may re-enter the skin a second time at the lower part of the arm, and finally escape near the shoulder-joint; thus leaving four apertures, two of entrance, and two of exit. Such an occurrence is, of course, quite rare ; but its possibility should not be forgotten, as it is of great interest in a medico-legal point of view. A man, for example, might be shot in a duel, and his friends seeing the number of openings in the limb, might accuse his adversary of foul play, on the ground that he had used more than one ball. A ball striking an extremity may pass not only completely through it, but also through its fellow, thus making four openings ; or it may perforate the upper part of the thigh, and then pass through the head of the penis, leaving GUNSHOT WOUNDS. 327 two orifices in the former and two in the latter, as in a case which I saw in the Hospital at Alexandria, under the care of Dr. Sheldon, after the engage- ment near Centreville, Virginia, on the 18th of July; or, finally, it may traverse both buttocks, or it may perforate one and lodge under the integu- ments on the outer side of the other, as in a man who was wounded in the battle at Bull Run. When there is but one opening, it is natural to conclude that the ball has lodged, and this, as already stated, is usually the fact. Instances, however, occur, although they are very rare, where the reverse is the case. Thus, a ball has been known to pass for some distance into the pectoral muscle, and to be immediately ejected by the recoil of a rib. The knee-joint has occa- sionally been opened, the ball being supposed to have lodged in the head of the tibia, but upon amputating the limb no ball was found, although there was but one opening. Lastly, a ball may enter the body, perhaps rather deeply along with a piece of cloth, upon extracting which the missile may drop out. Instances, illustrative of the possibility of all these occurrences are circumstantially narrated in the admirable and instructive works of Percy, Guthrie, Hennen, Baudens, Macleod, and other military surgeons, and de- serve an attentive perusal. Large balls, fragments of shell, pieces of iron, and other substances, occa- sionally bury themselves deeply among the muscles, where, owing to the small size of the opening made on entering, they have been known to remain for a long time without exciting any suspicion of their presence. Larrey nar- rates a case in which he extracted a ball, weighing five pounds, from the thigh of a soldier, who had suffered so little inconvenience from it that it had been entirely overlooked by the surgical attendant; and Hennen refers to a similar instance as having occurred at Seringapatam. Here, however, the ball weighed twelve pounds. Considerable difference generally exists between the openings of entrance and exit. The former is usually rounded with even or slightly inverted edges, as if the skin had been tucked in a little, and there is frequently more or less bluish or blackish discoloration of the adjacent surface, from the contact of burnt powder, deposited upon the ball at the moment of the explosion, and rubbed off as the ball strikes the body. When the discharge takes place within a few feet of the surface, scorched grains of powder often adhere to the skin, or are even imbedded in its substance. The opening of exit, on the contrary, has generally a slit-like appearance, looking rather as if it had been made with a sharp knife than an obtuse body; it is free from discolora- tion, and its edges, instead of being inverted, are turned out. I have met with cases where both openings had an incised appearance, but such a condi- tion is rare. The size of the two openings is variable. In general, the round ball will make a larger orifice of entrance than of exit, the reverse happening when the injury is inflicted with the conical ball. These peculiarities were remark- ably apparent in the wounds of the Federal troops after the battle at Bull Run, on the 21st of July last. I had occasion also to notice the immense size of the openings in gunshot wounds of the integuments, made by the conical ball, especially when the two apertures were close together. In nearly all the cases of this class of lesions that I saw in the hospitals at Alexandria, Washington, and Georgetown, the holes, especially that of exit, were dispro- portionately large, as well as remarkably irregular and ragged. Shell wounds, and wounds inflicted with stone, nails, splinters, and similar missiles, always exhibit a lacerated appearance, owing to the irregular shape of the vulnerating body. A similar character is often imparted by flattened bullets. A ball, flying in a straight line, under a strong impetus, will, on reaching 328 W 0 U N D S. the surface of the body, penetrate it in the same direction, dividing all before it in the cleanest and neatest manner, even to the bones, and probably issuing at a point directly opposite. If, on the other hand, its force is partially spent, then it will either not enter at all, or, if it do, it will be turned out of its course, the slightest resistance, as that offered by a tendon, ligament, or aponeurosis, serving to change its direction. The circumstances which tend to weaken the force of a ball are two, the attraction of the earth and the resistance of the atmosphere. It has been ascertained that a strong wind blowing perpendicularly to the direction of the American rifle-musket ball, will deflect it from its course 12 feet in 1000 yards, about one-fourth that dis- tance in 500 yards, and about six inches in 200 yards. Besides, its impulse may receive a serious check by coming in contact with the person's accoutre- ment, or some article of dress, as a button, or breast-plate, or some substance that may happen at the time to be in his pocket, as a key, pencil, knife, watch, or piece of coin. If, from these, or any other cause, the force of the projectile is partially spent, it may, on reaching the surface, either glance off; or, if it enter, it will be likely to be deflected ; and the course which it sometimes pur- sues under such circumstances is very remarkable. Thus a ball has been known to pierce the forehead, but instead of penetrating the frontal bone, it has passed round the skull, underneath the scalp, and lodged upon the occiput, at a point nearly opposite to that of entrance; or, what is still more extraordinary, it has travelled nearly completely round the head, issuing only a short distance from the place where it struck. In the same manner a ball has been found to describe the circumference of the chest, its course being marked by a reddish weal or line. Several well authenticated cases are mentioned by writers on military surgery where the missile, piercing the wall of the chest by the side of the sternum, made the circuit of the thoracic cavity by passing between the costal and pulmonary pleura?, and either falling down upon the diaphragm, or lodging in the wall of the chest behind, without inflicting the slightest in- jury upon the lung. Examples of a similar kind occasionally occur in the abdomen, the ball, after entering the skin, being turned out of its direction by the tendon of the external oblique muscle, so as to pass round the belly beneath the integuments, and effect a lodgment near the spine, or, perhaps, escape somewhere upon the back. Finally, cases are not wanting, although they are certainly rare, where a ball has entered the abdomen in front, and issued behind, in a straight line, without wounding any of its contents. Such occurrences might challenge credibility, if the authors who have related them were not, from their high position and character for veracity, entitled to im- plicit confidence in their statements. They find their counterpart in sword, bayonet, and dagger wounds of the abdomen, in which the walls of that cavity are sometimes completely transfixed, and yet its contents escape unharmed. A case is related by Dr. William H. Herring, of the army, where a musket ball, entering the superior and posterior part of the neck, was discharged at the end of five months by the anus, having, as was supposed, passed by ulcer- ation into the pharynx and thence into the stomach. Different tissues possess the faculty of deflecting balls in different degrees. Thus bone offers a greater amount of resistance than cartilage, cartilage than tendon, tendon than aponeurosis, and aponeurosis than muscle. Arteries, as already seen, often escape in a remarkable manner, their astonishing elasticity enabling them to glide away from the flying projectile. Common integument, too, readily throws a partially spent ball out of the straight line. Deflection of every description, however, is much less frequent now than formerly, owing to the substitution of the conical for the round ball, the former readily pene- trating everything, even when fired at a great distance, whereas the latter is easily spent, and arrested on coming iu contact with the more resisting tissues. GUNSHOT WOUNDS. 329 A ball, upon meeting a sharp bone, as the crest of the tibia, is sometimes cut in two as smoothly and evenly as if it had been divided with a knife. Some years ago I attended a gentleman, who, in a street rencontre, was wounded with a pistol, the ball striking the clavicle, which cut it into two nearly equal portions, one bounding off, and escaping, the other lodging in the lower part of the neck, from which I removed it several months after- wards. Cases have occurred in which, as before stated, bullets have been split into a number of pieces, each perhaps makiug a separate orifice in the skin. The old round ball, in passing through the bones, often made a hole much larger than itself, especially when its force happened to be partially spent. Indeed, cases were occasionally observed in which the opening was so capa- cious as to admit, not only the ball, but also the barrel of the weapon from which it was discharged. The opening made by the conical ball is, on the contrary, comparatively much smaller ; but, although this is the fact, the mis- chief which it inflicts is proportiouably much greater, owing to the manner in which it breaks and comminutes the osseous tissue, the loose splinters them- selves thus often becoming a source of severe injury to the soft parts. Grave injury is sometimes inflicted upon a bone, even without the occur- rence of fracture, simply from the violence of the shock which it experiences. The bullet strikes its surface with great force, bruising the periosteum, and causing dreadful concussion of the osseous tissue, but the force with which it is impelled is not sufficient to enable it to effect penetration. Erysipelatous inflammation is set up, followed by exhausting suppuration, and, perhaps, sloughing and death. Windage of Balls.—The older writers on military surgery had much to say respecting the windage of balls. It is well known that the most horrible injuries may be inflicted upon the body by cannon shot, completely pulpify- ing the muscles, lacerating the vessels and nerves, laying open large joints, and literally mashing the bones, and yet, perhaps, hardly bruise the skin, much less produce any serious wound. To account for these phenomena, various theories were invented, and it is not a little strange that the correct explanation of them should have been reserved for comparatively modern times. Even as late as the early part of the present century, several writers puzzled their minds to solve the much vexed question by a series of ingenious reasoning and argumentation worthy of a better cause. Thus we find that one gentleman has endeavored to account for the accident by supposing that the ball, as it passes by the body, powerfully condenses the atmosphere, thereby creating a vacuum, which is instantly succeeded by the forcible ex- pansion of the part and its consequent laceration. The explanation was in- tended to apply more particularly to injuries of this kind as they occur in the hollow viscera, as the stomach and bowels. Another ingenious speculator has imagined that the effect is due to the action of the electric current gene- rated by the rapid movement of the missile through the air. Finally, Mr. Spence, au English naval surgeon, informs us that the cause, at least on ship- board, where such accidents are not infrequent, is the violent contact of the wadding and other substances, as pieces of canvas and rope-yarn, which are so liable to be carried along with the ball. We may admire the ingenuity which prompted these views, but their fallacy is too apparent to admit of deception. The true cause of these injuries is the manner in which the pro- jectile strikes the surface. It has already been seen that a ball in rapid motion will, on reaching the body, pass through it in a straight line; or that, instead of this, it will, if it be large, as in the case of a cannon ball, carry away the part completely. But it is very different when the missile is pro- jected lazily, or when, in consequence of the great distance over which it has travelled, its force is measurably exhausted. Then the slightest resistance 330 WOUNDS. will tend to deflect it, or change its course; it no longer passes in a straight line, but rolls or turns upon its axis after the manner of a billiard ball, and hence if, while in this condition, it strikes the body, it may inflict the most frightful injury both upon the muscles and bones, and yet not perhaps leave a trace of its effects upon the skin, the elasticity of which enables it to slide out of harm's way, while the other and deeper structures, which possess this property in a less degree or not at all, readily yield to its influence, and are severely injured in consequence. That the older notions upon this subject are of a purely hypothetical cha- racter is shown by the fact that, during naval and military engagements, soldiers often have pieces of their dress, accoutrements, and even of their persons carried away by balls in rapid motion, without sustaining any serious injury in their bones and muscles. The faculty possessed by the integuments of gliding out of the way of mischief is admirably exemplified in railroad ac- cidents, which strongly resemble those inflicted by partially spent cannon balls, and in which they frequently escape in the most astonishing manner, while the deeper parts, soft as well as hard, are frightfully torn and pulpi- fied. These gunshot lesions are much less frequent now than formerly, in consequence of the general introduction of the conical ball, which does its work more neatly and effectually, as well as at a much greater distance, than the old round ball, which, however, is still occasionally used. The distribution of wounds during a battle will necessarily vary with cir- cumstances. In an engagement on the open field, the chances are that nearly all parts will suffer alike. In nearly four hundred cases of gunshot injury which I saw after the battle at Bull Run on the 21st of July, almost all the wounds were situated in the extremities, and in nearly equal proportion in the upper and lower. A few only had been struck on the head, chest, back, and abdomen. This cannot, however, be taken as a fair criterion of the result of the engagement, since those that were most severely wounded fell into the hands of the enemy. According to Hennen, of the wounds received in battle, ten will be in the upper extremity, seven in the lower extremity, seven in the head, four in the neck and chest, and two in the abdomen. Scrive, from his observations in the Crimean war, estimates that, in the open field, one-tenth of the wounds will be in the head, one-twentieth in the chest, and one-fortieth in the abdomen. Men, fired at behind breastworks, are most liable to suffer in the head, neck, chest, shoulders, and arms, the lower parts being protected by the defences. Symptoms.—The symptoms of gunshot wounds necessarily resolve them- selves into local and general, or into such as are peculiar to the part and system ; and, it need hardly be added, vary greatly in their character, ac- cording to the extent of the lesion, the importance of the tissues involved, and the idiosyncrasy and other circumstances of the individual. The pain consequent upon a wound of this kind is often quite insignificant, the person, although perhaps severely hurt, not being conscious of having received any injury until some minutes after it has been inflicted. In general, it is of a dead, heavy character, altogether different from that which attends an incised or punctured wound; it is only when a large nerve has been par- tially cut across that it is apt to be at all severe, and then it is usually very sharp, pricking, or burning. In this case, too, there will also be more or less numbness in the part below the wound, and sometimes, as when the principal nerve has been entirely severed, complete paralysis. Thus in gun- shot wounds of the thigh, involving the division of the sciatic nerve, there is always loss of motion, and often, also, of sensation of the knee, leg, and foot, which feel as if they were cold and dead. The suffering is generally great when a bone is broken, a large joint penetrated, or a visceral cavity laid open, and the shock is then also much more severe and protracted. The pain, GUNSHOT WOUNDS. 331 however slight at the moment of the injury, is sure to be greatly aggravated upon the supervention of inflammation, so that the patient frequently requires large doses of anodynes for its suppression. The hemorrhage in gunshot wounds is generally not at all in proportion to the severity of the injury, owing, as is commonly supposed, to the contused nature of the lesion. The structures immediately around the track of the ball are usually so much condensed that, unless the divided vessels are large, or numerous, the bleeding will, in the majority of instances, be so slight as to excite little, if any, alarm for the patient's safety. Very frequently, in- deed, it amounts to the merest oozing, which soon ceases spontaneously, or under the application of cold water. If a large artery, however, happens to be laid open, the hemorrhage will not only be copious, but may be so great as to prove speedily fatal, perhaps in a few minutes at farthest, and, conse- quently, long before the surgeon will be able to interpose his skill for the preservation of life. Such an event will be more likely to occur if, as often happens iu this class of injuries, the vessel is only partially divided, so as to prevent its retraction ; here the blood will flow most freely, and, although it may be temporarily arrested by syncope, the clot will be washed away the moment reaction takes place, and thus the case will go on, the fainting re- curring until the patient has bled to death. If, on the other hand, the artery is completely divided, there may hardly be any hemorrhage whatever until the occurrence of reaction, or, perhaps, not even until the separation of the sloughs. The ball often passes directly in the course of a large artery, perhaps the principal artery of a limb, and yet the vessel may completely escape injury, or, at most, be merely grazed by the missile. The reason of this is the resilient power of the vessel, which enables it to jump, as it were, out of the way of the projectile. Such an artery, however, will be particularly ob- noxious to gangrene, and therefore to secondary hemorrhage during the separation of the sloughs. The hemorrhage is generally external, the blood issuing at both orifices of the wound. The reverse, however, may be the case, especially if the injured parts have been thrown out of their relative position, or if, as sometimes happens, there has been extensive separation of the muscles; in such an event a large quantity of blood may be effused among the deep-seated struc- tures, with hardly any outward bleeding. In wounds of the chest, abdomen, and pelvis, the hemorrhage is usually internal, and therefore the more dan- gerous, because concealed. Gunshot wounds are, for the reasons already mentioned, extremely prone to secondary hemorrhage. A large artery may have been merely grazed, and, inflaming, a slough may form, which, separating, may give rise to severe, if not fatal bleeding in the space of a few minutes. Or an artery, of consider- able size, may have been completely severed, but its ends, as well as the sur- rounding parts, having been violently contused, a clot is instantly formed, which thus affords a temporary barrier to the escape of blood ; by and by, however, reaction takes place, and then perhaps the artery is reopened, its contents now gushing out in a full stream ; or the event may not take place for some days, perhaps not until after the establishment of suppuration or the occurrence of gangrene and sloughing. Sometimes the injured vessel is completely blocked up by the ball or other foreign substance, upon the removal of which copious hemorrhage ensues. Secondary hemorrhage, the result of sloughing, usually occurs from the tenth to the fifteenth day ; much, however, will depend, in this respect, upon the size of the ball and the amount of injury sustained by the soft parts around the wound, as well as by the vessel itself. In some instances it does not appear before the twentieth, twenty-fifth, or thirtieth day ; and, on the 332 WOUNDS. other hand, it occasionally occurs as early as the fifth, sixth, or seventh day. However this may be, the patient should be most sedulously watched until he has safely passed the critical period. The constitutional symptoms of the lesion are subject to much diversity. The shock is sometimes severe in a degree altogether disproportionate to the violence of the injury ; the stoutest and most courageous individual will often swoon away from the most insignificant wound, and, on the other hand, a man may have his limb completely shattered, and yet not evince any serious alarm; his mind is perfectly calm and collected, and he is perhaps able to give the word of command or cheer on his comrades up to the very moment of his dissolution. Temperament and idiosyncrasy have much to do in the production of these phenomena, and should have due weight in regard to our prognosis. It is said that veterans upon the field of battle generally, other things being equal, suffer much less apprehension and alarm from their injuries than new and inexperienced troops. The subjoined case affords a good example of the manner in which shock occasionally causes death in gunshot wounds in civil life:—An army officer in 1851 fell in a duel near Louisville, the ball, which was very large, round, and fired from a rifle at a distance of forty yards, entering the left thigh a little above its upper third, lacerating the soft parts in the most horrible manner, laying open the femoral vein, and crushing the bone into numberless frag- ments. The missile then passed into the right thigh, where it lodged, pro- ducing, however, but little mischief. Although hardly a pint of blood was lost, yet the system never rallied; the face continued deadly pale, the extre- mities cold, and the pulse small and feeble, notwithstanding the free use of brandy, up to the moment of the patient's death, which happened in two hours after the rencontre. Prognosis.—The prognosis of gunshot wounds varies with so many cir- cumstances as to admit of being pointed out only in a very general manner. Some of the milder cases of this class of injuries often recover promptly, without a solitary untoward symptom, the parts occasionally uniting, as I have myself seen in several instances, by the first intention. In other cases, on the contrary, apparently of a mild character, severe nervous symptoms may arise, or the wound may take on erysipelas, or a bad form of inflamma- tion, and the patient lose his life. Two years ago I attended, in this city, a young man who had been shot with a pistol, the ball, which was small, having entered the outer and back part of the arm, just above its middle, grazing the humerus, and lodging immediately under the integuments, from which I removed it an hour afterwards. The ordinary treatment was em- ployed ; but in thirty-six hours violent erysipelas set in, and death occurred in less than eight days from the time of the injury. On the other hand, seemingly the most desperate cases will sometimes recover. Much will of course depend, in every instance, upon the size and situation of the wound, the presence or absence of complications, the state of the patient's constitu- tion, the condition of the atmosphere, and the nature of the treatment. Some gunshot wounds must necessarily be fatal, either instantaneously, as when they involve one of the more important organs, or a large vessel, or, more or less remotely, as a consequence of the resulting inflammation, gan- grene, or profuse and exhausting discharge. The danger to limb, if not to life, will be great when a large joint has been laid open, the main artery, vein, or nerve severed, the bone crushed, or the integument extensively stripped off; or when all, or nearly all, of these parts suffer together. Gun- shot wounds of the lower extremity are, other thiugs being equal, more dangerous than those of the upper, sharing, in this respect, the same fate as ordinary lacerated and contused wounds. The presence or absence of complications will necessarily exert no little GUNSHOT WOUNDS. 333 influence upon the issue of the case. Thus, a person, even if but slightly wounded, will often suffer most severely, and perhaps even die of the effects of his injury, if he was laboring at the time he was hurt under any serious disease of some internal organ, as the liver, lung, or bowel. The habits of the patient must also be taken into the account; if he is intemperate, his chances of recovery will be diminished, and so also if his constitution has been enervated by long residence in a warm, unhealthy climate. Wounds inflicted in battle are generally more fatal than those received in civil life, especially if they are treated in crowded, ill-ventilated hospitals. Death then often occurs from sheer neglect, or the want of good nursing and suitable surgical treatment. The causes of death in gunshot wounds are, first, shock and hemorrhage; secondly, tetanus; thirdly, pyemia and erysipelas; fourthly, gangrene; and fifthly, profuse suppuration and hectic irritation. Remote Effects.—The remote effects of gunshot wounds are often very troublesome, entailing much suffering, and being occasionally followed by loss of life at the distance of many years. In a case of gunshot wound of the chest, related by Dr. M. H. Houston, of Wheeling, Virginia, a thick linen patch, with which the ball had been enveloped, remained in the left lung for twenty years, when the patient died in a state of extreme marasmus, his general health never having been good since the occurrence of the accident. Sometimes a bullet lodges in the head of a bone, where, although it may for a while be comparatively harmless, it ultimately causes necrosis, with inflam- mation and discharge in the soft parts, thus necessitating the removal of both substances, if not of the limb itself. It is related of Marshal Moncey that he died from the effects of a gunshot wound forty years after its receipt. . . On the other hand, however, a ball may occasionally remain m the body for a long time—perhaps in an organ even of vital importance—without inducing any particular mischief. Thus, in a case recently reported by Dr. Henry Wurtz, of New York, an ounce bullet was found, on dissection, in the middle lobe of the right lung of an old soldier, forty-five years after its intro- duction at the siege of Badajoz. It was inclosed in a distinct cyst, an inch below the surface of the organ, having entered between the fourth and fifth ribs, as was proved by the existence there of an old cicatrice. Treatment.__In the treatment of gunshot wounds five distinct indications are presented : 1st. To revive the patient, or promote reaction; 2dly. To arrest hemorrhage; 3dly. To extract the ball and any other foreign matter that may have entered along with it; 4thly. To remove any detached or loose pieces of bone; and 5thly. To circumscribe the resulting inflammation. 1st. The first indication is to relieve shock, and this is to be fulfilled by the employment of the ordinary restoratives. If the patient be faint, he must be placed at once in the recumbent posture, with his head as low as the rest of the body; cold water must be dashed upon the face, the fan be freely used, and smelling bottles held near the nose. If the symptoms are urgent, sina- pisms are applied to the chest, spine, and extremities, a stimulating injec- tion is thrown into the bowel, and, if the power of deglutition is not gone, brandy or wine and ammonia are given by the mouth. If there be internal hemorrhage, however, care is taken to bring up the pulse slowly and gently, allowing time for the formation of coagula, and guarding against the occur- rence of violent inflammation. A kind look, or a soothing expression will often do more to revive the patient and encourage recovery than anything else. 2dly. If the hemorrhage be capillary, or caused by the division of very small vessels, it will probably cease of its own accord, or simply by exposure of the part to the cold air, or under the application of cold water, pounded 334 wounds. ice, or some astringent lotion. If it be venous, compression will probably suffice; but if it proceed from a large artery, such as the radial or tibial, nothing short of the ligature will do, and no time should be lost in its appli- cation. The case is very simple when the vessel is superficial, and the wound capacious; but under opposite circumstances the duty of the surgeon is often exceedingly embarrassing. Here it becomes necessary either to dilate the wound, so as to expose the artery and tie it at both ends, which is by far the best plan; or, where this is impracticable on account of the depth of the ves- sel, its proximity to important structures, or the great swelling and infiltration of the parts, as may happen when some time has elapsed since the receipt of the injury, to cut down upon the main trunk of the vessel, and to secure it as in the Hunterian operation for aneurism. The latter procedure, however, will rarely succeed, inasmuch as the bleeding is extremely liable to be kept up by the recurrent circulation; hence it is always best, if practicable, to cut down at once upon the injured artery, and to apply a ligature to Fig. 72. each extremity, which cannot fail to put an effectual stop to the flow of blood. The more promptly the operation is performed the better; if the surgeon wait till inflammation has supervened he will expe- rience great difficulty, not only in exposing the artery, but also in inducing the ligature to maintain its hold upon its softened and partially disorganized tissues. When the hemorrhage has been very profuse, but has gradually or suddenly stopped, it will hardly be safe to intrust the case to the efforts of nature, because, when reac- tion occurs, the vessel will almost be sure to be reopened, and thus the bleeding may progress until the system is completely exhausted; but if the surgeon has done his duty, the parts will be placed in the best possible condition for speedy recovery. It is a good rule, in such cases, to do whatever may be necessary without the slightest temporizing. 3dly. The third indication is the extraction of the ball; but to do this it is necessary, in the first place, to ascertain where it is; to grope about in the wound without any definite ideas as to its precise location, would only be to inflict additional pain and injury. In order to conduct the examination with the greatest advantage, the part should be put as nearly as possible in the position in which it was at the time of the accident. This is the more necessary, be- cause, as was before stated, the missile often pursues a very different route from what might be supposed from merely looking at the orifice of entrance or exit; the slightest resistance may change its direction, and compel it to lodge at a situation far beyond what it would have sought had it been permitted to pass in a straight line. Hence attention to the position of the part becomes, in all cases, a matter of paramount importance. Care must be taken in searching for a ball not to mistake for it an osseous prominence. Stromeyer refers to two cases in which he saw this blunder committed ; in one the surgeon cut down upon the head of the fibula, and in the other upon a metatarsal bone. The asser- tion of a patient that the ball has dropped out is seldom reliable, unless the missile is found in his pocket. The best probe for conducting the examination is the finger, pro- vided it is sufficiently long and slender; it possesses the same value, in such cases, as direct auscultation possesses iu the exploration of the chest, or the finger in the examination of the uterus and rectum, and should therefore always be used when practicable. If the digit be inadequate, recourse is had to a stout probe, fig. 72 or fig. 73, at least from ten to twelve inches in length, as thick as a medium- GUNSHOT WOUNDS. 335 sized bougie, slightly flexible, and blunt-pointed, being composed either of silver or brass. The ordinary pocket probe is much too small. Wrhen such Fig. 73. o o an instrument as that just described is not at hand, the necessary exploration may be performed with a female sound or catheter, or even with a long, slender pair of bullet-forceps. Whatever instrument is employed, it should be passed along the track of the wound with all possible care and gentleness, and in such a manner as not to insinuate its point into the surrounding cel- lular tissue, or among the muscles, tendons, nerves, and vessels; a circum- stance which may very easily happen if the surgeon do not observe the utmost caution in performing the operation. The contact of the probe with the ball usually produces a sensation of roughness and resistance, together with a dull noise if the instrument be struck against the foreign body by short jerks. The parts being now accurately maintained in the position in which the ball was found, the forceps take the place of the probe, the blades being firmly closed as they pass along the track until the point comes in contact with the extraneous substance, which is then seized and extracted, care being taken to include none of the surrounding tissues Occasionally the operator will derive important aid in his manipulations from counter-pressure, the hand or the thumb and a few fingers being applied to the opposite side of the wounded parts. Bullet-forceps and extractors, of Fig- 74. Fig. 75. various forms and sizes, are in use. The most important qualities of such an instrument are lightness, strength, and slenderness, with length of blade, which should not be less than four inches. The extremity should be well rounded off, and fashioned in such a manner that it shall adapt itself readily to the shape of the foreign body, and at the same time grasp it with great firmness, without the risk of including any of the adjacent struc- tures. The old forceps, fig. 74, did good service during the reign of the round ball, but will hardly answer for the extraction of the conical. For the latter purpose Mr. Tiemann, of New York, devised, not long ago, the ingenious instrument depicted in fig. 75. It is quite slender in the blade, and is provided with short, stout teeth, projecting somewhat like the incisors of a mouse, their object being to take a firm hold upon any part of the bullet by partially bury- ing themselves in its substance. The instrument of Mr. Tiemann has been greatly improved by Mr, Gem rig, by making the end of One blade CUp- The old bullet forceps. Tiemann's forceps. 336 WOUNDS. shaped, with two curved prongs, separated in front by a narrow interval, and terminating each in a point. The other blade has only one prong, also curved, but central, and terminating in a point, wdiich, when the forceps are shut, is received in the interval here alluded to, thus rendering its extremity perfectly blunt. The instrument, represented in fig. 76, answers for the round as well as'the conical ball, and possesses the great advantage of facility of application with firmness of grasp. The forceps delineated in fig. 77 were made last summer, at my suggestion, by Mr. Gemrig. They are about nine inches and a half in length, light, slender, and fenestrated at the extremity, which is scooped out in such a manner as to embrace the ball with great facility, while its inner surface, roughened like that of a stirrup, maintains its hold with extraordinary firmness. Fig. 76. Fig. 77. Fig. 78. Fig. 79. Gemrig's forceps. Author's forceps. Kolb^'s extractor. European extractor. When the wound is unusually large, and the ball not deeply seated, the extraction may sometimes be effected with a small lithotomy scoop, the com- mon dressing or polypous forceps, or an instrument like that sketched in fig. 78, made for me by Mr. Kolbe, of this city. It consists of a silver tube, inclosing a steel stylet, terminating in two blades, cup-shaped on the inside, and movable by a hinge. The extremity of the instrument is seen grasping the ball. Fig. 79 represents a similar instrument used by the British and French surgeons. GUNSHOT WOUNDS. 337 The gimlet-like instrument, so much extolled by the older surgeons, is now rarely used, although it might still occasionally be employed with advantage when the extraneous substance is lodged in a bone thickly covered by mus- cles. The trephine, however, is generally preferred under this and other similar circumstances. A ball, after having traversed the thickness of a limb, or of the body, occa- sionally lodges immediately beneath, or among the superficial muscles, where its presence is readily detected by the probe or finger. In such a case the best plan is to remove it by a counter-opening, that is, by cutting down upon it at the nearest point; a procedure which often saves an immense amount of pain and trouble. When the ball cannot be found without much probing and the risk of inflicting serious additional mischief, reason and experience alike suggest the propriety of letting it remain, in the hope that it may either become encysted, or that it will be detached and washed away by the discharges. In general, however, every justifiable effort should be made to remove it, on the ground that, if left behind, it will be almost sure to excite violent inflammation, fol- lowed by profuse suppuration and extensive separation of the tissues. Such an event will be the more likely to happen if the ball has become rough, jag- ged, or flattened by contact with a bone; for then it never can be encysted, but must necessarily keep up irritation as long as it remains. The great importance of not permitting balls to remain unextracted has been placed iu a forcible light by the observations of Mons. Hutin, chief sur- geon of the Hotel des Invalides of Paris. Of 4,000 soldiers examined by this distinguished practitioner, within a space of five years, only 12 presented themselves who had experienced no inconvenience from the retention of foreign bodies, while the remainder, 200 in number, had all suffered more or less severely until they had been relieved by operation. Another reason for the early extraction of these missiles is that persons soon after the receipt of their injuries will, in general, submit much more readily to the necessary operation than they will after they have partially recovered from their effects; their dread usually increasing in proportion as they get well, and beyond the reach of immediate danger. When a ball has entered a movable joint, it should always be promptly extracted if it lie loose within its cavity; if, on the other hand, it has lodged in the adjoining bone, it should be allowed to remain, in the hope that it may soon be covered over with plastic matter, and thus become comparatively harmless. The only exception to this rule is where the ball projects into the cavity of the articulation, in which case it should be removed at all hazard, since its retention would inevitably lead to violent, if not fatal, inflammation, and utter uselessness of the part. No sensible surgeon ever thinks of searching for a ball in any of the great cavities of the body; such a procedure would be sure to increase the dangers of the accident, and cannot, therefore, be too pointedly condemned. If it be necessary to the welfare of the part and system to remove a ball, which is a comparatively innocuous substance, how much more important is it to extract the various foreign bodies which so often enter along with it, and the presence of which is an incessant source of irritation and annoyance, however protracted it may be. The rule here is imperative, and applies to the smallest, as well as to the largest substance; to the little piece of wad- ding and the stoutest splinter, the linen shred and the brass button ; in short, to all extraneous matter whatever. Wherever it may be, it must be sought for, and, if possible, extracted without delay. There is no chance here of the formation of a cyst, as sometimes happens with a ball; nature admits of no such liberty. In naval and military engagements large pieces of wood, metal, and other substances are liable to be impelled into the body, in which vol. i.—22 338 WOUNDS. they are often buried at a great depth, or lodged among the muscles, which sometimes close over them in a sort of valve-like manner, rendering it ex- tremely difficult not merely to extract but even to find them. Much may be done in such cases by the gentle use of the finger and probe, aided by counter-pressure. 4thly. Any detached splinters of bone, or pieces of bone so much loosened as to render it improbable that, if left behind, they will become reunited, should be removed as early as possible after the occurrence of the accident, experience having shown that their retention is always productive of exten- sive and protracted suppuration, if not of worse results. By the timely extraction of such bodies immense suffering may be prevented, and ultimate recovery vastly expedited. It is surprising that surgeons should ever hesitate in such a case; and yet the instances are not uncommon where the most cul- pable neglect is observed. A remarkable example of the kind fell under my notice in 1847, in the person of Lieut. George Adams, of the United States Marine Corps, who was desperately wounded in the right thigh by a large musket ball during our war with Mexico, at the battle of the National Bridge, between Vera Cruz and Jalapa. The soft parts were extensively injured and the bone was shattered into numerous fragments, not less than twenty-four of which, some of them upwards of an inch and a half in length, I removed nine months afterwards, from the enormous callus that had formed around the seat of the fracture; most of them were completely imprisoned in the osseous matter, and it was therefore found quite difficult to extract them. The inci- sions healed kindly, except at one point, which refused to close, and from which a small fragment of bone was subsequently removed by the late Pro- fessor Warren, of Boston. When powder is imbedded in the skin, the first thing to be done is to pick out, with a cataract needle, or delicate bistoury, every particle of it, regard- less of pain. If this be neglected the powder will speedily excite inflamma- tion, besides causing disagreeable and permanent disfigurement by the bluish spots which it leaves. The operation is tedious, and is always attended with severe suffering. The resulting inflammation is to be combated in the usual manner; cold water, or cold saturnine lotions, being generally the best local remedies. 5thly. The fifth and last indication is to circumscribe and moderate the resulting inflammation. To accomplish this, attention to various points is necessary. In the first place, the parts must be properly dressed. Works on surgery generally direct that the orifices of the wound shall be lightly covered with lint and adhesive plaster. Is such a procedure rational ? It certainly is not, for its direct effect must inevitably be to prevent discharge, of which there must always be more or less in every such case, and conse- quently to aggravate the local mischief. A much better plan is to allow the orifices to remain open, while we attempt, by means of a light compress and bandage, to close the sides, with a view of facilitating their union by adhesive action. The roller should be carried up from the distal part of the limb to some distance beyond the wound, care being taken to perforate it opposite its orifices, in order to admit of free drainage. In this manner nature may often be immensely assisted in the cure; the inflammation will generally be moderate, infiltration of fluids will be obviated, and the patient will frequently recover in a surprisingly short period, and with but little suffering. The bandage, however, must be used with great caution, for there is danger, espe- cially if there be much swelling, of its producing injurious compression, and thus becoming a source of gangrene. My experience in the treatment of gunshot wounds is necessarily limited, but it is sufficient to justify me in asserting that adhesive plaster should, as a general rule, be dispensed with; it is certainly not easy to perceive how it is possible for it to do any good. GUNSHOT WOUNDS. 339 In gunshot wounds of the extremities, involving the deep muscles and aponeuroses, great advantage will accrue, during the progress of the treatment, from the use of the bandage, applied in such a manner as to prevent the for- mation of sinuses and favor the escape of pus. When considerable inflam- mation is present, the dressings may be kept wet with a spirituous lotion com- posed of two parts of alcohol to eight of water. The part having been dressed, and placed at rest in an easy and elevated position, cold water is applied, provided there is no contra-indication to its use, on account of the state of the weather or the intolerance of the part and system. If the weather be mild, and the patient young and robust, cold will usually be borne better than warmth, and the most eligible form is that of water, either simple, or medicated with opium and acetate of lead. The use of cold water in the treatment of this class of lesions dates as far back as the time of Biondo, towards the middle of the sixteenth century, and its beneficial effects, although lost sight of for a long time, were again brought prominently before the notice of the profession by Kern, Larrey, Guthrie, and other army surgeons, during the continental wars which deluged Europe early in the present century. Cold water, however, is not tolerated equally well by all patients, and hence the rule is, where it disagrees, to substitute warm applications, either in the form simply of tepid water, or in that of a light emollient cataplasm, which, after all, makes, in many cases, an admirable dressing, soothing pain, and promoting discharge. When much contusion exists, as is so often the case in shell and cannon wounds, I am satisfied that the best local remedy is some spirituous lotion, as, for example, two parts of alcohol to ten of water, with the addition, if there be offensive discharge, of a small quantity of chlorinate of soda, or Labarra- que's solution. The tissues, deprived of nervous power, must be slightly stimulated, otherwise they will be in danger of running into profuse suppura- tion, if not gangrene. If the inflammation assumes a threatening aspect, especially if it becomes erysipelatous, and is attended with great pain, tension, and swelling, free in- cisions, and sometimes counter-openings, must be made, otherwise extensive mischief will result from the burrowing of fluids, and the consequent destruc- tion of the connective tissues. Besides, the parts, if not timeously relieved, might mortify. The older surgeons made it a rule of practice to dilate all wounds of this kind as soon as possible after their infliction, with a view of preventing these and other untoward results, but this procedure has become obsolete, the modern practitioner resorting to it only when the necessity arises in consequence of the severity of the inflammation ; assuming that a man ought not to be cut merely because he has been shot. The orifices of the wound will usually begin to granulate in from four to six days, even when there is slight gangrene of their edges, and the whole track will often close in an almost incredibly short time. Much of it, espe- cially if it be long, will be in the condition of a subcutaneous wound, and there- fore highly favorable to reparation. When the passage is slow in filling up, the healing process raay be expedited by the use of slightly stimulating in- jections, thrown in twice in the twenty-four hours; few cases, however, will demand such interference. The wound at the point of exit generally heals first. Conjoined with these local measures must be perfect rest of mind and body, along with good diet, gentle purgatives, and anodynes, for the double purpose of allaying pain and spasm, and inducing sleep. Opiates will generally be borne in large doses, and can rarely be dispensed with in any case, however mild. If the wound is severe, and especially if it be attended with serious hemorrhage, active purgation must be scrupulously abstained from, and also antimonials, on account of their depressing effects, and their tendency 340 WOUNDS. to provoke tetanus. In all cases due allowance must be made, in our treat- ment, for the drainage which is likely to attend such injuries. Hence much judgment is often required to steer clear of difficulty and danger. Bleeding by the lancet is hardly to be thought of under any circumstances; in young and plethoric subjects, however, blood may occasionally be taken advantage- ously by leeches. In ordinary cases, the diet should be plain and simple, rigid abstinence not being required, excepting when there is unusual fulness of habit. If decided exhaustion be present, whether from shock, loss of blood, or inflammatory disturbance, prompt recourse must be had to milk punch, quinine, and nutritious food. When a tendency to erysipelas or pyemia arises, the patient, in addition to the means already indicated, should be promptly put under the influence of iron and strychnia, or of these two articles with quinine and brandy; and, if large numbers of wounded are crowded together, no time should be lost in effecting their sequestration. QUESTION OF AMPUTATION IN WOUNDS. The most horrible wounds are generally those which are inflicted by machi- nery in rapid motion, the passage of a railway car or the wheel of a heavy wagon, and the explosion of fire-arms, violently lacerating and contusing the soft parts, extensively crushing the bones, and perhaps opening one or more of the larger joints. In many cases, the character and extent of the mischief are apparent at first sight; in others, as when it is principally subcutaneous, it becomes so only after a most patient and thorough examination. The latter class of injuries is particularly to be dreaded, as it is often impossible, even with the greatest care, to determine the extent of the lesion. When the exa- mination necessary to ascertain the condition of the parts is likely to be painful or protracted, commiseration for the sufferer always dictates the pro- priety of administering chloroform, although the effect of the anaesthesia will rarely be required to be carried to the extent of complete unconsciousness, a few full and prolonged whiffs being generally sufficient to effect the desired tolerance. In attempting to determine the question as to whether an attempt should be made to cut off or save a limb, not a little stress should be laid upon the age, habits, and previous health of the patient, the manner in which the injury was inflicted, and the number, variety, and importance of the structures in- volved. Young adults bear severe accidents much better, other things being equal, than the two extremes of life, childhood and decrepitude, in both of which, but especially the latter, the power of reaction is generally very feeble, and the effect of shock and hemorrhage felt for a long time. Nevertheless, there is not a practitioner of any experience that has not occasionally witnessed striking exceptions even under these circumstances. A temperate man usually bears up under a severe wound much better than a dissipated one, and the resident of the country than the inhabitant of the crowded citv; a person in ill health at the time of the accident will be likely to suffer more than one in an opposite condition. The worst class of accidents in civil practice are those inflicted by railway cars, steamboats, and steam factories, and these are often of such a nature as to require the prompt removal of the mangled and muti- lated parts. But of all the circumstances influencing the recovery of the patient, and the ability of the surgeon to save the mutilated parts, the most important, by far, is the extent of the injury, or the number and nature of the tissues involved. QUESTION OF AMPUTATION IN WOUNDS. 341 To place this subject in a clear and tangible light, it is requisite to consider it somewhat in detail. Before doing this, however, it is proper to premise that amputation should never be performed in wounds of any kind until after reaction has taken place; as, if this precaution be neglected, the additional shock which the operation would necessarily impart to the system might prove fatal, either before the patient is removed from the table, or soon after. As long as he is deadly pale, the pulse small and thready, the surface cold, and the thirst, restlessness, and jactitation excessive, it is obvious that recourse to the knife must be wholly out of the question. The proper treatment is re- cumbency, with mild stimulants, sinapisms to the extremities, and other means calculated to re-excite the action of the heart and brain. Power being restored, the operation, if deemed necessary, is proceeded with, due regard being had to the prevention of shock and hemorrhage, the two things now mainly to be dreaded. The advantage of primary over secondary amputation, in all severe wounds, is too obvious to require comment. Mr. Guthrie long ago ascertained that the loss after secondary operations, in gunshot injuries, was at least three times as great as after primary, and the results of his observations have been amply confirmed by the more recent experience of military surgeons. In the Crimean war, where the wounds were, for the most part, inflicted with the conical ball instead of with the round, as in the cases seen by Mr. Guthrie, the difference was less marked, but still strikingly in favor of primary inter- ference. Thus, the mortality in 690 primary amputations was 175, or in the ratio of 25.3 per cent., and 38 in 89 secondary, or in the ratio of 42.7. The following circumstances may be enumerated as justifying, if not im- peratively demanding, amputation in cases of wounds, whatever may be their nature:— 1st. When a limb has been run over by a railroad car, fracturing the bones, and tearing open the soft parts, amputation should, as a general rule, be per- formed, even when the injury done to the skin and vessels is apparently very slight, experience having shown that such accidents seldom do well, if an attempt is made to save the limb, the patient soon dying of gangrene, pyemia, or typhoid irritation. The danger of an unfavorable termination in such a case is always greater when the lesion affects the lower extremity than when it involves the superior. 2d. No attempt should be made to save a limb when, in addition to serious injury done to the integuments, muscles, or bones, its principal artery, vein, or nerve has been extensively lacerated, or violently contused, as the result will be likely to be gangrene, followed by death. 3d. A lacerated or gunshot wound penetrating a large joint, as that of the knee or ankle, and accompanied by comminuted fracture, or extensive lacera- tion of the ligaments of the articulation, will, if left to itself, be very prone to terminate in tetanus, mortification, or pyemia, and is therefore a proper case for early amputation. 4th. Gunshot wounds attended with severe comminution of the bones, the fragments being sent widely around among the soft parts, lacerating and bruising them severely, generally require amputation, especially in naval and military practice. Gunshot fracture of the thigh-bone is generally considered by military surgeons as a sufficient cause for primary amputation. The rule, however, admits of exceptions. 5th. Extensive laceration, contusion, and stripping off of the integuments, conjoined with fracture, dislocation, or compression and purification of the muscles, will, in general, be a proper cause for the removal of a limb. In all severe lacerated and contused wounds, whether induced by cannon shot, falls, blows, machinery in rapid motion, or the passage of the wheel of a rail- road car, the limb should be amputated, as a general rule, at a considerable dis- 342 WOUNDS, t tance above the apparent seat of the injury. If this precaution be neglected, mortification will be liable to seize upon the stump, owing to the fact that, in such cases, the injury, both of the soft and hard parts, usually extends much further than the naked eye can discover. Should amputation be performed when a limb, the subject of a severe wound, laceration, or contusion, has been suddenly seized with mortification, manifesting a rapidly spreading tendency, extending, perhaps in a few hours, up as far as the middle of the leg, or even as high as the knee ? In general, such cases are desperate ; no local or internal remedies can arrest the morbid action ; the system has sustained a profound shock, and the affected parts perish, not by inches, but literally by feet. I have repeatedly seen this variety of gangrene extend from the toes, instep, or ankle as far as the hip- joint in less than thirty-six hours, and that, too, in cases where there was but little visible injury, the mischief being evidently deep-seated, involving muscle, nerve, vessel, and bone. If amputation be not performed, the dis- ease, whose march is indicated by a bluish or livid, crepitating, and tender streak along the limb, will be sure to terminate fatally in a few days, and the operation should therefore, in my judgment, be resorted to at the earliest possible moment, the surgeon not foolishly waiting for a line of demarcation, which cannot take place, since neither, part nor system has the power of ar- resting the morbid action. The event, it is true, will generally be unfavor- able, but as it is the only chance the patient has, he should, slender though it be, certainly have the benefit of it. In the few cases in which I have amputated under these unpropitious circumstances, the result in all has been fatal. Lacerated, contused, and gunshot wounds are often of so frightful a nature as to render it perfectly certain, even at a glance, that the limb will be obliged to be sacrificed in order that a better chance may be afforded for preserving the patient's life. At other times, the injury, although severe, may yet, apparently, not be so desperate as to preclude, in the opinion of the practitioner, the possibility of saving the parts, or, at all events, the propriety of making an attempt to that effect. The cases which may reasonably require and those which may not require interference with the knife are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious and unpleasant apprehension, lest we should be guilty, on the one hand, of the sin of commission, and, on the other, of that of omission; or, in other, and more comprehensive terms, that, while the sur- geon endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have been promptly amputated. It is not every man, however large his skill and experience, that is always able to satisfy himself, even after the most profound deliberation, what line of conduct should be pursued in these trying circumstances; hence the safest plan for him generally is to procure the best counsel that the emergencies of the case may admit of. But in doing this, he must be careful to guard against pro- crastination ; the case must be met promptly and courageously ; delay even of a few hours may be fatal, or, at all events, place limb and life in imminent jeopardy. Above all, let proper caution be used if the patient is obliged to be transported to some hospital, or to a distant home, that he may not be subjected to unnecessary pain, exposed to loss of blood, or carried in a posi- tion incompatible with his exhausted condition. Vast injury is often done in this way, by ignorant persons having charge of the case, and occasionally even by practitioners whose education and common sense should be a suffi- cient guarantee against such conduct. The transportation of a patient to a distance of perhaps a hundred or a hundred and fifty miles upon a railway car, after he has been desperately wounded, iu the hope, it may be, of obtain- SECONDARY EFFECTS OF WOUNDS AND CONTUSIONS. 343 ing better aid, cannot be too severely reprehended, as involving not only the loss of precious time, but often also the infliction of additional injury upon a part and system already overwhelmed by shock and hemorrhage. Resection in gunshot and other injuries involving the articulations is, as will be more fully explained elsewhere, applicable chiefly to the shoulder and elbow-joints, in cases unattended with serious lesion of the soft parts. In the former, a portion of the humerus, embracing, if necessary, from three to five inches in length, together with a part or even the whole of the glenoid cavity of the scapula, may be safely, and expeditiously removed under such circumstances, and yet the patient have an excellent use of his arm. Expe- rience shows that primary excision of the other joints, excepting, of course, the smaller ones, as those of the hand and foot, is generally very unfavorable. Further observations upon this subject will appear in the chapter on am- putation, and in those on fractures, dislocations, and resections. SECONDARY EFFECTS OF WOUNDS AND CONTUSIONS. Every practitioner occasionally meets with cases of wounds and bruises in which the patient, happily escaping from the primary effects of the injury, suffers severely from what may be termed the secondary effects, coming on several weeks or months afterwards. These lesions have not received suffi- cient attention from systematic writers. It has fallen to my lot to see quite a number of such cases, and I select the following from my note-book in illus- tration of the subject:— A farmer, aged thirty, in August, 1851, got his left foot twisted and bruised by a fall from his horse. The accident was instantly followed by severe pain, and next day by excessive swelling, which, however, gradually subsided under the usual antiphlogistic remedies. In the course of a few weeks the man was able to exercise on crutches, but the foot was now observed to be very sore and tender, cold, clammy, withered and benumbed, and to be completely destitute of power. There was also frequent twitching of the three small toes, particularly at night, so as to interfere with sleep. These symptoms were aggravated in damp, cold states of the atmosphere, when there were also occasionally neuralgic pains in the part. The general health likewise materially suffered, the appetite being bad, the bowels irregular, and the mind much dejected. When I saw the patient, nearly a year after the acci- dent, he had been subjected to various plans of treatment, with hardly even any temporary relief. I placed him upon tonics and alterants, and ordered the hot and cold douche, with frictions with veratria liniment and the use of the bandage ; but many months elapsed before he experienced much benefit from the treatment, and I believe he has never entirely recovered the use of his foot and ankle. A man, aged 25, cut himself, in October, 1852, with an axe on the instep of the left foot, directly over the internal cuneiform bone. The weapon pene- trated the bone, and evidently severed the extensor tendon of the great toe, as the toe could no longer be moved by the effort of the will. The wound healed completely in a few days, but in a short time afterwards the parts be- came tender and remained so for several months. Meanwhile, the foot and leg grew sensibly thinner, and were habitually cold and clammy; a state of things which has now continued for several years. Whenever exercise is taken, the parts swell, and become tender. The muscles of the whole limb are flabby and wasted. The general health is much disordered ; the man has lost thirty pounds of flesh, and has been unable to attend to any business 344 WOUNDS. since the accident. His tongue is habitually coated, he sleeps badly at night, and he is subject to frequent fits of despondency. A man, aged 35, consulted me in March, 1854, on account of an accident similar to the above. He was a bricklayer by occupation, and previously was always in good health up to October, when he cut himself with a hatchet in the left instep, immediately over the internal cuneiform bone, as nearly as possible in the same situation as in the preceding case. The wound healed rapidly, but the man soon began to suffer with exquisite pain and tenderness in the parts, extending up the leg, and subject to severe exacerbation from damp states of the atmosphere, exposure to cold, and derangement of the digestive organs. The suffering was not regular in its recurrence, but it was generally worse at night, and often sadly interrupted his sleep. The limb was cold and clammy, as well as much emaciated, and the parts immediately around the scar were hard, as if from the presence of organized lymph. The general health was much impaired, the tongue was coated, and the sleep was usually much interrupted by spasm of the limb. A prominent symptom in the case was great soreness in the hollow of the foot, in front of the heel. When the man attempted to walk, the foot became very tender, and began immediately to swell. Both in this and in the preceding case the patient was obliged to use crutches. A lady, aged 27, the wife of a medical gentleman, in February, 1852, punctured the forepart of her right wrist, towards the ulnar margin of the forearm, with a small slender sewing needle, which entered the skin directly over the ulnar artery, and passed, apparently, obliquely inwards and outwards towards the centre of the joint, without, however, penetrating it. The needle was immediately withdrawn, but not examined, and the patient, consequently, was uncertain whether a portion had broken off and remained behind. The accident was followed by the most excruciating pain, pervading the entire extremity from one end to the other, but being particularly severe at the seat of the injury and in the thumb and first two fingers. A violent rigor soon succeeded, and for ten days the patient suffered the most horrible tortures, being frequently threatened with tetanus, and constantly annoyed with spas- modic twitches of the muscles of the hand and arm. Considerable swelling arose soon after the receipt of the injury in the forearm, wrist, hand, thumb, and the fingers above named. About the end of the tenth day a small cir- cumscribed abscess formed at the site of the puncture, which, upon being lanced, discharged about a drachm and a half of thick pus, much to the relief of the patient. In a week the matter had reaccumulated, and the part was again lanced, followed by the same relief as before. Subsequently the skin was scarified several times, the cuts bleeding profusely at each operation, but not yielding any pus. During the following summer the patient experienced severe and constant pain, especially in the anterior part of the arm, between the elbow and the insertion of the deltoid muscle; it was always more violent in the evening, and was of a dead, heavy aching character; the limb was stiff and numb. When I first saw the patient, in November, 1852, she informed me that her general health had been very bad for the last six years, that she was sub- ject to dyspepsia, and that she was naturally of a nervous, excitable tempera- ment. She had formerly suffered, at intervals, from rheumatism. For the last four months she had had a seton in the upper and fore part of the arm, on account of the severity of her pain, which, however, at this time, was much less than formerly. She thought she had derived much benefit from the seton. Her hand and thumb, together with the fore and middle fingers, swelled every evening, becoming stiff and sore, so that she could with diffi- culty flex or extend them. In the day the parts felt much more comfortable. The pain and soreness were always greatest at night. Pressure at the seat MAGGOTS IN WOUNDS. 345 of the puncture gave rise to uneasiness rather than to pain, but was always followed soon after by so much distress as to prevent sleep during the suc- ceeding night. The ring and little fingers were natural, free from swelling, and easily moved. The whole limb was cold and considerably wasted. The probability is that, in this case, the needle pricked the ulnar nerve at the wrist, producing a condition of things, in her bad state of health, simi- lar to that which occasionally results from the puncture of a nerve in bleed- ing at the arm. Under the use of an alterative and tonic course of treatment, with strych- nine and arsenious acid ; the hot and cold douche, followed by friction with veratria ointment; a nutritious diet and exercise in the open air; the gene- ral health rapidly improved, and the local suffering finally disappeared, though the limb has never recovered its original powers. Bad effects not unfrequently follow upon gunshot wounds ; they present themselves in different forms and degrees, and often entail great suffering along with partial loss of function. Among the more common and annoy- ing of these secondary effects are neuralgic pains and a sense of numbness in the parts, progressive atrophy of the muscles, contraction of the aponeu- roses and tendons, and anchylosis of the joints. In regard to the treatment of these secondary lesions, it is impossible to lay down any definite plan of action ; every case must be managed accord- ing to the peculiarities of its symptoms. Much benefit may generally be ex- pected from attention to the state of the general health, which is nearly always more or less seriously disordered. Neuralgic pains, altered sensibility, and atrophy usually require a course of tonics and arsenic, purgatives, the hot and cold douche, and dry frictions. Rigidity of the joints must be coun- teracted by passive motion and sorbefacients ; contraction of the tendons and aponeuroses by the use of splints and the bandage. MAGGOTS IN WOUNDS. The development of maggots in wounds and compound fractures is a cir- cumstance worthy of notice in a practical point of view. Such an occur- rence is met with chiefly in hot weather, but I have also seen it in the autumn and early part of winter, in consequence of the artificial heat of the patient's apartment. In tropical climates the formation of maggots in wounds and ulcers is almost unavoidable, despite the best directed efforts to prevent it. The soldiers in Syria, under Larrey, and our troops during the war with Mexico, suffered greatly from this cause. Dr. Proctor informed me that wounds, however carefully cleansed one morning, were found, on the suc- ceeding evening, to contain large numbers of these animals, and if the slight- est neglect took place, they speedily collected in incredible quantities, and of prodigious size, their diameter equalling that of a small-goose quill, while their length ranged from three to nine lines. The soldiers had a great hor- ror of them, and from the disposition which they evinced to burrow deep among the muscles, they were productive of no little pain and distress. Fortunately the formation of maggots is not often seen in civil practice, where patients can enjoy all the conveniences and comforts of home ; nor is it usual to meet with them in public institutions; still, the fact that such an occurrence is possible cannot be too firmly impressed upon the mind of the young and inexperienced practitioner. The best preventive of this occurrence is cleanliness, with a frequent change of dressing, and burying the affected parts in light bran, so as to place them beyond the reach of flies, which, under almost any other mode of manage- 346 WOUNDS. raent, are sure to find their way to the wounded surface, the slightest crevice affording them access to the much coveted spot. Moisture and a high tem- perature are the causes which most rapidly conduce to the formation of mag- gots. The means that prove most destructive to them are spirits of turpen- tine, creasote, and alkaline solutions, particularly chlorinated soda. Dr. Atkinson, of the British army, has found no remedy so efficacious as calo- mel, sprinkled upon the wound, or blown into it from a quill. Horrible suffering has been known to result from the development of mag- gots in the nose, from the accidental deposition of larvae during a fit of intoxication. Dr. Bamford, who formerly practised in Texas, has commu- nicated to me the particulars of the case of a man who perished from the effects of maggots formed in the nasal cavities and frontal sinuses, from which it was found impossible to dislodge them by any means that could be devised for the purpose. The patient suffered great agony, and died in raving deli- rium. It is easy to conceive how, in a hot climate, in consequence of the want of cleanliness, the larvae of the fly might be deposited in an ear affected with profuse suppuration, or, from a similar cause, even in the vagina. Dis- gusting as such an occurrence is, it is by no means a matter of improbability. SECT. VIII.—POISONED WOUNDS. Under this head are included four distinct classes of wounds : first, those inflicted by venomous insects and snakes; secondly, those caused by the bite of rabid animals; thirdly, those produced by inoculation with the poison of glanders; and lastly, wounds received in the examination of dead bodies, constituting what are called dissection wounds. 1. WOUNDS INFLICTED BY POISONOUS INSECTS. There are various genera of insects which naturally secrete a poison, which, when instilled into the living tissues, is capable of producing serious and even fatal consequences. Of these the most common, at least in this country, are the humble-bee, the honey-bee, the wasp, hornet, and yellow-jacket. The poison of these insects is contained in a small vesicle in the abdomen, and is under the control of a peculiar muscular apparatus by which it is injected into the punc- ture made by the barbed sting of these little creatures. It is highly acrid in its qualities, especially in the honey-bee, hornet, and yellow-jacket, transparent, and of a sweetish taste at first, but afterwards hot and disagreeable, being particularly active during the heat of summer. When roused to anger, these insects sting with great fury, producing a wound which is instantly followed by a sharp, pungent, itching pain, and in a few moments after by a circum- scribed inflammatory swelling, pale, and elevated at the site of injury. In some persons, owing to idiosyncrasy and other causes, the symptoms are exceedingly severe and even alarming, the patient having dimness of sight, vertigo, nausea, palpitation, and a feeling of indescribable oppression, with a disposition to swoon. Instances have occurred in various parts of the country of persons having been stung to death by a single honey-bee; one such case, of which I have the particulars, occurred, many years ago, in Ken- tucky, in a man upwards of thirty years old. He was wounded on the face, and died in a few hours. I know a young raan who always suffers from severe sickness of the stomach and great nervous depression when he is stung by a bee. Violent effects sometimes proceed from the sting of a bee, wasp, or yellow-jacket in the fauces, oesophagus, or stomach, when these insects are accidentally swallowed in cider and other drinks. WOUNDS INFLICTED BY POISONOUS INSECTS. 347 As the sting is often left in the skin, in the infliction of this class of wounds, the part should be carefully examined, in order that, if present, it may at once be extracted. The most promptly efficacious remedies are, in general, salt water, alcohol, laudanum, vinegar, hartshorn, spirits of camphor, Cologne water, soap liniment, solutions of the acetate of lead, and dilute tincture of iodine. Turpentine is also a highly valuable article. Whether these and other similar remedies act by neutralizing the poison, or merely by relieving the resulting inflammation, we are unable to say. In those cases in which the system becomes affected, immediate recourse should be had to internal stimulants, of which the best are brandy and ammonia. If the insect has passed into the throat, a mustard and salt emetic will be the proper remedy, followed, if urgent swelling and impending suffocation ensue, by leeches to the neck, and, perhaps, by laryngotomy. Various species of the mosquito tribes are poisonous, and therefore capable of inoculating the wounds which they make by their bite. In the Southern States, as well, indeed, as in some of the western, and along many parts of the Atlantic coast, the mosquito abounds in vast numbers, and often inflicts serious injury both upon man and animals. I have met with a number of instances in which the bite of this insect was productive of severe inflammation, and several in which it was followed by considerable ulceration. The late Professor Dorsey, of this city, observed a case of gangrene and death from a wound of this kind in a lady, previously in good health. So serious an effect as this is probably always dependent upon some idiosyncrasy, or upon the occurrence of erysipelas, consequent upon the bite. The stinging sensation and swelling which attend the application of the poison of the mosquito usually soon subside of their own accord, or under the use of some mild stimulant, as Cologne water, alcohol, vinegar, or laudanum. When the effect is more serious, the tincture of iodine and warm water-dressing may be necessary. The poison of the scorpion has many of the properties of that of the bee and wasp, although it is much more active. It is of a whitish color and oleaginous consistence, and is contained in a small reservoir near the end of the tail, whence it is ejected through two little pores on each side of the sting. In North America and Europe the wound inflicted by the animal is comparatively harmless, the only effect generally being a tolerably smart but transient inflammation ; but in Africa and Asia it is often followed by great suffering and even loss of life, death sometimes occurring in a few hours. In these countries the scorpion frequently attains an enormous size, having a huge body, and a length of from six to ten inches. Several species of this insect, of large size, are found in Texas and Mexico, but I am not aware that their sting is particularly venomous. The great Eastern remedy in this variety of wound is olive oil, and an idea prevails that its virtues are greatly increased by infusing in it the bodies of some of these animals previously to its application. Spirits of hartshorn would doubtless be a more valuable addition. Such a wound should always be immediately well washed with salt water, then scarified, next thoroughly rubbed with volatile liniment, and then covered with an emollient poultice. If constitutional symptoms arise, they must be met with anodynes, brandy, and ammonia, the treatment being very similar to that adopted for the sting of the bee and wasp. Bad effects have occasionally followed the bite of the spider; and the fabulous stories about the poisonous qualities of the tarantula are known to every reader of history. As yet, we know too little of the character and habits of these insects to speak with any certainty of the effects of their bite; but judging from what has been published upon the subject by reliable authorities, it is fair to conclude that, while there has been much exaggeration and actual misrepresentation, there is also much that is true. The symptoms 348 WOUNDS. of the bite of the tarantula, so far as they have been studied, would seem to be very similar to those produced by the sting of the common scorpion. Hence similar treatment would probably suffice. 2. WOUNDS INFLICTED BY VENOMOUS SERPENTS. The number of poisonous serpents in different parts of the world is very considerable; but in this country there are, so far as is at present known, only three genera that are at all dangerous on account of their bite. These are the crotalus, trigonocephalus, and elaps. Of the crotalus, or rattlesnake, so called from the peculiar appendage to its tail, Professor Holbrook, in his Herpetology of North America, has described not less than six species, of which the banded, striped, and miliary are the most common ; all are venom- ous, and consequently capable of inflicting deadly wounds. These reptiles formerly abounded in almost every section of the United States, especially in the swampy and mountainous regions, but are now hardly ever met with in our denser settlements. All the different species of rattlesnakes are provided with two small sacs, each of which contains a minute quantity of poison, and communicates, by means of a short excretory duct, with the canal in the fang on each side of the upper jaw. It is inclosed by a bony framework, situated external to the proper jaw, and is under the control of appropriate muscles, the action of which aids materially in expelling its contents. The fangs, situated just at the verge of the mouth, are very long, sharp, and crooked, like the claws of a cat, and are naturally retracted and concealed in a fold of integument; but, when the animal is irritated, are capable of being instantly raised, and darted forwards with great force into the skin, followed by an emission of poison. The snake, then, does not bite, but strikes, making a punctured wound. The annexed illustration represents the head of the rattlesnake, and one Fig. 80. Fig. 81. Fig. SO. Head of the rattlesnake, a, a. Poison gland, and its excretory duct; the latter cut open at its extremity, e. Anterior temporal muscle. /. Posterior temporal muscle, g. Digastricus. h. External pterygoid, i Middle temporal, q. Articulo-maxillary ligament, which joins the aponeurotic capsule of the poison gland, r. The cervical angular muscle, t. Vertebro-mandibular muscle, u. Costo-man- dibular muscle. Fig. SI. Poison fang, magnified, p, p. The pulp cavity of the tooth, v, v. The canal along which the venom flows, truly on the outside of the tooth. of the poison fangs, with the canal along which the venom flows when the animal is in the act of inflicting its wound. WOUNDS INFLICTED BY VENOMOUS SERPENTS. 349 The poison of the rattlesnake is a thin, semi-transparent, albuminous fluid, of a yellowish color, with, occasionally, a tinge of green. According to Dr. S. WTeir Mitchell, of this city, who has carefully studied its qualities, it is of a glutinous consistence, devoid of smell and taste, distinctly acid, of the spe- cific gravity of 1044, and coagulable at a temperature of 140° to 160°. Its toxic activity is not materially, if at all, impaired by boiling and freezing, and alcohol, acids, alkalies, iodine, and chlorides, do not destroy its viru- lence. When dried, it retains its dreaded power for an indefinite period. Chemically examined, it is found to contain, besides coloring matter, and an undetermined substance, both soluble in alcohol, a trace of fatty matter, chlorides and phosphates, and two albuminoid principles, one coagulable at 212° F., the other, termed crotoline, not coagulable at this temperature, neutral in its action, freely soluble in water, and of a nitrogenous nature. The quantity of venom contained in the poison-bag does not generally ex- ceed a few drops; but it accumulates when the animal is inactive, and Dr. Mitchell had a snake which, on one occasion, ejected fifteen drops, its fang not having been used for several weeks. It is peculiarly acrid and deadly in hot weather and during the procreating season. In winter and early spring the reptile is in a torpid condition, and the poison is then diminished in quantity, and unusually thick, though not less virulent. The effect of the wound of th»e rattlesnake varies with many circumstances, as the situation of the part, the acrid character of the poison, and the age of the patient. Experience has shown, as in the case of the bite of rabid ani- mals, that most of those hurt in this way escape either entirely or suffer only in a very slight degree ; the poison either failing to reach the tissues, or being too inert to make any decided impression upon the system. It is also known that adults are less liable to suffer than children, simply because they possess, as may be supposed, greater vigor of constitution, and consequently greater power of withstanding the influence of the venom. The deleterious effects of the poison seem to be much weakened, if not actually exhausted, by a rapid succession of bites. The experiments of Captain Hall, of Caro- lina, and of the late Professor Barton, of this city, place this subject in a very clear light. Of three dogs bitten in succession by a rattlesnake four feet long, the former gentleman found that the first died in less than fifteen seconds, the second in two hours, and the third in three hours. The subjects of Barton's experiments were chickens, and the results were almost identical with those of Hall. Of three fowls, bitten on three consecutive days, the first perished in a few hours, the second lived for some time, and the third finally recovered, although not without considerable suffering. Instances occasionally occur in the human subject of almost instant destruction from the bite of the rattlesnake; at other times the case proceeds more slowly, the patient not dying under several hours, or, perhaps, several weeks. Dr. Wain- wright, of New York, lost his life in less than six hours from the time he was wounded. The animal, an uncommonly large one, had lain in a torpid state for some time, when, unexpectedly becoming warmed, he reared himself and struck his victim furiously on the last phalanx of the middle finger of the left hand. Although the wound was immediately sucked, and soon afterwards excised and cauterized, a ligature being also tied firmly round the wrist, the hand soon became enormously swollen, the tumefaction rapidly extending up the limb nearly as far as the axilla, and the surface, in the greater part of its extent, exhibiting a mottled bluish and greenish yellow hue. The pulse soon became very feeble, and beat one hundred and twenty in the minute; in four hours the patient was in a state of stupor, and died soon after in a completely comatose condition. Finally, in another series of cases, the patient, after having been near death's door for several weeks, eventually perishes, or re- covers. When death occurs almost instantaneously, the probability is that 350 WO-UNDS. the poison is injected directly into the blood, the fang having penetrated some tolerably large vessel. Under such circumstances, the fluid is found to be thin and black, and refuses to coagulate when exposed to the atmo- sphere. When this poison has been freely instilled into a wound, the symptoms will always be proportionably severe. The moment the inoculation has taken place, excessive pain is experienced in the part, rapidly followed by swelling, which soon diffuses itself extensively over the surrounding surface, and is attended with a livid mottled appearance, dependent upon extravasation of blood in the subcutaneous cellular tissue. If the wound, for instance, occu- pies a finger, the tumefaction speedily extends up the limb, as far as the shoulder, and, perhaps, over a large portion of the corresponding side of the trunk, a feeling of numbness, weight, and coldness attending the other symp- toms. Within a few minutes after the first manifestation of the local affection, marked evidence appears of the absorption of the poison into the system. The patient looks excessively pale, sees objects indistinctly, is sick at the stomach, perhaps ejecting its contents, and has frequent swooning fits, with clammy sweats, and coldness of the body. By and by, as the system be- comes more fully impressed with the deleterious effects, insatiable thirst arises; a sense of constriction is experienced in the chest; the breathing is op- pressed ; the pulse is feeble and vacillating ; great anxiety and restlessness exist; the tendons twitch ; the mind wanders, or is furiously delirious; and death soon closes the scene. In the worst cases of the affection, a universal yellowness of the skin is observed, and the parts are not only frightfully swollen, but, if the patient survive some hours, large vesicles appear upon the surface, containing bloody serum, and indicating the approach of morti- fication. When death does not take place for a considerable number of days, large abscesses form in the cellular substance and among the muscles, and the system gradually sinks under the resulting irritation. The appearances presented in the bodies of those who die from the effects of this poison are pretty uniform. In the birds, rabbits, guinea-pigs, and dogs, experimented upon by Dr. Mitchell, extravasation of blood and soften- ing of the tissues in the neighborhood of the bite were almost invariably observed ; the brain and spinal cord were more or less injected; the heart was distended and flabby ; the lungs were sometimes engorged ; and the in- testines were occasionally ecchymosed. In several instances, the kidneys were filled with blood, and exhibited all the evidences of acute congestion. The ureters and bladder contained sanguineous urine. The blood in the heart and vessels was dissolved, and of a dark color. The genus trigonocephalus includes several species, of which the water moccasin, or cotton-mouth, and the copperhead, are the most important. They have no rattles, but the upper jaw is armed with poisonous fangs, and their bite is said to be very deadly. The cotton-month snake is met with extensively in the Southern States, its northern limit being the Pedee River in North Carolina. Professor Holbrook states that it is the terror of the negroes about the rice plantations, being more dreaded by them than the rattlesnake, which only attacks when irritated, whereas the water moccasin makes war on everything that comes within its reach. Of the genus elaps, the only species, according to Dr. Holbrook, known in this country, is the elaps fulvius, whose body, twenty inches in length, is of a beautiful red color, surrounded with black rings, margined with yellow. Its upper jaw is armed on each side with a permanently erect poisonous fang. It is found chiefly in the Southern States, in sweet-potato fields, and is so gentle in its habits as to be regarded as almost harmless. The most noxious serpent in the East Indies is the cobra di capello, the WOUNDS INFLICTED BY VENOMOUS SERPENTS. 351 spectacled or hooded snake, of which there are a number of varieties, all distinguished for their venomous properties. The effects of its bite .are very similar to those which follow the bite of the rattlesnake, only that they are in general somewhat more tardy, and accompanied by less swelling. The poison is of a semi-transparent, yellowish appearance, not unlike olive oil. It has been known to kill a large dog in less than twenty minutes ; and in the case of the keeper at the Zoological Gardens in London, who was bitten by a cobra on the root of the nose, death occurred in ninety-five minutes. The internal viscera were found, on dissection, to be intensely congested, and the blood, which was dark, alkaline,'and fluid, emitted a peculiarly acid and sickening smell. In Europe, the common viper is the most venomous serpent known. It is uncommon in England, but exists in considerable numbers in France, Spain, and Italy, as well as in several of the more northern States of the Old World. The poison, which has a yellowish oily appearance, may be swallowed almost with impunity, provided there is no abrasion upon the mouth. It is most active in hot weather, killing small birds and animals almost instantly. Ap- plied to the human subject, it causes acute pain and diffuse swelling, followed by a puffy, cedematous state of the subcutaneous cellular substance, and a livid and vesicated condition of the skin. The general symptoms, which seldom manifest themselves under three-quarters of an hour to an hour, bear so close a resemblance to those produced by the wound of the rattlesnake as to render it unnecessary to describe them. A great deal has been written concerning the treatment of wounds inflicted by venomous serpents, and yet it is remarkable that we have not a solitary remedy upon which any reliance can be placed. The fact that so many ar- ticles have been recommended as specifics clearly shows that these lesions are often so slight as not to require any treatment at all, the unpleasant effects generally passing off spontaneously in a few hours, either because the poison has not been introduced in sufficient quantity, or because it has not been sufficiently noxious to produce any serious harm. The first thing to be done, as far as the part is concerned, is to constrict the limb as tightly as possible, a short distance above the wound, which is then to be instantly excised and cupped, the glass being retained as long as the blood is disposed to flow, when the surface should be well washed with the dilute tincture of iodine, the same remedy being thoroughly applied to the skin over the whole extent of the swelling. Subsequently, warm water-dressing, medicated with lauda- num and acetate of lead, will form the most suitable application. The practice of sucking the wound is of great antiquity, and we find that there have been men, from time to time, in different parts of the world, who have made it their special occupation. The Psylli, of" Africa, and the Marsi, of Italy, acquired great celebrity for their skill in this particular branch of business, and the custom still prevails among many of the Indian tribes' of this continent. The operation, however, cannot be performed with safety if there be any abrasion upon the lips or in the mouth, and should therefore always give way to the cupping glass. Professor Brainard, of Chicago, has suggested the practice of injecting a solution of iodine under the skin for the purpose of destroying the poison. The only objection to the procedure is the difficulty of administering the re- medy, such accidents nearly always happening in places remote from the apothecary and the surgeon. Pain must be relieved, and the strength supported by morphine and alco- hol, the latter being given, in any of its more common forms, to the utmost possible extent compatible with the patient's power of endurance. Whiskey seems to be the great remedy among the mountaineers of this country, for this class of wounds, and there can be no question, from what has appeared 352 WOUNDS. in the public prints upon the subject, that it is entitled to great consideration. The treatment should be rapidly pushed to gentle inebriation, though such an occurrence is seldom to be looked for when there is such marked depres- sion of the general system as so often attends this lesion. Ammonia might, perhaps, be advantageously combined with the alcoholic remedies, for there can be no doubt that it must, under such circumstances, be productive of benefit, whether we regard it merely as a stimulant, or as a neutralizer of the poison. When there is excessive prostration, along with great gastric irrita- bility, enemata of brandy and laudanum should be employed. Olive oil has been highly recommended as an antidoteagainst snake bite; but, there is no reason to believe that it possesses any such virtues. In the East Indies, the Tanjore pill formerly enjoyed great celebrity in the treatment of wounds in- oculated with the poison of the cobra di capello and other noxious serpents, its efficacy being supposed to depend upon the arsenic which enters into its composition. Fowler's solution has also been much lauded for its supposed neutralizing qualities, especially of the poison of the fer-de-lance, a venomous serpent in the Island of St. Lucia; it is administered every three hours in doses of two drachms along with a small quantity of laudanum, until active vomiting and purging are induced. But none of these remedies are reliable, and my opinion is that no time should be wasted upon their exhibition. In the former edition of this work attention was directed to the use of Bibron's antidote, as it has been called,—a mixture of bromine, iodide of potassium, and bichloride of mercury—as a means of neutralizing the effects of the poison of the rattlesnake; but it has been ascertained by Dr. Mitchell that it possesses no such properties; nor are arsenic and ammonia, or, indeed, any other known articles of the materia medica, endowed with such virtues. In regard to topical remedies, he found, experimentally, that iodine, injected subcutaneously, exerted a great influence over the local effects of the venom, but none in preserving life or defending the system at large. Some simple astringents also possess this power, and are as useful as iodine itself. Among the internal stimulants, he assigns, in comraon with all American practitioners, the highest position to alcohol, looking upon it, not as a chemical antidote, or neutralizer of the venom, but as a great supporter of the vital powers. When the patient is too weak, or too sick, to swallow, he recommends it to be given as an enema; and he also, in that event, advises the inhalation of hot alcohol, or even of ether, as a means of re-exciting the flagging powers of the system. When the patient has recovered from the immediate effects of the poison, quinine and a nutritious diet will be necessary, along with the spirituous stimulants, to aid restoration. Finally, it may be observed, in regard to the so-called antidotes for snake- bite, that the remedies which have, from time to time, been invested with this virtue, doubtless owed their temporary reputation to the fact that the cases in which they were used were cases of a comparatively slight character, which would probably have recovered as well, or nearly as well, without as with their use. The history of surgery certainly warrants this conclusion. 3. WOUNDS INFLICTED BY RABID ANIMALS. There is a peculiar disease among man and animals known by the name of hydrophobia, its characteristic symptoms, at least in the human subject, being a dread of water, as the term by which it is generally designated literally signifies. It is due to the influence of a particular poison, generated by cer- tain animals, and capable of propagating the disease by inoculation. Of the nature of this poison all we know is that it is contained in the saliva, and that, after having remained latent for some time in the wounded part, it is WOUNDS INFLICTED BY RABID ANIMALS. 353 absorbed and carried into the system, where it produces the peculiar effects by which the malady is distinguished. That the virus of hydrophobia resides in the saliva, or in the saliva and other secretions of the mouth and fauces, is a circumstance which has been fully established by experiments upon inferior animals. Thus, Dr. Zine in- oculated a dog, cat, hare, and cock, with the saliva of a rabid dog, and readily induced the disease. Similar results followed the investigations of Dupuy, Youatt, and other veterinary surgeons. The former of these writers rubbed a sponge wet with the saliva of a mad dog upon the sore of a sheep, which subsequently perished from hydrophobia; and the latter communicated the affection from one brute to another by means simply of a silk thread, impreg- nated with this fluid and used as a seton. While hydrophobia, however, may be readily propagated in this manner, we are ignorant as to the precise source of the poison, whether, although it is contained in the saliva, it is really secreted by the salivary glands, or whether it is derived from the mucous membrane of the mouth and fauces. The former supposition is certainly the more plausible of the two, but the fact could only be verified by taking the fluid directly from one of these organs; an experiment which, so far as I am aware, has never been made. There are certain animals which have the faculty of generating the poison of hydrophobia spontaneously; they belong chiefly, if not exclusively, to the canine tribe, and consist of the dog, wolf, fox, jackall, and badger. The cat is commonly supposed to possess a similar power, but this is still an unsettled question. Man and other animals do not produce the virus spontaneously, but are susceptible of the disease, and, with the exception of man, are pro- bably all capable of propagating it when under its influence. Breschet repeatedly provoked the malady in dogs by inserting the saliva of rabid horses and asses; and several cases have been reported of human beings having suffered from the bite of rabid horses and pigs. It is uncertain whether hydrophobia can be communicated from one person to another. In the case of Mr. Wheeler, a dresser in Guy's Hospital, London, who was bitten by a rabid patient, no ill effects followed, and I know of no well authenticated instance of the disease having been induced in this wise. Rab- bits and similar animals, as well as fowls, soon die from inoculation with this poison, without exhibiting any of the ordinary symptoms of hydrophobia. The inoculation in hydrophobia is usually effected by a tooth, which, how- ever, need not necessarily penetrate the true skin, numerous cases having occurred where the disease was communicated by the slightest scratch, or abrasion. One instance has been reported where death was produced by the licking of a wart upon the face, by a little poodle supposed to be laboring, at the time, under rabies. It is, indeed, not improbable that the disease may be communicated merely by the contact of the saliva of a hydrophobic animal with sound skin and mucous membrane. It is also supposed to be possible that a mother may transmit the affection to her infant through her own milk. Cases now and then occur which lead to the suspicion that the disease may be induced by dogs and other animals not actually mad, but simply enraged; whether this, however, be a fact or not remains to be proved. Finally, ex- periments have been performed which go to show that the morbid saliva may be administered internally with entire impunity. The period of latency of this disease varies from a few weeks to several months. In 89 cases, analyzed by Dr. Blatchford and Dr. Spoor, of Troy, the average period was about seventy days, the minimum in 23 cases was thirty days and under, and the maximum in 6 cases was upwards of two hun- dred days. In the only two cases of hydrophobia that I have ever seen, the disease appeared, in one, at the end of four weeks, and in the other at the end of nine months from the date of the inoculation. According to John vol. i.—23 354 W 0 U N D S. Hunter, the extremes range from thirty days to eighteen months. An Eng- lish writer, Dr. Bardsley, refers to an instance where the disease did not show itself for twelve years, but such a statement must be received with great allowance. The period is generally considerably shorter in animals than in man, and in very young persons than in adults. Although a considerable period always elapses between the inoculation and the appearance of hydrophobic symptoms, yet it is extremely probable that the virus is speedily absorbed into the system, though some time is necessary to develop its zymotic properties. What countenances this view of the subject is that nearly all the other known poisons, when brought in contact with the living tissues, are promptly absorbed, so as to make, sooner or later, their peculiar impression upon the constitution. The poison of the rattlesnake is taken up almost instantaneously, and the probability is that the same is true with respect to the poison of smallpox, measles, scarlatina, and other zymotic affections. A certain period, however, is necessary, in every case, to enable the poison to explode upon the general system, or, in other words, to multiply itself, and extend its influence. With regard to the virus of rabies, it is certain that the disease is often developed within the usual period, after the most prompt and complete excision of the bitten parts. Many persons are bitten by rabid animals who yet never contract the dis- ease, the virus having either been exhausted before the rencontre takes place, or, what is more probable, having been wiped off by the clothes in the act of inflicting the wound. In this way more than half of those bitten occasionally escape with impunity; but, on the other hand, it sometimes happens that nearly every one is effectually inoculated. It is not impossible that idiosyn- crasy may exert an important influence in the production of the disease. It is well known that this is true of other zymotic poisons, and it is therefore reasonable to suppose that it may also hold good of this. Out of fifty dogs that had been inoculated by Dr. Hertwich, of Berlin, with saliva taken from a rabid animal of the same species, not one in five was infected. Hydrophobia occurs at all ages. It has been observed in infants at the breast, in children, and at every period of adult life. In the Transactions of the American Philosophical Society are the particulars of a case in a man of seventy-three. Women are equally as subject to the disease as men, and, if they suffer less frequently from it than they do, it is simply because they are less exposed to the attacks of rabid animals. It prevails in all countries, in all climates, and at all seasons of the year. Northern Europe, however, has furnished a greater number of cases than perhaps any other part of the world. It is also frequent in England; and, as a general rule, it is more common in northern than southern regions. Throughout the West Indies it is compara- tively rare, although the number of dogs there is unusually great as compared with the number of inhabitants. Hydrophobia is more common in Canada and y.ew England than in the Southern States of the Union. The symptoms of rabies necessarily divide themselves into local and con- stitutional ; or those furnished by the wounded part, and those afforded by the system, after the absorption of the specific virus. The wound inflicted by a rabid animal generally heals as kindly as any similar wound made by a sound animal; the scar, perhaps, remaining a little red and tender, as it usually does after an ordinary bite, but exhibiting no other peculiarity, and the system being perfectly free from disease. By and by, however, when the period of incubation is about to draw to a close, the part begins to itch, burn, or smart, and soon becomes sore and irritable, hot, numb, or rigid, pain darting through it in different directions, and sometimes extending to a considerable distance beyond the site of injury, as from the hand up to the shoulder, or from the foot to the knee or groin. Sometimes a red line can be traced in the direction of the lymphatics. Occasionally, WOUNDS INFLICTED BY RABID ANIMALS. 355 though rarely, the cicatrice has been known to open afresh. Almost simul- taneously with the local affection evidence of general indisposition appears. The patient feels unwell; his head aches; his sleep is disturbed by unpleasant dreams; he feels melancholy and depressed; and he has occasional attacks of chilliness, with a highly impressible state of the system. The poison is now fairly at work, and in a few hours—generally from ten to twenty-four— explodes with frightful violence. The period of latency is passed ; the dis- ease has reached its second stage; the dread of water and the difficulty of deglutition have declared themselves; in a word, hydrophobia is fully esta- blished. The patient, on attempting to drink, is suddenly seized with spasm in the throat, and finds that he is unable to swallow a particle of fluid; he tries and tries, but every effort is only succeeded by a renewal of suffering, and presently he dashes away the cup as if it were charged with some deadly poison, unwilling again to bring it to his lip. Tortured with thirst and a sense of dryness of the mouth, he will rather endure his discomfort than sub- ject himself to the dreaded spasm. Should he succeed in forcing down a little water, he will be instantly seized with suffocative cough, convulsive tremors, and lividity of the face, compelling him to jump up in bed, and to pant for breath. The painful sensations are usually referred to the throat, and are often accompanied by a feeling of constriction in the chest, difficulty of respiration, a disposition to sigh, and a frequent desire to clear the mouth and fauces, which soon become clogged with an inordinate secretion of thick, viscid saliva and mucus, which greatly aggravate the patient's suffering. At this stage of the disease, and generally, indeed, before it has reached this point, there is superadded to the previous distress a remarkable susceptibility to atmospheric impressions, the slightest contact of cold air being a source of profound torture, producing a sense of suffocation, and even violent con- vulsions. The agony thus occasioned is sometimes much greater than that caused by the attempt to swallow fluids. The least opening of a door, the slightest motion of a fan, or even the smallest whiff of air directed from the attendant's mouth upon the body, instantly brings on a paroxysm of this kind. Light and noise too are always offensive ; and hence the patient usually insists upon his room being kept dark, quiet, and closed. The mind, at this stage, is peevish and fretful; and nothing that can be done can please the sufferer, who, in consequence, often quarrels with his best friends. At times his imagination is completely perverted ; he fancies that he hears noises and sees objects that have no real existence ; he gets out of bed, walks about the room, screams, or gesticulates, very much like one affected with delirium tremens. In the last stage, which is characterized by an aggravation of all the pre- vious symptoms, the countenance has a haggard and distressed appearance, horror and anxiety being depicted on every feature; the eyes have a wild and glaring expression ; the tongue is perfectly dry and parched; the strength is much impaired ; the voice is hoarse and shrill, almost like that of a dog; the respiration is short and panting ; more or less delirium is present, often amounting to complete mania; and the pulse, small and feeble, beats from one hundred and thirty to one hundred and sixty in the minute. Thus the disease progresses, paroxysm after paroxysm recurring until the frame is worn out by exhaustion, death usually taking place suddenly in a fit of suffo- cation. Occasionally a slight calm is experienced a few hours before the fatal event; the spasms almost completely subside, the power of swallowing returns, the mind becomes clear, and the patient, perhaps, sinks into a tran- quil sleep. The duration of the attack varies from eighteen hours to a week, the average being about three days. In a case of hydrophobia which I attended in 1842, the patient, a young man of about twenty-one years of age, was attacked precisely four weeks 356 WOUNDS. after having been bitten in the left hand by a rabid dog. When I was called in, the disease was in its second stage, well-marked symptoms having ap- peared the previous day. The difficulty of swallowing and the morbid sensi- bility of the skin were" present in a high degree. Every effort at drinking, nay, the very mention of fluid of any kind, and the attempt to raise the glass to the lip, caused violent convulsions ; the countenance was flushed and tumid; the eyes red and suffused; the mouth parched; the throat stopped with viscid mucus; the pulse frequent and rather strong; the respiration hurried; the thirst and restlessness intense; the mind exceedingly peevish and irritable; and the sensibility of the skin so exalted that the slightest approach of a current of air, inappreciable by any one else, produced the most horrible torture. The inability to bear light and noise was also very great. The hand felt numb and painful, though the wound had not reopened. These symptoms gradually progressed, increasing steadily in severity, until towards the end of the third day from the attack, when the young man expired in a state of complete exhaustion. The pulse, during the latter stage of the malady, was exceedingly irregular, and upwards of one hundred and fifty in the minute; the breathing was short and panting; and the mind was excessively agitated and distressed, but clear and intelligent, except when the patient was on the verge of a convulsion. The voice was not materially affected. It is impossible to mistake hydrophobia for any other disease. The dread of water, the difficulty of deglutition, and the dread of cold air, are always sufficiently diagnostic of the affection, even when no history of it can be obtained. The dissection of persons dead of this disease has thrown no real light upon its seat and pathology. In the case of a young man of twenty-four, who died in 1840, nine months after he had been bitten on the hand, and whose body I assisted in examining, no lesion whatever could be detected, by the closest scrutiny, anywhere. The mouth, fauces, pharynx, and oeso- phagus, the larynx, trachea, and bronchial tubes, where disease might natu- rally be supposed to exist, under such circumstances, were perfectly free from morbid appearances. The brain and spinal cord, the lungs, stomach, bowels, and other viscera, were in as natural a condition as I ever saw them in any case. Occasionally, especially in protracted instances, the membranes of the brain have been found congested, and the ventricles partially filled with serum. The stomach, oesophagus, and pharynx have also been found in- flamed ; and several dissections are mentioned where pus was discovered in some of the larger joints. Very little reliance, however, it seems to me, should be placed upon the statements that have been published upon the subject, especially when we consider the loose manner in which most of them are drawn up, and the fact that comparatively few men are competent to make accurate dissections of dead bodies. The prognosis of hydrophobia is always bad, the disease invariably ending fatally. If there is a case of recovery, of a reliable character, upon record, I am not aware of it. I know that a number of instances have been published in which the patient is said to have gotten well, but there is not a single one, so far as I am acquainted with them, that can withstand the test of scientific scrutiny. The period at which death occurs is, in general, very short. The average in 72 cases, analyzed by Dr. Blatchford and Dr. Spoor, was three days. In 120 cases, analyzed by Dr. J. L. Smith, of New York, 65 perished in from one to two days. In some instances, the disease proves fatal during the first twenty-four hours, while in others this event does not happen until the tenth day, although when postponed so late it necessarily creates some doubt in regard to the true nature of the case. WOUNDS INFLICTED BY RABID ANIMALS. 357 In the treatment of this variety of poisoned wound, reliance must be placed solely upon preventive measures ; for, as has just been seen, when the disease is once developed, there is no possible chance of doing anything more than mitigating the suffering, and even that only in a slight degree. If, as I have supposed, it be true that the poison is speedily absorbed after being brought into contact with the living tissues, the importance of promptly dislodging it cannot be too forcibly impressed upon the attention of the practitioner. As soon, therefore, as such a case is presented to his notice, the injured part should be thoroughly excised, care being taken to embrace a portion of the sound tissues. The flow of blood is then to be encouraged with a cupping glass, retained for some time, when the raw surface is well cleansed, and im- mediately cauterized with nitrate of silver. If the teeth of the rabid animal have penetrated between two bones, as, for example, when the bite has been inflicted upon the hand, excision must be performed with increased care, otherwise a portion of virus will be almost sure to be left behind. In such a case it might become a nice question to determine whether the operation should not be made to include a portion of the bones also ; for almost any local sacrifice is justifiable to secure immunity from so horrible a disease. It would seem from the observations of Mr. Youatt and Mr. Blane, two eminent veterinary surgeons, that there is no remedy which so certainly neutralizes this poison as nitrate of silver. The former of these writers, whose opinion is entitled to the greatest respect, on account of his large experience in the treatraent of canine madness, has repeatedly employed this article, under these circumstances, in his own case, and such is his confidence in its virtues that he regards it in the light of a specific. His plan is to cleanse the parts well in the first instance with soap and water, and then to use the caustic most thoroughly, previously enlarging the wound, if necessary. If I were so un- fortunate as to receive such an injury upon my own person, I should certainly feel more confidence in my escape, if the wounded parts had been excised and cupped prior to the cauterization. Excision should also be practised when the injured part has been neglected, or imperfectly removed in the first instance, it being well known that the individual may escape the constitutional effects of the disease even after the wound has partially reopened. But even if there were no reasonable hope of preventing the occurrence of the disease by this procedure, it should, never- theless, be practised, if for no other reason than that it will have a soothing effect upon the mind of the poor sufferer. Everything calculated to allay his fears and contribute to his happiness is justifiable under such trying circum- stances. If the symptoms of hydrophobia, however, are already developed, neither such an operation, nor even the amputation of the limb above the site of injury, will be of any service. When the poison has reached the system, and has evinced its explosive effects, no treatment, however judiciously and perseveringly conducted, can be of any avail as a curative agent. The experience of two thousand five hundred years fully attests the truth of this statement. There is hardly an article of the materia medica, potent or impotent, vegetable or mineral, that has not been used, singly or combinedly, for the cure of this disease, and yet, as was mentioned in a previous paragraph, there is not one solitary instance, of a reliable kind, upon record, where any beneficial result followed its exhi- bition. I need not, therefore, recount the various methods of treatment spoken of by authors, as this would only be a waste of time and space. Nor shall I say anything of internal prophylactics, experience having shown that there are no such remedies in hydrophobia. To relieve the frightful suffering from the disease, chloroform and ether, either alone, or variously combined with each other; morphia in large quan- tities in the form of enemas; the application of steam conveyed to the 358 WOUNDS. patient's body as he lies in bed; and the exclusion of cold air, noise, and light from the apartment, constitute the most reliable means. General bleeding, the hot bath, and tartar emetic, so much vaunted by some, will only, as a general rule, expedite the fatal issue, without affording any decided mitigation of the suffering. Opium is of no use, even if given in enormous quantity, as the stomach does not appear, in this disease, to have the power of dissolving it. If anodynes are exhibited at all internally, they should be used in the form of morphia, laudanum, or black drop. Dr. Physick, with a view of relieving the difficulty of breathing, and preventing suffocation, advised laryngotomy, but I am not aware that it has ever been practised, or, if practised, that it has ever done any good. It certainly could not cure the disease, and it admits of doubt whether it would even moderate the spasm. Hydrophobia in the Dog.—In concluding the subject of hydrophobia, a few words may be said respecting the character of this disease as it occurs in the dog, as it is important for the practitioner to be able to judge of the pro- bability of his having been mad in the event of his having bitten a human being. How the disease originates in the dog, one of the animals in which it is generated spontaneously, is not ascertained. It has been supposed that sexual abstinence, the use of filthy and unwholesome food, too close confine- ment, and extremes of heat and cold, constituted so many causes of the malady ; but it is obvious that, although this may be true, yet our know- ledge at preseut amounts to nothing but conjecture, which further and more carefully conducted observation alone can either verify or disprove. The average period of incubation is about forty days, the minimum being a fort- night, and the maximum three months and a half. The early symptoms of rabies in the dog are thus graphically described by Mr. Youatt: "In the greater number of cases," he remarks, "there are sul- lenness, fidgetiness, and continual shifting of posture. When I have had opportunity, I have generally found these circumstances in succession. For several successive hours perhaps he retreats to his basket or his bed. He shows no disposition to bite, and he answers the call upon him laggardly. He is curled up, and his face is buried between his paws and bis breast. At length he begins to be fidgety. He searches out new resting-places; but he very soon changes them for others. He takes again to his own bed; but he is continually shifting his posture. He begins to gaze strangely about him as he lies on his bed. His countenance is clouded and suspicious. He comes to one and another of the family, and he fixes on them a steadfast gaze as if he would read their very thoughts. ' I feel strangely ill,' he seems to say : ' have you anything to do with it ? or you ? or you ?' Has not a dog mind enough for this ? If we have observed a rabid dog at the commencement of the disease, we have seen this to the very life." Delirium is an early and characteristic symptom ; the dog sees imaginary objects, and often springs at them with a furious dart; he is restless and excessively irritable, gazing wildly around, and snapping at everything within his reach. The saliva is secreted profusely, and collecting at the corners of the mouth, the animal makes frequent attempts to detach it with his paws ; his appetite is strangely perverted, and he will sometimes greedily devour horse-dung, or even his own excrements ; the voice is changed in its character, being generally hoarse, and more or less shrill: the eyes are singularly bright; and the thirst is intense and insatiable, the dog drinking frequently, and having no fear whatever of water, as is the case with the human subject. The disease is now in full force, and tending rapidly to a fatal issue. The muscular powers being greatly exhausted, the animal finds it difficult to sus- tain himself upon his limbs; he reels and staggers about like a man in a drunken fit; his tail is depressed, and the tongue protruded ; the eyes have GLANDERS, FARCY, OR EQUINIA. 359 lost their brightness, and are of a dull, glassy appearance; the respiration is hurried and panting; finally, worn out by his suffering, the poor creature dies, either from convulsions, or from sheer exhaustion, the duration of the attack varying from three to five days. The power of communicating the infection exists, according to Youatt, in all the confirmed stages of the dis- ease, and continues even for twenty-four hours after the death of the animal. 4. GLANDERS, FARCY, OR EQUINIA. The horse, ass, and mule are capable of spontaneously generating a disease, which, although it affects the whole system, expends itself with peculiar force and virulence upon the mucous membrane of the nose, causing violent inflam- mation and a copious discharge of thick, fetid matter. It is accompanied by a pustular eruption of the skin ; and the name by which it is generally known is glanders, from the fact that it is always associated with disease of the maxillary glands and of the lymphatic ganglions of the ear and neck. There is a form of the affection which is characterized by the development of small tumors beneath the skin in different parts of the body, varying from the size of a pea up to that of a hazelnut, of a spherical shape, very hard, almost immovable, and generally exquisitely painful to the touch. When very numer- ous, they give the surface a remarkably tuberculated appearance. To this disease the terra farcy is commonly applied; and an attempt has been made by several writers to establish for it a distinctive character. Others, on the contrary, assert that it is identical with glanders, differing from it only in its location, or in the character of the structures in which it appears. This view of the case derives confirmation from the fact that the two affections often coexist, which would hardly happen if they did not possess a strong natural affinity for each other. It has been observed that the animals in which this disease arises spontane- ously are generally half-starved, over-worked, and of broken constitution. Whatever, however, the cause may be by which the affection is originally engendered, it is certain that it is both contagious and infections, and that the strongest and most healthy animals will often speedily contract it when exposed to its influence; confinement in damp and ill-ventilated stables, especially if underground, powerfully predisposing to its occurrence. It was at one time thought questionable whether the disease could be propa- gated by atmospheric agency; but multiplied observation long ago fully settled that point. It would seem, indeed, that the air of an infected stable, after all the wood work, pavement, and plastering have been completely re- placed, and every possible precaution used in regard to cleanliness, is capable of reproducing the disease in all its former severity. The fact that glanders may occur in the human subject was first enunciated by Mr. Muscroft, in the Edinburgh Medical and Surgical Journal, in 1821. The case which he therein reports was that of a man who had accidentally inoculated his hand in cutting up for the kennel a horse that had died of this disease; violent symptoms soon showed themselves, and he expired in great agony at the end of a week. Since that time a number of similar examples have been recorded by other observers, thus indisputably establishing the transmissibility of glanders from animals to the human subject. As yet no facts had occurred proving that the affection might be communicated from one human being to another, or from man to beasts. In 1840, however, a case of this kind took place at St. Bartholomew's Hospital, London, which conclusively settled the question. The patient, a knacker, died of glanders, and the nurse who attended him took the disease and also perished from it. These facts regarding the transmissibility of glanders from animals to man, from man to man, and finally from man to beast, are of great pathological 360 WOUNDS. interest, and serve to inculcate the indispensable necessity of caution on the part of the professional attendants and nurses in their intercourse with indi- viduals laboring under this horrible disease ; since the smallest particle of the specific virus coming in contact with an abraded surface, or even the mere inhalation of the infected air of the patient's apartments, may give rise to the malady. In the equine tribes of animals, glanders raay be propagated by inoculation with the pus and mucus of the pituitary membrane, the fluids being inserted under the skin with a lancet, or rubbed upon the greasy heel of the horse. It may also be produced by applying these secretions to the mucous lining of the nose ; and a curious case has been reported of its having been caused by introducing balls of farcied matter into the stomach. An experiment performed by Mr. Coleman, the distinguished veterinarian, shows that the blood of a glandered animal transfused into the carotid artery of a sound one, will rapidly engender the malady in its most virulent form. The period of latency of this disease is generally very short, rarely exceed- ing two or three days. It is probably a little longer in the human subject than in animals, but the difference, if any, is very slight. It has already been seen that the first case that ever occurred, so far as is ascertained, in the human subject, terminated fatally at the end of a week from the time of the inoculation. The first local evidence of the disease is generally some swell- ing and tenderness of the maxillary glands and inflammation of the mucous membrane of the nose; sometimes the one, and at other times the other, taking precedence. The symptoms of glanders naturally divide themselves into constitutional and local. Shortly after the inoculation has taken place, the patient begins to feel unwell; his head, back, and limbs ache ; chilly sensations, alter- nating with flushes of heat, creep over his body ; sleep and appetite are im- paired ; the strength sensibly diminishes; the joints are stiff and sore; the spirits are depressed ; the stomach is irritable ; and the bowels are costive. After the lapse of thirty-six to forty-eight hours, sooner or later, a severe and protracted rigor generally occurs, followed by violent fever and profuse perspiration ; an evidence that the stage of incubation is passed, and that the poison has gained full admission into the system. The symptoms now rapidly assume a typhoid character. The pulse becomes quick, frequent, and tremulous ; the tongue is dry and brownish ; sordes accumulate upon the gums and teeth ; the voice is weak and often husky ; the respiration is short, panting, and accompanied by a sense of constriction across the chest; the surface is bathed with fetid, clammy perspiration ; the thirst and jactitation are excessive; the urine is scanty and high colored; the alvine evacuations are slimy and excessively offensive; the mind wanders; and the pains are atrocious. Coincident with these phenomena are marks of serious disease of the mucous membrane of the nose, which is highly inflamed, and the seat of a copious, viscid, and irritating discharge. Excessive pain and soreness exist in the forehead, over the frontal sinuses, evidently from an extension of the inflammation to the lining membrane of those cavities; and for the same reason there is generally great uneasiness in the throat and larynx. The nose and cheeks soon become hot, swollen, purple, excoriated, and exquisitely painful; the discharge from the nostrils assumes a bloody, purulent char- acter, and is both copious and disgustingly offensive ; the eyelids are infiltrated and nearly closed ; and the features are hideously disfigured. About the tenth or twelfth day hard pustules make their appearance on various parts of the body, especially on the trunk, face, genital organs, and inside of the limbs, resembling those of smallpox, and attended with profuse fetid sweats. Occasionally they are accompanied by black bullae, which, breaking, discharge a thin, sanious fluid, and bring into view gangrenous spots, varying from the GLANDERS, FARCY, OR EQUINIA. 361 size of a three cent piece to that of a quarter of a dollar. In some cases, again, numerous tubercles appear in different situations, interspersed among the pustules, or pustules and vesicles ; they are generally small, of a roundish shape, hard, and exceedingly painful; as the disease proceeds, they give way on the surface, and exude a thin, ichorous fluid. The lymphatic ganglions of the groin, axilla, and other regions, frequently participate in the disease, becoming enlarged, tender, and painful; the lungs are also apt to suffer, and, indeed, it is not uncommon to see serious involvement of various viscera. As the disease progresses, the prostration rapidly increases; the fever displays a more malignant character ; deep coma supervenes ; and the body exhales a horribly offensive odor, almost characteristic of the disease, and strongly denotive of the dissolved state of the blood and the putrescent nature of the secretions. The period at which death occurs varies from eight or ten days to four or five weeks. In a majority of the reported cases, the disease terminated fatally before the eighteenth day; some of the patients died as early as the end of the first week, while a few lived until after the fiftieth day. When glanders pursues this rapid course it is said to be acute, and chronic when it is more tardy. In the former case, the local symptoms usually pre- cede the general, frequently setting in within a few hours after the absorption of the virus. The inoculated part becomes red and tender, and the epidermis is soon elevated into a vesicle, or pustule, from which the inflammation rapidly extends along the lymphatic vessels as high generally as the glands of the groin or axilla. The swelling is excessive ; the limb is stiff and numb; and the areolar tissue, infiltrated with sero-albuminous exudation, before long becomes the seat of numerous abscesses. In the more severe cases, black spots appear upon the surface, indicative of the existence of gangrene. Sometimes the local disease begins in the lymphatic ganglions of the groin or axilla, from which it spreads over the corresponding side of the trunk and even over the whole limb. In contemplating the progress of this disease ; it is impossible not to be struck with the resemblance it bears to that of a dissection wound. It evi- dently belongs to the hemotoxic class of affections, consisting essentially in a disorganized condition of the blood and solids, paralyzing and crippling the heart and brain, and thus bringing about that typhoid condition of the system which forms so prominent a feature of the complaint. Dissection always discloses the existence of serious lesions in the nose and internal organs. The pituitary membrane, of a deep purple or livid hue, is coated with tough, viscid secretions, studded with tubercles, ulcerated at some points, and gangrenous at others; the nose is occasionally nearly eaten away; and large cavities generally exist upon the cheeks. The frontal sinuses, larynx, and bronchial tubes are livid and excessively congested; and the lungs often contain abscesses, occupied by ill elaborated matter, looking more like aplastic lymph than genuine pus. The heart is commonly softened. The mucous coat of the stomach and bowels is diminished in consistence, discolored, and sometimes studded with minute tubercles, similar to those observed in the nose. The pustules which exist beneath the skin and in the cellular tissue among the muscles, bear a great resemblance, in the nature of their contents, to metastatic or multiple abscesses; they contain no real pus, at least not in their earlier stages, but a dense, solid fibrinous matter, strik- ingly like that so generally found in pyemia and other forms of blood-poison- ing. The diagnosis of glanders is, in general, sufficiently easy. An inexperienced practitioner, deceived by the aching pains and soreness of the joints and limbs, might possibly mistake it in its earlier stages for rheumatism ; but the occurrence of secondary symptoms would soon dispel the illusion. From 362 WOUNDS. the effects of a dissection wound it may be readily distinguished by the pecu- liar discharges from the nose, and by the character of the cutaneous eruption. The history of the case, too, will furnish important diagnostic data, and should therefore always receive due consideration. The fact that the patient has nursed or examined a glandered horse or person, will generally of itself afford strong presumptive proof of the true character of the attack. In the latter stages of the disease, the nasal discharges, the existence of pustules, abscesses, and gangrenous spots, and the horribly fetid exhalations from the body, are signs which it is impossible to mistake. The character of the prognosis in this disease may be gathered, in great measure, from what precedes. The acute form of the disease is nearly always fatal. Of fifteen cases, collected by Rayer, one only recovered. The danger in chronic glanders, on the other hand, is much less. Thus, of ten cases, mentioned by the same writer, seven recovered and three died. The treatment of this affection is preventive and curative. The former con- sists in the adoption of proper measures for destroying the poison as speedily as possible after the inoculation. With this view the affected or abraded surface should be freely washed by holding it for a considerable length of time under a concentrated stream of water, and then thoroughly cauterized with acid nitrate of mercury, or some other active escharotic, or, what is better, effectually excised. If the operation be impracticable, and the wound is of a punctured nature, it should at once be enlarged, and then brought fully under the influence of some caustic, otherwise a portion of the poison lurking deep in the wound may escape its contact, and thus be absorbed into the system. If a person is known to have died of glanders, the safest plan for the practitioner is to avoid a post-mortem examination, especially if there are any abrasions, however slight, upon his hand and fingers. The curative treatment, if it deserve such a name, has hitherto been entirely unavailing. Bleeding, both local and general, purgatives, tonics, and stimu- lants, have proved alike useless. Obviously our chief reliance must be upon the employment of supporting measures, especially quinine, carbonate of ammonia, tincture of the chloride of iron, and brandy, given in large and frequently repeated doses, in combination with liberal quantities of morphine, with a view both of allaying pain and controlling gastric irritability. Infil- trated fluids and abscesses should be promptly evacuated, and the affected parts wrapped up in flannel wrung out of saturnine and anodyne lotions. The nose should be frequently injected with tepid water impregnated with creasote, or tannate of iron; liquid chlorinated soda should be freely sprinkled upon the body and bedclothes ; the apartment should be constantly ventilated ; and the utmost attention should be paid to cleanliness. To these means should be added, in chronic cases, change of air, or residence near the sea-coast. 5. WOUNDS INOCULATED WITH A PECULIAR SEPTIC POISON GENERATED IN DEAD ANIMAL BODIES. a.—Dissection Wounds. Wounds contracted in the examination of dead human bodies are named dissection wounds, and are deserving of special attention from the severe effects they are capable of producing. These injuries generally occur in the form of punctures, abrasions, or slight incisions, and would, in general, be altogether unimportant if it were not for the fact that they are often inocu- lated with a peculiar poison, septic in its character, and therefore liable, if absorbed, to contaminate both the part and system. The instruments with which they are usually made are the scalpel, tenaculum, and needle, especially DISSECTION WOUNDS. 363 the latter, as it is very apt to prick the fingers in sewing up dead bodies. Not unfrequently the inoculation is effected through the medium of a pre- existing abrasion, or scratch, of the presence of which the person may, at the time, be perfectly unconscious. Of the nature of the poison which produces these severe effects nothing whatever is known. It is supposed that it is generated a short time before death, during the act of dying, or soon after dissolution, and that it is de- pendent for its development upon a vitiated state of the blood, though that state has not been pointed out. The idea is certainly plausible, supported as it is by the circumstance that the poison is generally most virulent when it is communicated by persons dead of puerperal fever, erysipelas, carbuncle, pyemia, carcinoma of the liver, and other kindred affections. Once formed, it becomes, like the virus of chancre, independent of the source whence it was derived. A good illustration of this fact was afforded me, a few years ago, in the person of a young cutler, who, in sharpening a case of dissecting instruments for me, which had not been used for nearly five months, slightly pricked one of his fingers. The consequence was that the hand and arm soon became exceedingly painful, as well as a good deal swollen, a charac- teristic red line extending up as high as the axilla, the glands of which were also in a short time involved in the disease. Nearly a month elapsed before he recovered from the immediate effects of his injury. A prick of the finger received in cleaning bones has sometimes been followed by severe suffering, and even loss of life. It is generally supposed that fresh bodies are more liable to convey the poison than such as have been kept for some time. This, however, is not always true; for in a subject which had been on hand for nearly a month, and which I dissected, in 1827, with Dr. Temple, of Virginia, that gentleman came very near losing his life from a little puncture which he received at the end of that time. It is worthy of remark that the body was that of an old female, who had perished from the effects of tertiary syphilis, as was apparent from the extensive disease of the skull and other portions of the skeleton, and that the attack of my friend was one of extraordinary severity. Violent effects sometimes follow the dressing of wounds, in consequence of the contact of foul and irritating discharges, and several instances are upon record where surgeons have lost their lives from this cause. Similar results occasionally occur during the removal of cancerous growths, from inoculation with the secretions of the affected structures. The health of Professor Dud- ley, of Lexington, suffered seriously for several years from the inoculation of the hand with the matter of an encephaloid tumor during the amputation of an arm, performed for the purpose of getting rid of the disease. Dr. Physick met with a case where death occurred from the effects of a slight scratch with the shell of an oyster, received in the act of opening the animal. The period of latency of this poison is usually very brief, or, more properly speaking, only a short time elapses before the occurrence of well-marked symptoms ; for it is extremely probable that it begins its peculiar operation upon the inoculated structures almost immediately after its introduction, although its explosive effects may not manifest themselves nearly so soon. Generally they do not come on before the end of the second day, or the commencement of the third. In one case—the most remarkable, in this respect, on record—the symptoms were quite severe within the first twelve hours, and the patient died in forty hours from the receipt of the wound. In the case of Dr. Temple, above alluded to, violent indisposition ensued in less than thirty-five hours from the time he pricked his thumb. The accident happened late on a Saturday night, and on the following Monday morning, on his way to the college, he was taken so ill that he was obliged immedi- ately to return to his room, which he did not leave again for nearly two 364 WOUNDS. months. In the case of young Kissara, a medical student of ^Sew York, related by the late Dr. Godman, violent symptoms supervened in less than fifteen hours, although death did not occur until the fifth day. On the other hand, the patient occasionally remains free from suffering for a comparatively long period, as in the instance of Mr. Newby, an English surgeon, who punctured himself in opening the body of a child dead of enteritis, where no serious inconvenience was experienced until the commencement of the fourth day. There is no question that some persons are peculiarly prone to suffer from this poison. I am acquainted with a physician who was formerly much engaged in pathological researches, who rarely opened a dead body without having a dissection boil upon his hand, thumb, or finger. Occasionally the consequences were more serious, the disease extending up the arm, along the course of the absorbents, as high as the axilla. Disordered health, hard study, general debility, mental anxiety, and other causes, no doubt, power- fully predispose to the development of the disease. A student who has for weeks inhaled the foul atmosphere of the dissecting-room, taken little exer- cise, and sat up late at night, eating, perhaps, withal, very heartily, will be much more likely to contract the disease, and to suffer severely, if he wound himself, than one who has taken better care of himself. Symptoms.—The usual point of departure of this disease is the inoculated part, from which it rapidly spreads in every direction. A smarting, stinging, or burning sensation is generally the first circumstance which attracts atten- tion. Upon looking at the part, it is found to be covered with a little whitish vesicle, perhaps hardly the size of an ordinary pin's head, filled with serum, and resting upon a hard, reddish base, extremely sensitive on pressure. When this vesicle breaks, as it usually does in twenty-four hours, a small ulcer is exposed, having a foul base, and discharging a thin, sanious fluid. The pain by this time is generally very distressing, burning, and pulsatile, depriving the patient of appetite and sleep ; the sore enlarges ; the swelling augments; and the surface feels exceedingly hot, tense, heavy, and numb. Generally a red line is seen extending from the seat of the inoculation along the arm to the axilla, marking the course of one of the absorbent vessels. As the poisonous influence spreads, the whole limb becomes enormously enlarged, pitting on pressure, and exhibiting a dusky, erysipelatous appear- ance. With this increase of swelling there is a proportionate increase of pain, which now amounts to torture ; the limb feels like a mass of lead, and is completely deprived of the power of motion. In bad cases the inflamma- tion extends to the top of the shoulder, the axilla, and even to the corres- ponding side of the trunk. Such is the ordinary course of the disease ; but cases occur where the order of the symptoms is reversed, the poison exploding in the axilla, and thence extending up the neck and down the side, the arm being, perhaps, almost free from inflammation, and there being no appearance, or only a very slight appearance, of disease at the seat of inoculation. The swelling, which sometimes reaches as low as the crest of the ilium, is, at first, of a doughy character, and of a pale pinkish hue; but it soon becomes hard, and assumes the peculiar erysipelatous blush already described as belonging to the more common variety. The pain is generally exquisite from the beginning, and is sometimes of itself sufficient to crush the system, before sufficient time has elapsed for the formation of the characteristic pustule. Such cases, which are always fraught with danger, have been known to terminate fatally in a few days. It is not every case of inoculated dissection wound that gives rise to gene- ral symptoms; on the contrary, in the great majority of instances, the affection is altogether of a local character, being confined to the immediate neighbor- DISSECTION WOUNDS. 365 hood of the original injury, diffused over the hand and wrist, or, it may be, limited to a few absorbent vessels, as seen by the red lines extending up the limb. Under such circumstances the patient may feel a little unwell, have some headache, and want of appetite, or suffer from chilliness and aching of the limbs, but there will be no serious disturbance of the general health. This will, however, be sure to occur, if the virus has gained full admission into the system, the symptoms showing themselves, on an average, in from twelve to twenty-four hours. The patient, at first, has merely a feeling of depression, or faintness, with a sense of chilliness, pain in the head, and slight derangement of the digestive organs. This prodroma is speedily succeeded by violent rigors, alternating with flushes of heat, nausea and vomiting, ex- cessive restlessness, intense thirst, an increase of cephalalgia, a haggard, wo- begone state of the countenance, and indescribable despondency. The tongue is coated, the respiration hurried, the skin dry and hot, and the pulse sharp and frequent, but feeble. The bowels are either constipated, or, as more fre- quently happens, harassed with diarrhoea. The disease, in its worst forms, soon reaches its crisis, the system rapidly falling into a typhoid state. During this downward course the symptoms above described become more and more marked; the tongue dry and brown; the pulse quick and tremulous; the countenance sallow and withered; the skin yellow and covered with clammy sweat; and the suffering indescribably severe. Delirium always sets in at an early period, and is a prominent symp- tom throughout. Death occurs in a few days to a few weeks, according as there is overwhelming exhaustion, or depression from gangrene and metastatic abscesses. The appearances discovered on dissection are variable. When the case has run its course very rapidly, the internal organs may, apparently, be entirely free from disease, or there may be evidence of slight effusion into the chest, with an engorged condition of the lungs, the affected structures themselves being somewhat infiltrated with serum and lymph. Under opposite circum- stances, there will generally be marks of inflammation of the arachnoid mem- brane, of the pleura, lungs, and peritoneum, with, perhaps, deposits of pus in the larger joints, among the muscles, and in the subcutaneous cellular tissue. The parts more immediately involved in the morbid action will be found to be enormously distended with the ordinary products of inflammation, highly softened at some points and greatly indurated at others, with here and there an. abscess, and, perhaps, a gangrenous spot. The prognosis of this affection may be deduced, in some degree, from the preceding remarks. When the disease is strictly local, much suffering may be the consequence, but ultimate recovery will be certain, the part imme- diately affected becoming, perhaps, withered and completely useless, as often happens when the lesion is seated in a finger. In the very worst cases death raay occur in less than forty-eight hours, from the empoisoned condition ap- parently of the nervous system, with little or no evidence whatever of local disease. In another class of cases, also very bad, the patient may live five or six days, and then perish from the violence of the resulting inflammation; or he may linger on for weeks and months, abscess after abscess forming in the limb, on the side, or in other regions of the body, and finally die from constitutional irritation; or, lastly, he may, after having been for a long time on the very brink of the grave, struggle through the disease, and in the end make a good recovery, or he may remain permanently weak, and crippled in some internal organ. Some persons are a long while in recovering from apparently very trifling accidents of this kind, depending either upon some idiosyncrasy, or upon some derangement of the general health. I myself formerly suffered a great deal in this way. On one occasion my thurab, which had been accidentally 366 WOUNDS. pricked in examining the body of a woman dead of phthisis, remained sore for fifteen months; and a former colleague of mine, Professor Rogers, of Louisville, once had an affection of this kind upon one of his fingers which troubled him for upwards of three years. When the disease is thus pro- tracted, the probability is that disorder of the digestive organs is essentially concerned in nursing its latent embers. Treatment.—The treatment is preventive and curative. As soon as a wound of this kind has been received, the part must be most thoroughly washed, first with warm water and castile soap, and then by holding it under a stream of cold water, suction being at the same time performed with the mouth. If the wound be very small, or valvular, the best plan will be to dilate it, as a preliminary step, in order to facilitate the extraction of the poison. Whatever method be adopted, the operation is completed by effect- ual cauterization with the acid nitrate of mercury, inserted into the wound by means of a small pointed stick of wood. In the absence of this article, which I prefer to everything else for the purpose, use may be made of nitrate of silver, butter of antimony, hydrochloric, nitric, or sulphuric acid, or a satu- rated solution of equal parts of alum and nitre. Persons who are in the habit of suffering from dissection wounds should always employ some precau- tionary measures in examining dead bodies, such as anointing the hands well with pomatum, lard, tallow, or simple cerate, and even wearing thin leather gloves, any fluids that raay be present being previously removed by an assist- ant. Fortunately, since the introduction of chloride of zinc injections now in such common use in our schools, suffering, in any form, from dissection wounds is much less common than formerly. In the Jefferson Medical Col- lege, no case of a serious character has occurred since this article first began to be used by Dr. Wallace, the able demonstrator of anatomy. The pupils of the other schools of this city have, I believe, been equally exempt. If the case has been neglected, or if, in spite of the precautions here men- tioned, a vesicle forms at the site of the wound, this should be at once opened by a free incision, when, bleeding having been encouraged by immersion in warm water, the part should be thoroughly cauterized with the nitrate of silver, or wet with the dilute tincture of iodine, an ectropic effect being still hoped for, though not likely to be attained. Warm water-dressing with laudanum is then applied, and the patient must take a brisk cathartic, keep quiet, and live light, watching the progress of events. If the disease extend, the indications will be to limit its action as much as possible, and to sustain the system under the approaching struggle. In view of the inevitable ty- phoid tendency, all exhausting remedies must be carefully withheld, especially the lancet and active purgation. If nausea and vomiting are present, a mus- tard and salt emetic, or an emetic of ipecacuanha is administered, and the bowels and secretions are regulated by mercurial laxatives, aided, if there be high fever, by tepid sponging of the surface, and the use of the neutral mix- ture. To relieve the excessive pain and restlessness, opium must be given in large and sustained doses, united, if there is much dryness of skin, with a little antimony or ipecacuanha. The distressing headache which so often attends the disease must be treated with cold applications to the scalp, the hot foot-bath, and the exclusion of light and noise; but anodynes will, in general, afford more ease than anything else. If inflammation of the arach- noid is threatened, a few leeches may be applied to the temple, or a blister to the nape of the neck. The moment typhoid symptoms appear, the proper remedies will be milk punch, quinine, iron, and ammonia. In the more ter- rible forms of the disease, commencing with violent pain in the axilla, side, and shoulder, these means should be used at once, in large quantity, espe- cially the brandy, with the hope of neutralizing the poison, and thus arresting its zymotic tendency. Although we know nothing of the nature of this poi- MALIGNANT PUSTULE. 367 son, yet it is not at all improbable, judging from the good effects which are said to attend the employment of alcohol in the treatment of snake bite, that brandy and other spirituous liquors might be of great service in dissection wounds. The suggestion, at any rate, seems to me to be worthy of attention. Their beneficial effects might possibly be increased by the free use of carbon- ate of ammonia; certainly by that of anodynes. As it respects the parts more immediately concerned in the disease, the best remedies, after the first ten or twelve hours, will be the warm water- dressing, medicated with laudanum and Goulard's extract, acetate of lead, or hydrochlorate of ammonia, preceded and accompanied by the dilute tinc- ture of iodine. Lint wet with oil of turpentine and laudanum sometimes affords great comfort. Blisters and nitrate of silver are objectionable, their vesicating effects interfering with other applications. Leeches are occasion- ally productive of great relief, but they are not to be used, except in very robust subjects, and in the early stage of the affection. When there is much oedema, the pressure of the bandage will be useful. Tension is relieved, and matter evacuated, by free and timely incisions. Covering the parts thickly with strong mercurial ointment, along the whole track of the inflamed lymphatic vessels, is sometimes useful in arresting the spread of the morbid action, and promoting the absorption of effused fluids. Dr. Wallace speaks in terms of high commendation of this mode of treat- ment, and the facts which he has communicated to me warrant me in saying that it is worthy of fair trial in the early stages of every case of the disease likely to come under the notice of the practitioner. The secondary effects of this class of injuries are removed by change of air, attention to the secretions, tonics, iodide of potassium, and cod-liver oil. In obstinate cases, a mild course of mercury may be necessary. The most eligible topical remedies are evaporating spirituous lotions, or lotions of acetate of lead, Goulard's extract, or hydrochlorate of ammonia. Some- times a deep and free incision will afford more prompt relief than anything else. b.—Malignant Pustule. This is a disease of the cutaneous and cellular tissues, commencing in the form of a little vesicle, and rapidly terminating in gangrene, its cause being a septic virus generated by horned cattle laboring under murrain. The French surgeons usually describe it under the name of charbon, and in many parts of Europe it is vulgarly known by the term Persian fire, or malignant pimple, the former having reference to the horrible pain which attends it, the latter to its destructive tendency. The disease is met with in various sections of the Union, though it ap- pears to be less common here than in Europe. Cases of it have occasionally been noticed in this city and its vicinity, and I have myself seen it in Ken- tucky, where, as well as in Ohio, Illinois, Tennessee, Mississippi, and Loui- siana, murrain sometimes prevails as an epidemic. In the latter State it caused great havoc, in the summer of 1851, among the stock of the parishes of St. Mary and Vermilion, carrying off an immense number of cattle, as well as a considerable number of horses and mules, among the latter of which it first broke out. Hogs and dogs that ate of the carcasses took the distem- per, and soon died of it. Several cases occurred in which the disease was communicated to the human subject by the green carrion fly. During my residence at Louisville four cases of the malady came under my observation, all having been contracted in flaying and eviscerating cows dead of murrain. Three of the cases were males. In Europe, malignant pustule has hitherto been chiefly observed on the continent, particularly in France, Holland, Switzerland, and Germany. The 36S WOUNDS. inhabitants of Great Britain appear to be nearly exempt from it; at least we may so infer from the fact that hardly any allusion is made to the disease in any of their works. In France it is said to be very common in Lorraine, Franche-Comte, Burgundy, Provence, Lyonnais, and some of the other south- ern regions, although no part is wholly exempt from it. It appears to be rare at Paris, but frequent at Marseilles, showing that locality is favorable to its production. The disease is most common upon the hands and face, because these parts, being habitually exposed, are most liable to inoculation. Persons who work among hides, both green and dry, tanners, butchers, shepherds, blacksmiths. and veterinary surgeons, are most liable to its attacks. It is often contracted by common people in flaying and eviscerating animals dead of murrain. It has also occurred from introducing the hand into the rectum and vagina of a cow laboring under putrid fever. Cases have been observed wdiere the virus was conveyed by insects from the diseased brute to man. I have al- ready alluded to the fact that it may be communicated by the green carrion- fly. It would seem that certain parts of an animal, as the hair and wool, retain the poisonous matter for a long time, and even after they have been most thoroughly washed and cleansed. Dr. Bourgeois refers to the case of a man in which the disease was apparently produced by picking the horse- hair taken out of an old sofa. A very common way in which it is contracted is by handling dry hides. Even tanned leather is said to be capable of com- municating the affection. It has been conjectured that it might be con- tracted by eating the flesh of brutes dead of murrain, but we know of no facts that justify such a conclusion. Whether it can be conveyed from one human being to another, or from man to the inferior animals, is also unde- termined. What the nature of the poison is which produces this disease, or when, where, and how it is developed, is a question which we have no means of solving. It is evidently of a zymotic character, like the virus of smallpox and chancre, and is generated by most of our domestic animals, especially cattle dead of murrain, its occurrence being less frequent in the horse, mule, ass, and sheep. It is also probable that it may be generated by birds, as the hen and turkey. In a case which occurred a number of years ago in Ken- tucky, and of which I have collected the particulars, the disease was con- tracted by three persons in picking and eviscerating several buzzards with a view of extracting their oil. Both the hands and.forearms of each individual were inoculated. Violent local and constitutional symptoms showed them- selves by the end of the second day after the operation, the parts becoming excessively swollen and painful, and covered with numerous vesicles, which, upon bursting, exposed ill-looking ulcers, discharging a thin sanious fluid, and remaining open for many weeks. The inflammation reached up to the axilla, the glands of which were enormously enlarged, some of them finally suppurating. Recovery took place only after a long time, and after great suffering, reducing the patients to the very verge of the grave. It is difficult to say whether, in these cases, the poison was actually generated by these birds, or merely conveyed by them through their feathers. However this may be, the facts involved in them are of much interest. Symptoms.— The period of latency of the disease is very brief, generally, perhaps, not exceeding a few hours. The first distinguishable evidence of the operation of the poison is a small reddish point, not larger than a pin's head, and the seat of a burning, itching sensation, attended with a desire to scratch. Gradually spreading in size, it is speedily followed by a little vesicle, filled with a thin, turbid serum, which, in its turn, is soon replaced by a pustule of a yellowish, brownish, or reddish color, according as it contains pure pus, or pus mixed with blood. Around the pustule is a distinct areola, MALIGNANT PUSTULE. 369 not unlike that of smallpox; the part is exquisitely painful, hard, and cir- cumscribed, allowing itself to be raised up from the subjacent structures. Continuing to extend, it becomes gradually more and more prominent, and at length acquires a base equal to the diameter of a twenty-five cent piece, half a dollar, or even a dollar. Meanwhile the pustule bursts, revealing a foul, gangrenous ulcer, discharging a sanious, fetid, irritating fluid, sometimes quite abundant. Long before the disease has reached this crisis, the affected limb is enormously swollen, stiff, numb, heavy, and exquisitely painful, the inflammation often reaching as far as the shoulder, and seriously involving the axillary glands. The number of vesicles is variable ; in one of my cases there was only a single one ; in another there were two, one on the hand and the other on the forearm; in the third there were five; and in a fourth the whole arm and hand were literally covered with them, their number amount- ing to several hundred. When numerous, they are always proportionably small, not exceeding the diameter of a currant or a split pea. When the disease is seated in the face, the swelling is generally so great as to give rise to the most hideous distortion, it being almost impossible to distinguish one feature from another. The eyelids are closed and distended like bladders, the lips are several times the natural thickness and hardly movable, the cheeks are enormously puffed out, and the natural line of de- marcation between the jaw and neck is completely effaced. The face, in fact, looks more like a dark, shapeless mass than a human countenance. When seated here, the malady is apt to extend to the throat, causing great swelling of the palate and tonsils, attended with immense difficulty of deglutition and respiration, and sometimes followed by suffocation. The constitutional symptoms are those, in the first instance, of general malaise, or uneasiness, with a feeling of depression and foreboding of evil. Presently high fever sets in, preceded and accompanied by rigors; and then, in a very few days, the patient sinks into a low typhoid condition, commonly attended with low muttering delirium, loss of sleep, and excessive restless- ness. Death often follows in three or four days from the first manifestation of the disease; but sometimes it does not take place under a week, and in a few rare cases not before the end of a fortnight. The patient's habits and state of health at the time of the inoculation, the quantity of matter absorbed into the system, and the nature of the treatment, all, doubtless, exercise an important influence upon the issue of the case. As a general rule, however, it may be stated that few recoveries occur under any circumstances. Dissection has hitherto thrown no light upon the nature of this disease. The internal organs, especially the lungs, are generally considerably engorged; and in a few rare instances metastatic abscesses have been found. The affected limb is usually distended with serum and lymph, the latter of which often exists in large quantity, giving the parts their characteristic hardness, and exhibiting occasionally, here and there, a greenish, gelatinous appear- ance. In one case I discovered several depots of blood. If the patient sur- vive sufficiently long, abscesses will be found in the subcutaneous cellular tissue, or evidences of purulent extravasation. The inflammation seldom extends deeply among the muscles, being apparently limited by the aponeu- roses. The axillary glands are sometimes much enlarged, softened, dis- colored, and infiltrated with various kinds of fluids. In the immediate neighborhood of the vesicles the parts are of extreme density, cutting with a grating noise very much like fibro-cartilage. Doubtless the veins and ab- sorbents are implicated in the disease, but in what manner, or degree, has not been ascertained. There is usually, after death, a tendency to rapid de- composition. Treatment.—The treatment is prophylactic and curative. As soon as it is ascertained that an individual has been inoculated, the part should be im- VOL. i.—24 370 WOUNDS. mediately cut out, after which it should be well washed with warm water, to encourage vascular disgorgement, and then still further drained by the cup- ping-glass, these means being followed by thorough cauterization with dilute acid nitrate of mercury or the solid nitrate of silver. Or, instead of this, the part is destroyed with the Vienna paste, or the hot iron. When early and effectual riddance has been neglected, or found impracticable, the treat- ment must be conducted upon general principles, by mild, soothing, and sup- porting measures. All sanguineous depletion, both by the lancet and leeches, active purgation, and other debilitating means are avoided, as calculated, inevitably, to hasten the fatal crisis. The secretions, always seriously de- ranged in this disease, are rectified by small doses of calomel, the excessive pain is allayed by full doses of morphia, and the system is sustained by the liberal use of brandy, quinine, and other stimulants. The limb, placed in an elevated position, is wrapped up in light flannel cloths, wrung out of a tepid solution of lead and opium, and if there be much tension and throbbing, early and free incisions are practised to afford vent to the effused fluids. Sometimes great comfort is experienced from the employment of an emol- lient cataplasm, covered with laudanum and olive oil. Fetor is allayed by the chlorides, which may also sometimes be advantageously given internally. Should convalescence take place, the cure must be promoted by nutritious drink and food, and change of air. EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. 371 CHAPTER X. EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. Under this head may be included the more immediate effects of injuries, as nervous depression, or shock, and traumatic delirium, as it has not inaptly been termed. These effects may succeed to almost any lesion, however trivial or complicated, their production being greatly influenced by the temperament, habits, age, and idiosyncrasy of the individual; and they deserve the most careful study, inasmuch as they are frequently followed by the worst conse- quences. The subject of tetanus might properly be included under the present division, but as this disease occasionally arises without any external injury, the consideration of it will be postponed until I come to speak of the affections of the nerves. SECT. I.—PROSTRATION, COLLAPSE, OR SHOCK. Shock may be defined to be a depression of the vital powers, induced sud- denly by external injury, and essentially dependent upon a loss of innerva- tion. It bears, in effect, th#same relation to the nervous system that syncope does to the vascular; in the one case, the result is caused by a diminution of nervous fluid, in the other by a diminution of blood; in both, the consequence is more or less prostration, with perturbation of body and mind, extremely variable both as to intensity and duration. When nervous shock is severe, it may instantaneously terminate in death, as so often happens in falls and blows upon the head; inore generally, however, after having continued for an indefinite period, it passes into reaction, the powers of life gradually coming up, as the different organs and the general system regain their ner- vous fluid. The most severe and fatal cases of shock are generally those that supervene upon direct injury to the great nervous centres, as the brain and spinal cord; no less disastrous effects occasionally succeed blows upon the epigastric region, in consequence of the violence thus inflicted upon the solar plexus of nerves. In some of these and other similar instances life is de- stroyed with the same rapidity as by lightning, the nervous fluid being instan- taneously annihilated without the individual being rendered conscious of his doom. Such cases have their counterparts only in those frightful hemor- rhages in which, a large artery, as, for example, the aorta, being divided, the patient perishes in a few seconds from loss of blood. The blood has long been known by physiologists as the vital fluid, so necessary has its integrity always been regarded to the well-being of the system and the maintenance of healthy action. But it is certainly not the only fluid entitled to this distinc- tion ; the nervous fluid is both more subtle and more important as a life pre- server. Wrhen blood flows away in a mighty and overwhelming torrent, the person dies, and life is then said to be destroyed, as it certainly is, by the excessive sanguineous drainage. But in shock, the same effect may happen, and yet the body be literally surcharged with blood, not a single drop perhaps 372 EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. having been spilled in the accident causing the fatal result. Thus, of the two fluids, the nervous is, in every respect, the more important, because the more essential to life; and its disturbance is therefore a more frequent cause of death. It would be out of place in a work on surgery to inquire into the nature of the nervous fluid, or to attempt to settle the question, so often propounded, whether there really is any fluid of this kind at all. Such an investigation belongs more properly to physiology; but there is no sensible practitioner who has not occasion daily to lament, in the exercise of his profession, his want of knowledge of the functions of the nervous system, and I feel sure that cases of disease and accident are constantly permitted to slip through our hands simply because of our forgetfulness that there is such a thing as a nervous fluid. No one is unmindful that a patient has blood, that a certain quantity of this fluid is necessary to the maintenance of health and life, and that, like the solids, it is subject to a thousand diseases, often of themselves sufficient to cause death. Unfortunately, we can never acquire any intimate knowledge of an agent so subtle as the nervous fluid; like the electric, or galvanic, which it is supposed to resemble, we can know it only by its effects. Shock may be produced by a great variety of causes, some of a bodily, others of a mental character; some externa], others internal. It may be purely nervous, or partly nervous and partly hemorrhagic, that is, dependent upon the conjoined loss of the nervous and sanguineous fluids. The nature and extent of shock are greatly influenced by the state of the general health at the time of the accident, the amount of the injury, the importance of the part more directly assailed, and, also, in an especial manner, by the idiosyn- crasy of the individual. There are some persons, soldiers, for example, of the most undoubted courage, men who would not hesitate to face the mouth of the cannon, who fall into a state of the most profound prostration from the most trifling accident; who turn pale and tremble like a leaf; whose minds are perfectly bewildered, and who are, as it were, completely stunned, from injuries so insignificant as not to affect, in the slightest degree, ordinary persons. Such an occurrence can only be explained by a reference to idio- syncrasy; and it has its counterpart in those persons who, although extremely plethoric, faint from the slightest loss of blood, or even from the mere sight of that fluid. There are other persons, on the contrary, whom hardly any accident, however severe, can shock ; they are insensible to pain ; their nervous system is obtuse; nothing affects them, either bodily or mentally; a severe blow may stun them, but the effect is transient; in a few minutes they are completely restored to consciousness and power. Here, again, is an example of idiosyncrasy, a peculiarity of organization; in the former case, the individual is all nerve, all sensibility; in the latter, all blood, all muscle. But it is not only the nervous and irritable that suffer from shock; the fat and corpulent are prone to be affected by it from the slightest causes, and hence such persons seldom make good subjects for the knife; they bear the loss of blood badly, and are extremely liable to perish from erysipelas and pyemia, in consequence, as it appears to me, rather of loss of nervous fluid than from any toxic state of the blood, or blood-poisoning, properly so-called. There are some individuals whom the slightest operation will kill; touch them, and they are sure to die; they are destitute of life-power, and inca- pable of resisting the slightest shock. The fainting produced by the prick- ing of a needle and the introduction of a bougie affords a familiar illustration of shock from trivial causes. Among the external causes of shock deserving of particular notice, on account of their crushing effects, are injuries upon the skull and spine, such as are produced by a fall or blow ; gunshot, railway, steamboat, and factory wounds; dislocations and fractures; violent sprains, burns, and scalds; and PROSTRATION, COLLAPSE, OR SHOCK. 373 some of the more severe operations, as the extirpation of enormous tumors, and the amputation of the larger limbs, even when not attended with any considerable hemorrhage. Severe shock is frequently produced by internal causes. One of the most familiar examples of this kind is afforded in perforation of the bowel, conse- quent upon typhoid fever, and followed by extravasation of fecal matter. The moment this takes place, the shock is immense ; if the patient had been struck severely on the head, it could not be more so; in some cases it is so overwhelming as to destroy life in a few hours. The pain which attends the passage of a gall-stone, or of a urinary concretion, is often followed by similar results ; extravasation of urine may be mentioned as another example. Many a woman has perished from shock induced by severe labor; and the excessive prostration consequent upon apoplectic seizures is familiar to every practi- tioner. Mental shock is often extremely severe, and is occasionally followed by the worst consequences, especially when it occurs during the progress of a severe illness, or after a severe surgical operation. Fright is perhaps the worst of the causes of mental shock. The effect of terror, in suddenly exhausting the nervous power, is well illustrated by the history of those persons, who, being sentenced to be bled to death, actually died on hearing water trickling into the basin, which they supposed to be blood issuing from their veins, after the arm had been slightly pricked, although no vessel had been opened. It is related of Desault that he one day lost a patient, about to be lithotomized, from sheer fright. The man, who was very cowardly, fainted and died under the impression that the operation was progressing, when this distin- guished surgeon was, in fact, only tracing the line of the intended incision on the perineum with his nail. A sick, bedridden person, in danger of being burnt to death, has been known to perish from shock, brought on by excessive mental trepidation. The receipt of disagreeable news, the sudden loss of property, and, in short, violent mental emotion of almost any kind, may give rise to similar effects. Mental and corporeal shock are often combined; and, when this is the case, it is not uncommon to see the former predominate, in a very marked degree, over the latter. The soldier on the field of battle may suffer from bodily shock induced by a severe wound ; he may feel that he is badly hurt, but still he is sanguine of recovery, and cheerfully and manfully bears up under his affliction. The surgeon examines his wound, and perceiving its grave character, informs him that it will probably cost him his life. Instantly the case assumes a different aspect; the system is overwhelmed with pertur- bation and excitement; the vital powers are depressed to the utmost; and death takes place perhaps several days sooner than it would otherwise have done. The symptoms of shock, although extremely variable, are generally such as attend syncope from loss of blood, or concussion of the brain, which is itself only a form of nervous depression, or expenditure of the vital forces. If the accident has been slight, the effect will be that of a moderate stun, that is, the patient will experience some degree of mental confusion, look pale, and feel weak and tremulous; objects will appear dark to him, and he will probably reel, if not fall. Presently, however, especially if he lies down, reaction will take place, and in a short time he will recover both his mental and physical powers, so as to be able to converse, act, and walk in the same manner as before he was hurt. When the injury has been severe, the effect upon the nervous system will of course be proportionably greater. The patient, unable to support himself, falls to the ground, often as he does so inflicting serious violence upon his person. Consciousness, special sensation, and volition are perhaps completely abolished; the countenance is deadly 374 EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. pale, the respiration is slow and feeble; the pulse is small, fluttering, and, at times, altogether imperceptible; the extremities become rapidly cold; and the surface is soon bathed with an abundant clammy sweat. Gasping and sighing, with convulsive tremors, are often present, and, in general, but too clearly denote the serious character of the lesion. Not unfrequently there are involuntary discharges from the bowels, with nausea and even vomiting. The duration of these symptoms is subject to no little diversity; at times they pass off in a few minutes, or, at farthest, in a few hours; at other times, they last for several days, and even then perhaps they do not disappear en- tirely, one or more hanging on for a considerably longer period. When the shock is very severe, death may occur instantaneously, or the case may linger on for some time in a state of doubt and uncertainty, with, now and then, an attempt at reaction, and at last prove fatal. Instances occasionally occur in which, after tolerably complete reaction has been established, the system sinks again into a partial state of collapse, the vital forces having evidently not sufficient stamina to maintain the action of the brain and heart. Such cases are very apt to end fatally, generally within the first twenty-four hours after their commencement. Reaction, after shock, is denoted by a gradual, or more or less rapid re- sumption of the functions of the different organs, which awake, so to speak, from their slumber, and spring back again into life and happiness. One of the first evidences of this change is a return of the color of the face, with an increase of the heart's action, as indicated by the state of the pulse, which is not only stronger and fuller, but more steady and regular; the respiration is more free and open ; the surface becomes warmer and dryer; the sphincters again obey the will; and the mind regains its self-possession and power of action. Often the first symptom of reaction, after severe shock, is vomiting, followed by complete clearance of the contents of the stomach, itself gene- rally a favorable sign, as it is denotive of a return of muscular power. There is a form of shock which has been called, not inaptly, insidious, as the symptoms are generally of a masked character, and are therefore well calculated to deceive both the patient and practitioner. The person, although severely injured, congratulates himself upon having made an excellent escape, and flatters himself that he is not only in no danger, but that he will soon be well; in fact, to look at him one would hardly suppose, at first sight, that there was anything serious the matter with him; the countenance appears well, the breathing is good, the pulse is but little affected, except that it is too soft and frequent, and the mind, calm and collected, possesses its wonted vigor, the patient asking and answering questions very much as in health. But a more careful examination soon serves to show that deep mischief is lurking in the system ; that the machinery of life has been rudely unhinged, and the whole system profoundly shocked"; in a word, that the nervous fluid has been exhausted, and that there is not enough power in the constitution to reproduce and maintain it. The skin of such persons soon assumes an icterode, or sallow, cadaverous appearance, feeling at the same time doughy and inelastic ; the extremities become deadly cold; the pulse makes a des- perate effort at seeming excellence, but is, at best, weak and tremulous; there is little or no pain ; and the patient is altogether too composed and tranquil for the amount of injury he has sustained. The system does not seem to be conscious of what has occurred; its sensibilities are blunted, and hence it is incapable of suffering. Nature, to use the language of Hunter, does not feel the injury. The countenance, in this form of shock, has often a peculiar melancholy expression, as if foreshadowing the fatal event; a sad smile plays upon the lip, and illumines the lower part of the face, while the upper part, on the contrary, wears a gloomy aspect, in striking contrast with the other. The PROSTRATION, COLLAPSE, OR SHOCK. 375 forehead, as the patient looks at his attendants, especially if he has just been roused from sleep, is strongly knit and wrinkled, giving it a scowling and sinister air. As the case progresses, the brain gradually sinks into a coma- tose condition, the signs of prostration become more pronouneed, and death finally occurs from mere exhaustion, life, under such circumstances, seldom lasting longer than three or four days. The treatment of shock must be conducted with two objects in view; the first is to promote reaction, and the second to moderate supervening inflam- mation, for to prevent it altogether is by no means always possible. To recover a patient from shock, he should immediately be placed recum- bently, everything tight or constricting should be removed from his person, free access of cold air should be provided, cold water should be dashed upon the face, smelling bottles should be held near the nose, and sinapisms should be applied to the extremities and precordial region. If the case be unusu- ally severe, and apprehension is entertained for the patient's safety, stimu- lating injections should be thrown into the rectum, and turpentine rubbed along the spine. If deglutition is practicable, brandy and water should be given, but in attempting to convey this or any other fluid into the stomach, great care must be taken, otherwise the liquid may descend into the wind- pipe, and so cause strangulation. The most prudent plan, under such circum- stances, is to introduce the drink with a spoon, the mouth being previously forced wide open, and a powerful effort made to excite the patient's attention by hallooing loudly into one of his ears. If he cannot swallow, no attempt should be made at compulsion, but, for the reasons just mentioned, the effort should at once be discontinued. In the milder cases of shock, the most simple treatment will often suffice to bring about reaction ; as, for example, the recumbent posture, a drink of cold water, and the use of the fan and smelling bottle. The blood and nerv- ous fluid soon resume their wonted channels, and the vital forces rapidly regain their supremacy. In the mental form of shock, a soothing word, or an assurance of absence of danger, will frequently go farther in promptly effecting restoration than the most powerful stimulants, steadily and regularly administered. Persons suffering from this variety of prostration are frequently much more frightened than hurt, and promptly regain their animation and self-possession when they are told that their injuries are altogether of a simple, trivial character, devoid of all danger, both present and future. Occasionally reaction is sadly interfered with by an overloaded and op- pressed stomach, as when the accident has occurred soon after a meal. In such cases, the patient often lies in a state of deadly pallor, with more or less retching, for hours, before he can shake off the oppressive burden. The indication obviously is to assist nature in her efforts at emesis, by the admi- nistration of a dose of alum, ipecacuanha, or sulphate of zinc, or, what, per- haps, is better, under such circumstances, equal parts of common salt and mustard. Serious lesion of the brain is hardly to be considered as a contra- indication to such a course, when it is recollected that the digestive powers are completely suspended, and with what difficulty reaction takes place when the stomach is oppressed by a heavy meal. The foolish and reprehensible practice of bleeding persons laboring under the exhaustion of shock, once so common, has become completely obsolete. No surgeon should do anything without a reason, and it is therefore difficult to perceive what could ever have induced a procedure so contrary both to physiology and good sense. In the opinion of the vulgar, there are no cases in which it is not proper, immediately after such an accident, to draw blood from the arm ; but assuredly no practitioner would yield his judgment to such an erroneous view, and perform an operation that might speedily prove 376 EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. destructive to his patient. Fortunately, whenever such an attempt is made by the ignorant and thoughtless charlatan, the blood generally refuses to flow, and consequentlv no harm is done. The second indication is to moderate the resulting inflammation. To do this, much may be accomplished in the way of prevention, by letting on the reaction gradually; avoiding, on the one hand, the undue use of stimulants, and, on the other, cautiously interposing antiphlogistics as occasion may arise for their exhibition. Proper allowance is made for the apparent vio- lence of the symptoms, the excitement without power; the struggle may be furious, but will in all likelihood be brief, for if the previous depression has been at all severe the flame will ere long cease of its own accord, or readily yield to the influence of very simple means, such, for instance, as sponging the surface frequently with cool or tepid water, and administering a little morphine and antimony, aided by rigid abstinence, and perfect tranquillity of mind and body. Bleeding should be practised only in young and plethoric subjects, with a tendency to serious inflammation of some important internal organ, and where, consequently, the fire is real, and not merely apparent. The opposite course often exerts a most pernicious influence upon the patient's recovery; impairing his vital powers, and preventing the system from keeping up a due supply of healthy nervous fluid, so conducive to the restoration both of the part and system. As the secretions are commonly materially deranged in all cases of severe shock, early and effectual means should be adopted for their correction and improvement; a gentle mercurial purge will often admi- rably fulfil the indication, and render any further use of this class of remedies unnecessary. The diet for the first few days should consist mainly of animal broths, aided, if necessary, by milk punch, or wine whey, and cautiously fol- lowed by food of a solid and more substantial character. Starvation, in cases of severe shock, is not to be thought of. Such a course cannot be too point- edly or too forcibly condemned, as it is contrary alike to sound sense and the dictates of an enlightened experience. Anodynes are always borne well after severe shock, and should be admi- nistered early and freely, to allay vascular action and tranquillize the nervous system. The most suitable article will be morphine, or the ammoniated tinc- ture of opium, either alone, or conjoined with valerian ; the latter remedy being especially serviceable in nervous, hysterical persons. If the vital powers flag sensibly after the occurrence of reaction, recourse must be had, in addition to anodynes, to quinine, carbonate of ammonia, and brandy, liberally and diligently administered. Determination to internal organs is met by leeches and blisters. SECT. II.—TRAUMATIC DELIRIUM. One of the most unpleasant effects with which the surgeon has to contend in the treatment of wounds and other iujuries, as well as after surgical operations, is the occurrence of delirium, at a period, too, perhaps, when everything is apparently progressing in the most favorable and gratifying manner. All of a sudden, the nature of the case undergoes a remarkable change for the worse ; the horizon, just a moment before perfectly calm and serene, like the summer's sky, is almost instantly overcast by a dark, lower- ing cloud; the system is thrown into nervous tremors, and the mind, agitated with disagreeable forebodings, is absorbed iu some peculiar fancy, in which the patient imagines himself pursued by his enemies, or annoyed by persons peeping at him through the keyhole of his door, making grimaces at him through the window, or concerting measures for his destruction. Great di- versity obtains in respect to the manner in which the disease is ushered in. TRAUMATIC DELIRIUM. 377 In some cases the symptoms are apparently of a hysterical character, the patient laughing and talking in a loud, boisterous, and incoherent manner; or perhaps indulging in unmeaning jokes about the nature of his disease, the way in which he was hurt, or the conduct which he exhibited during the ope- ration he has undergone. In another class of cases, by no means uncommon, he is completely absorbed in his business; he harnesses his horses, hitches them to the carriage, and swears at them because they do not move to please him. In some cases, again, he is seized with a species of religious phrensy ; he prays and sings, and utters pious exclamations. Occasionally, he labors under some demoniacal delusion ; he fancies that the devil has possession of him, and that he is about to be carried to the infernal regions. Finally, there are instauces in which the patient is sadly annoyed by the idea that he is pursued by snakes, dogs, or rats, or that some horrible reptile is trying to creep into his throat. In short, there is no end to these delusions, which are often as ludicrous to the observer as they are distressing to the patient, to whom they are always a source of severe suffering, not less so than if they were real. The cause of these symptoms is not always apparent. In the great majo- rity of cases, they are produced, either directly or indirectly, by the inordi- nate use of alcoholic spirits, suddenly interrupted by the occurrence of a severe injury, attended, it may be, by dreadful shock, or copious hemorrhage, thus greatly increasing the susceptibility of the nervous system to external and internal impressions. It is not necessary for their development that the individual should have been a habitual drunkard ; they often show themselves nearly as readily if he has merely been a free drinker without having carried the use of liquor to the extent of intoxication. On the other hand, they occasionally occur in persons of the most temperate habits, who have perhaps never used alcohol in any form, or for any purpose whatever. Dupuytren, who first called attention to this variety of the disease, has given it the name of nervous delirium, and in the paper which he has published on the subject he has reported a number of cases in which it supervened upon various kinds of injuries and operations, some of them of a very trivial character, or such as usually produce no unpleasant results of any description, the patient ra- pidly recovering from their effects. It cannot be doubted that, in these cases, the affection is generally of a purely nervous nature, arising from the effects of the commotion inflicted upon a delicate and highly susceptible constitu- tion. Under such circumstances, it is often mixed up with the effects of shock, rendering it difficult, if not impossible, to distinguish them accu- rately from each other. All practical surgeons have frequent opportunities of witnessing such cases. So far as my observation extends, I am not aware that any class of injuries is entirely exempt from the disease ; sometimes the most trivial scratch, or contusion, is followed by it. Corpulent persons, who generally bear injuries and operations very badly, are particularly prone to this form of delirium. Burns and scalds, railway lesions, lacerated wounds, and compound fractures may be enumerated as among the more powerful causes of the disease. It has been thought that children are less liable to suffer from nervous delirium than adults and elderly subjects; but this is certainly not true; on the contrary, such is the susceptibility of the system at this tender age to physical and mental impressions, that the slightest acci- dent is often sufficient to develop it. If women are less frequently affected than men, it is simply because they are less exposed to the various exciting causes of the disease. There is certainly every other reason why they should suffer quite as much as men, if indeed not more. Nervous delirium generally comes on within the first twenty-four or forty- eight hours after the application of the exciting cause; it may last for a va- riable period, but rarely longer than five or six days, and may terminate either 378 EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. in health, or in death, according to the gravity of the injury that has pro- duced it. Its leading symptoms are a confused, wandering, or flighty state of the mind, with excessive vigilance; incoherency of speech and manner; absence of fever; an open, moist state of the skin ; and little or no excite- ment of the pulse. The eyes have generally a wild expression, and the pa- tient is easily disturbed by noise and light, as well as by the presence of his attendants. The appetite is usually impaired, the bowels are costive, the urine is scanty and rather high-colored, and the feet are disposed to be cold. If the patient be spoken to, he is generally readily roused, but soon lapses into his former condition. Nervous delirium, properly so called, is easily distinguished from delirium tremens by the absence of tremors, which form such a striking feature in the latter disease as to be characteristic. In delirium tremens the limbs are in a constant trembling condition ; the symptom comes on early in the attack, and always lasts until the effects of the disease are nearly worn off. When the delirium is fully developed, the hands and fingers are incessantly in mo- tion, the patient carrying them to his mouth, face, and head, as if he were desirous of swallowing something, or removing some imaginary object from his person. The countenance is usually flushed, the eyes are deeply injected, the pulse is small, frequent, and quick, and the mind is roused with difficulty. Added to these circumstances is the history of the case, which generally affords valuable, if not conclusive, information respecting the patient's habits prior to his attack. Delirium tremens, the result of alcoholic stimulation, is an extremely com- mon occurrence after all severe operations and injuries, and is one of the most serious causes of their mortality. Hence operations should never, if possible, be performed upon this class of persons so long as they can be put off, or without due preparation of the system; special care should also be taken to avoid shock and loss of blood, as these are two of the most power- ful predisposing causes of the disease. It is well known that persons addicted to the immoderate use of opium and tobacco are liable to suffer from a peculiar form of nervous delirium after severe injuries and operations, characterized by excessive wakefulness, and a sense of indescribable wretchedness, with a bewildered and confused state of the mind, from which it is sometimes extremely difficult to rouse them, so as to induce them to take their necessary food and medicine. It is not impro- bable that the excessive use of coffee and tea may, in persons of a very nervous, excitable temperament, produce similar effects. In general, as was previously intimated, traumatic delirium usually sets in at an early period after the application of the external injury that provokes it; sometimes, however, the patient, perhaps contrary to expectation, goes on exceedingly well for some considerable time, happily surmounting the primary effects, but suffering severely from the secondary, the consequence commonly of profuse, unhealthy, and exhausting suppuration. Again, instances occur in which he may have several attacks of this nervous suffering, with a variable interval of from several days to several weeks, during which the mind may be perfectly clear and tranquil, the patient bearing up man- fully under his disorders, sanguinely and fully anticipating none other than the most favorable termination. Traumatic delirium, however induced, or in whatever manner it raay present itself, is often extremely difficult of management. In its worst forms, the mind is frequently so completely disordered as to render confinement of the patient with the strait waistcoat an indispensable item of the treatment. This is the more necessary when, as sometimes happens, the patient is dis- posed to tear off the dressings from his wounds, to commit suicide, or to hurt his neighbors and nurses. There is a remarkable circumstance which TRAUMATIC DELIRIUM. 379 has been noticed by all practitioners in this class of persons; I allude to their utter indifference to pain. So great is this, in many instances, that they will not only uncover their wounds, but absolutely take a sort of plea- sure in handling and picking them. Dupuytren refers to the case of an old man who, having been operated upon for strangulated hernia, tore away the dressings from his groin, and composedly squeezed his bowels, his friends all the while thinking he was getting on most admirably, such was his calm and quiet demeanor as he lay in bed. One of the most important indications, then, is to set a careful watch over the patient, in order that he may not do any harm either to himself or others; in wounds and fractures the most perfect quietude is generally necessary, and the greatest pains should therefore be taken to secure it to the fullest extent, for whatever has a tendency to disturb and fret the parts will be sure to act as a cause of additional excitement. Moral force alone will be of no avail; the patient can neither reason correctly himself, nor comprehend the reasoning of those about him. Hence if medicine does not promptly effect the object, the only resource is the strait jacket, applied of course with proper care, so that while, on the one hand, it shall not be so loose as to frustrate the intention of its use, it shall not, on the other, be so tight as to occasion injurious constriction ; a circumstance which, although a matter of paramount importance, is not always, as I well know from experience, as scrupulously attended to as it should be by nurses and practitioners. The next indication is to tranquillize the nervous system, and induce sleep, or, in other words, to get rid of the redundant excitement. To fulfil this indication, recourse must be had to anodynes, administered in such doses as shall most promptly and effectually bring about the desired result. The patient must sleep before he can obtain relief; the early interposition, there- fore, of suitable treatment is a matter of primary importance, attacking and routing the disease, as it were, in its very incipiency, ere yet it has taken firm hold of the system. The best remedy will be found to be opium, either in the form of morphia or of the acetated tincture, given in full and sustained doses, in combination with a sufficiency of tartar emetic to prevent vascular excitement and promote perspiration. Solid opium is objectionable, as it takes a long time to dissolve in the stomach, and often excites instead of tranquillizing the nervous system. Tartar emetic will always be found to be a most valuable adjuvant. In the milder cases, the disease frequently promptly yields under the influence of a small quantity of laudanum, as from fifteen to twenty-five drops, in half an ounce of camphor-water and a drachm of the compound tincture of cardamon, repeated every two or three hours. Dupuytren was in the habit of employing laudanum as an injection in this disease, giving from ten to twenty drops with a small quantity of water, and frequently repeating the dose, until he succeeded in accomplishing his pur- pose. He asserts that the medicine thus administered often exerts a much more prompt and happy effect than when given by the mouth; and the result of my own experience amply corroborates the truth of the statement. As a preliminary measure, the rectum should be well cleared out with an ordinary enema. When opium and its preparations cannot be borne, an excellent substitute will occasionally be found in hyoscyamus, lupulin, aconite, belladonna, and Indian hemp; aided by the cool shower-bath, followed by dry frictions, or, what will generally answer quite as well, and be more convenient, sponging of the surface freely and repeatedly with tepid, cool, or cold water. When the delirium is furious, leeches should be applied to the temples, or a large blister to the nape of the neck, and cold to the scalp, previously divested of hair. As a temporary expedient, and an auxiliary for allaying the violence 380 EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. of the spasms, the judicious inhalation of chloroform will be of service. General bleeding will rarely be proper in any case, whether of nervous delirium or delirium tremens. In nervous, hysterical females, the free use of assafoetida and of valerianate of ammonia often answers better than almost anything else. When the patient has been a habitual drunkard, or when the delirium can be distinctly traced to the effects of the sudden withdrawal of alcoholic stimulation, the dictates of common sense, not less than the results of sound experience, indicate the propriety of a resumption of the accustomed drink, or a resort to an appropriate substitute. Much judgment will of course be necessary under such circumstances, lest the remedy be carried too far, causing thereby additional excitement and vigilance instead of composure and refreshing sleep. SYPHILIS — GENERAL CONSIDERATIONS. 381 CHAPTER XI. SYPHILIS. SECT. I.—GENERAL CONSIDERATIONS. The term syphilis is applied to a class of diseases which, commencing in the genital organs in the form of a sore of a specific character, may, and often do, invade the lymphatic ganglions of the groin, the cutaneous and mucous tissues, and finally also the bones, cartilages, and fibrous membranes, leaving upon each and all of them, as well as upon the system at large, a peculiar and distinctive impress. These different parts, however, do not all suffer at one and the same time; on the contrary, it would seem to be necessary that the poison upon which the infection depends should lie for a certain period in the tissues in which it has been deposited in order to enable it to pre- pare itself for further action. Thus, in the first instance, the operation of the poison is strictly local, the sphere of its influence being limited to the genital organs, or to these organs and the lymphatic ganglions of the groin. After having lingered here for some time, varying, on an average, from four to six weeks, the cutaneous and mucous surfaces begin to suffer ; and at a still later period, that is, from six to eighteen months, the bon^s, cartilages, and fibrous textures are attacked. In this manner are produced three dis- tinct groups of syphilis, known, respectively, as primary, secondary, and tertiary, depending upon the peculiar modifications of the specific poison to which the malady owes its origin. It is not my intention here to enter into an account of the history of the origin of syphilis; such an undertaking, besides involving an immense amount of research—ethnological, literary, and biblical—would be entirely out of place in a treatise of this description, limited as it is to the practical details of surgery. I may remark, however, that, in my opinion, it is great folly to regard the disease as of modern origin. If the records of antiquity could be fully explored, it cannot be doubted that we should discover the most satis- factory and irrefragable evidence of the existence of syphilis in the most remote periods of society, now aggravated and now kept in abeyance, accord- ing to the habits and morals of the various races of mankind, and the nature of the climate of the countries in which they dwelt. If the history of the inner life of Sodom and Gomorrah could be laid open to our scrutiny, it would furnish a page to the history of prostitution as loathsome and disgust- ing as any afforded by the vilest and most depraved cities of the present day, either in the Old World or in the New. Syphilis is peculiar to man. Numerous experiments have been performed, by inoculation, upon almost all the domesticated animals, but in no instance whatever has the poison produced any specific effect. The little puncture made with the lancet in the operation became temporarily inflamed, but the impression soon passed off, and the parts rapidly recovered their natural condition. If, in the monkey, the inoculated surface assumed somewhat more of the appearance of a chancre than in the other classes of animals 382 SYPHILIS. subjected to trial, it was, nevertheless, not characteristic, and it is certain that no case has ever been reported where the insertion of the matter was followed by constitutional symptoms. The disease never arises spontaneously, but is always the result of inocu- lation with a peculiar poison, known as the poison of syphilis or of chaucre. Of the precise nature of this poison we have no knowledge; we only know it by its properties, or by the effects which it is capable of exerting upon the economy when brought in contact with it under circumstances favorable to its development. Thus, observation and experiment have shown that it always produces a disease similar to itself, the resulting sore or ulcer yielding a virus, in every respect identical with that which furnished it in the first instance. Like the poison of smallpox, it is a peculiar poison, capable of reproducing itself, and of multiplying itself by zymosis. The smallest, inconceivable atom, brought in contact with an appropriate surface, will speedily develop a disease which, if permitted to progress, may occasion the most horrible consequences, both local and constitutional, and so contaminate the solids and fluids as to render it transmissible from the parent to the offspring. As a little yeast may impregnate a large mass of dough, and cause a ferment that shall affect every particle of gluten entering into its composition, so a little syphilitic vims, so minute as to be utterly inappreciable by our senses, may affect the whole system, and poison every avenue of life and health. Zymosis having fairly commenced, it is impossible, iu any case, unless proper means be adopted to counteract it, to say when it may cease, or what may be its ultimate effects. The pus which contains the syphilitic virus, and which therefore serves as a vehicle for its propagation, does not, so far as can be ascertained, differ from pus supplied by ordinary inflammation, either in its physical, chemical, or microscopical characters. Thus, it may be thick and yellowish, serous, ichorous, or plastic; bland or acrid; acid, alkaline, or neutral; pure, or mixed with adventitious matter; and, lastly, perhaps even animalcular, although this point is not fully settled. The specific property of the virus is not destroyed for a number of weeks, if the pus with which it is combined is preserved in a well-corked vial; resembling, in this respect, the virus of vaccinia and variola. It is rendered inert, however, by chemical agents and also by gangrene of the tissues which have been inoculated with it. The infecting virus does not seem to have any particular predilection for age, sex, temperament, or occupation; all are alike liable to be affected by it. Previous disease does not prevent its action. It produces its peculiar impression most readily when applied to a clean ulcerated surface, an abra- sion, or a recent wound; but inoculation may take place independently of these circumstances, simply from the introduction of the virus into a mucous follicle, which thus serves to entangle and retain it until its structure is brought thoroughly under its influence. When the part to which the virus is applied is perfectly healthy, several days may elapse before it becomes impregnated ; or it may even escape entirely, the matter which contains it either not being able to penetrate its surface, or being wiped off before the occurrence of ab- sorption. For the same reason a person thus situated may communicate the poison to another so as to give rise to a chancre, while he himself experiences no ill effects. Such a result not unfrequently happens in women, in conse- quence of the matter of syphilis lodging in the folds of the mucous mem- brane of the vagina, from which it is afterwards transferred to the virile organ in the act of copulation. The syphilitic virus maybe communicated in various ways; first, by sexual intercourse, which is by far the most common; secondly, by unnatural con- nection, giving rise to chancres of the anus and perineum; thirdly, by the body and bedclothes of the persou ; fourthly, by surgical instruments and PRIMARY SYPHILIS — CHANCRE. 383 dressings; fifthly, by chamber-pots and water-closets; and sixthly, by the fingers of the affected individual. In this manner a patient may inoculate his lips, nose, eyelids, or any abraded, raw, or open surface upon any portion of the body. In this way, too, accoucheurs sometimes inoculate their fingers in examining women laboring under chancre of the vulva, vagina, or uterus. It is still a mooted point whether the virus of syphilis begins to act the moment it comes in contact with the living tissues, or whether, after having been absorbed by them, it remains there in a state of latency, as is supposed by some to be the case in inoculation in hydrophobia. Without attempting to decide this question, for which our data are perhaps still insufficient, it is reasonable to infer that the effects vary, in different cases and under different circumstances, according to the structure of the inoculated surface, the natu- ral susceptibility of the part, the purity and quantity of the poison, and the degree of the resulting inflammation. It is well known that a tolerably dis- tinct chancre is sometimes formed within the first twenty-four hours after an impure connection, whereas at other times this result does not follow under a week. The average period may be stated at from three to six days. My opinion is that the actual latency of the virus is very short, and that, like other zymotic poisons, it begins to act, although imperceptibly to us, within a very brief space after it has been inserted. The probability of this con- clusion is strengthened by what occurs in artificial inoculation, an operation which is usually performed upon the skin of the inner surface of the thigh. SECT. II.—PRIMARY SYPHILIS. • Primary syphilis consists, as already stated, of chancre and bubo : that is, of an ulcer of the genital organs, and of a swelling of the lymphatic gan- glions of the groin, often eventuating in suppuration and other bad effects. So long as the disease is limited to these structures it is strictly of a local cha- racter; but when it passes beyond them, so as to affect the system, it becomes constitutional. 1. CHANCRE. If a small quantity of matter be taken from the surface of an ulcerating chancre, and inserted with the point of a lancet into the substance of the skin, just beneath the epidermis, the earliest effect, manifesting itself within the first twenty-four hours, will be a little reddish speck, looking very much like a flea-bite, and denotive of very slight inflammation, such, for example, as might be supposed to result from any little puncture independently of the operation of any specific virus. During the next twenty-four hours, the part exhibits the appearance of a minute papula, or little swelling, somewhat ele- vated above the surrounding level, and encircled by a faint, narrow, rose- colored areola. From the third day to the fourth the papula assumes the form of a vesicle, the epidermis being raised by a drop of whitish, pearl-co- lored serosity; the inflammation is more considerable, and the areola is of larger size and of a deeper hue. At the end of this period the vesicle is transformed into a pustule; that is, the inoculated part becomes filled with pus, its centre is gradually depressed, and the areola acquires its most dis- tinctive features. From the fifth to the sixth day the structures immediately around the seat of the disease undergo a remarkable change; hitherto they had been quite soft, or, at most, only somewhat cedematous, but now they are observed to become indurated from the deposition of plastic matter, and to feel, when pressed between the thumb and finger, like a mass of fibro-car- tilage, or tolerably firm cheese, the sensation partaking at the same time of 384 SYPHILIS. an elastic character. Having assumed this character, the sore is possessed of the requisite properties for supplying infecting matter, of which, up to this moment, it was destitute. At the expiration of the sixth day, the pustule begins to turn dark, its contents solidify, and a firm, thick scab forms, com- posed of several strata, and having the shape of a truncated cone, with a depressed apex. Should the scab now fall off, or be accidentally removed, a large, deep ulcer will be exposed, having an excavated appearance, as if it had been scooped out with a punch, its edges being steep and slightly ragged, its bottom incrusted with a layer of grayish, aplastic lymph, and its base hard, firm, and slightly elastic like fibro-cartilage. The discharge is gene- rally of a thin, sanious, or ichorous nature, without any of the properties whatever of laudable or healthy pus. The ulcer thus formed constitutes what is termed an indurated chancre, or, from the faculty it possesses of con- taminating the system, the infecting chancre. It is also not unfrequently called the Hunterian chancre, from the fact that it was first accurately de- scribed by Mr. John Hunter in his treatise on the venereal disease. From what has been said, it will be perceived that, although the poison doubtless begins to act at an early period after inoculation, yet it requires some time before it can produce a true syphilitic sore, and that the local disease itself consists of several well-marked stages, running, however, gradually into each other; the first distinct evidence of its presence being a papula, the second a vesicle, and the third a pustule, followed by a hardened base and an exca- vated ulcer, bathed with infecting matter, which is capable of contaminating the constitution, fluids as well as solids. Although a chancre may occur on any part of the body, yet as it is by far most common on the genital organs, it is here that it has been studied with the greatest care and attention. Its most common sites are the head of the penis and prepuce, the vulva, vagina, and uterus. The disease may also attack the urethra in both sexes, especially in the male, although the occur- rence is very uncommon. Any portion of the head aud foreskin of the penis may be affected, but of the former the corona, or rather, the gutter just behind the corona, and the surface on each side of the frenum are most liable to be involved, from the circumstance that these parts are particularly apt to retain the infecting matter; for the same reason the free extremity of the prepuce is very prone to suffer. A severe chancre occasionally forms on the body or root of the penis. In the female the disease sometimes occurs on the perineum, on the outer surface of the labium, and around the anus. A chancre upon the mucous surface of the genital organs does not always pass through the same regular stages as a chancre upon the skin from arti- ficial inoculation. On the contrary, it frequently begins as an ulcer, in conse- quence of the matter having been brought in direct contact with an abraded surface, or a scratch, and in this case the evolution of the disease is always peculiarly rapid and well-marked. At other times, again, it commences as a boil or an abscess. This form is most comraon when the inoculation has taken place from the matter having insinuated itself into the orifice of a mucous follicle. Under such circumstances, the gland swells and becomes softened, and is soon after destroyed by ulcerative action. Moreover, it is important to remember that the vesicular and pustular stages above described may have passed by unnoticed, and that, consequently, when the sore is first inspected, it may possess all the characters of a well-defined chancre. No general symptoms precede or usher in the local disease, whatever may be the form in which it begins; all that the patient experiences is a slight sensation of heat, some itching, and an increase of the sensibility of the part which is about to become the seat of the infection. Chancre presents itself under two varieties of form, the indurated and the non-indurated or soft, all other distinctions being now abandoned, on the CHANCRE. 385 ground that, whatever differences of appearance the sore may exhibit, they are solely and entirely of an accidental character, and therefore altogether independent of the nature of the syphilitic virus. It is impossible, in the actual state of the science, to determine why one person should have a hard chancre and another a soft chancre. In the adjudication of such a question it will not do to invoke the existence of a corresponding number of poisons; to do so would be to destroy the unity of the disease, and to invest the sub- ject with inextricable confusion. The most philosophical course, in the ab- sence of facts, is to assume that there is really only one virus, but that this virus is capable of being so modified in its character, by local and constitu- tional causes, or by internal and extrinsic circumstances, as to produce effects apparently the very opposite of each other in different individuals. How else can we explain the occurrence of indurated and non-indurated sores upon the genital organs ? The laws of disease have their irregularities and anomalies not less than the laws of health ; exceptions meet us everywhere, and it would indeed be very singular if they should be altogether wanting in syphilitic affections. In the production of the two varieties of chancre here alluded to, some powerful modifying circumstances must be in operation, shaping, influencing, and controlling the result. Smallpox, scarlatina, measles, and other eruptive diseases are subject to remarkable departures from the natural standard, and yet no sensible pathologist would for an instant suppose that every new feature exhibited by these affections was indicative of the existence of a new poison. The modifying cause, whatever it be, may exist in the in- oculated structures, in the peculiar nature of the pus containing the specific virus, in the specific virus itself, or in the state of the constitution, or in all these circumstances combined. M. Ricord has recently published some very singular statements in regard to the peculiarities of these two varieties of chancre, which, if they shall be ultimately verified by the observation of others, would almost necessarily lead to the conclusion of the existence of two separate aud distinct varieties of syphilitic poison. Thus, he positively affirms, on the strength of a large clinical experience, that the indurated ulcer alone is an infecting ulcer, that is, a chancre capable of furnishing a fluid which, if conveyed into the system, may contaminate the solids and fluids in such a manner, and to such an ex- tent, as to give rise to secondary and tertiary accidents. The non-indurated chancre, on the contrary, he regards as a purely local affection, often trouble- some, it is true, but always free from the risk of invading the constitution in anywise whatever. My observations would lead me to infer that, while there really are two varieties of chancre, the indurated and the soft, as de- scribed by the French syphilographer, they do not by any means possess the properties which he ascribes to them. The hard chancre is unquestionably most frequently followed by constitutional symptoms, but to maintain that it is so exclusively is what, I am sure, no experienced practitioner will admit. So far from giving my adhesion to such a doctrine, I have had the most une- quivocal evidence, in numerous instances, of the infecting properties of the soft chancre. Indeed, I am satisfied that some of the very worst cases of secondary and tertiary syphilis that I have ever been called upon to treat have been cases of this description ; originating generally in very small sores upon the head of the penis or prepuce, perfectly soft in their consistence, very superficial, manifesting no disposition to spread, and soon completely disap- pearing. Such chancres not unfrequently exist without the knowledge of the patient, their discovery being, perhaps, purely accidental. It is doubtless this form of ulcer which has given rise to the absurd notion, not yet entirely exploded, of the possibility of the formation of bubo without the precedence or concomitance of chancre. The characters of the indurated chancre may be deduced from the account vol. i.—25 386 SYPHILIS. already given of artificial inoculation of the skin, which affords its best type. In order, however, to contrast its features with those of the soft chancre, it may be well here to reproduce the description of the principal phenomena which mark its progress. The indurated chancre, fig. 82, is usually rounded or somewhat oval, and from the diameter of a split pea to that of a five cent Fig. 82. piece. Its surface is hollow, as if scooped out, and incrusted with a layer of lymph, of a dirty grayish color, and very firmly adherent. The edges of the ulcer are hard, slightly elevated, and inclined a little slopingly from within outwards. The base is well- defined and remarkably hard, feeling, if pressed be- tween the thumb and finger, like a button of fibro- cartilage, or, to employ the comparison of Benjamin Bell, like a split pea, set in the tissues immediately around the chancre. The induration begins to form indurated chancre. about the end of the fifth day, and generally attains its maximum by the end of the tenth or twelfth. The amount of induration of the base varies; in general, it will be found to be less on the prepuce than on the head of the penis, the nature of the affected tissues doubtless influencing the result; and it usually lasts some time after the chancre is completely cicatrized, a circumstance, as will appear by and by, of great practical moment. The indurated chancre, if not generally solitary, is certainly so, on an average, in nearly five cases out of six ; for I find that, of 848 cases observed by Fournier, Clerc and Hammond, 185 only were multiple. Occasionally, though rarely, the number ranges from two to six, or even as high as nine- teen, as in an instance witnessed by Fournier. It has no distinct areola; its march is indolent; and it furnishes a thin, serous, sanguinolent, or ichorous fluid, small in quantity, and difficult of inoculation. Hence, unless the matter come in contact with a raw surface, or a surface well adapted for its absorption, a second chancre seldom arises during the progress of the primary one. Another feature of the indurated chancre is its extreme liability to infect the lymphatic ganglions and the general system, few persons, if any, escaping contamination after it has reached maturity. The soft chancre, also generally of a rounded form, but less regularly so than the hard, is much more common than the latter, and is often multiple, from three to six or eight occasionally occurring in the same subject. It is particularly apt to show itself at the free margin of the prepuce, and at, or just behind, the corona of the penis. Several often arise simultaneously, and others are liable to form during their progress from fresh inoculation, or the mere contact of their own secretion with the surrounding parts. The surface of the soft chancre is superficial, flat, uneven, and coated with a grayish, whitish, or dirty drab-colored deposit. In some cases it has a worm-eaten appearance. Its edges, when seated on the head of the penis, are steep and abrupt, as if made with a punch, but on the prepuce they are generally overhanging, sloping or shelving, extremely ragged, and less closely identified than those of the hard chancre with the neighboring struc- tures. The base of the chancre is entirely free from induration. The only exception to this is where irritating applications have been used, causing an increase of inflammation with plastic deposit. The soft chancre generally manifests a disposition to spread, and, in per- sons of a broken constitution, often takes on phagedenic action. It furnishes an abundance of purulent fluid, which is highly infectious, and therefore readily inoculable, thus accounting, as already stated, for the multiplication CHANCRE. 387 of ulcers during the progress of the disease, one sore being added to another in consequence of the dissemination of the matter over the surrounding sur- face. The soft chancre is frequently, but not generally, followed by bubo, the disease being usually limited to one ganglion, which, becoming inflamed and swollen, rapidly suppurates, and, in time, forms a large ulcer, the matter, like that of the chancre to which the bubo owes its origin, being at first inoculable, and capable, in turn, of producing a soft chancre. Finally, the soft chancre often affects the system, giving rise to secondary and tertiary symptoms ; attacks of this kind, however, are less common than in the indu- rated variety, though the effects are frequently not less deplorable. The period during which a chancre retains its specific character varies. Occasionally, though rarely, it loses its infecting properties in ten days or a fortnight. The average time, however, is much longer; and, on the other hand, an instance sometimes occurs where the specific poison continues to be formed for many consecutive months. As a general rule, it may be stated that no patient is safe so long as the ulcer is not in a granulating condition. The observations of Ricord tend to show that one attack of indurated chancre effectually protects both the part and system against a second attack, the syphilitic poison thus resembling, in its habits, the poison of smallpox ; the soft chancre, on the contrary, exercises no such influence, one attack affording no immunity against another. My own experience leads me to believe that this conclusion should be received with great reserve. The two varieties of chancre now described are liable to be modified in their appearances, progress, and modes of termination by local and constitu- tional circumstances, among which the most important are the want of clean- liness and the degree of the concomitant inflammation, the habits of the individual, the state of the general health at the time of the inoculation, and the occurrence of intercurrent diseases. The influence which these several causes are capable of exerting is, in many cases, so great as to change the whole outward feature of the existing ulcer; hence those numerous divisions and subdivisions of chancre which, even up to the present moment, disfigure the nomenclature of syphilis, and which have tended so much to embarrass the progress of our knowledge. It is impossible for this disease to observe the same uniform course in every instance ; alterations are inevitable, and must often occur despite the utmost caution both of the patient and his attendant. In this respect, a chancre holds the same relation as an ordinary ulcer, presenting one appearance to-day and another to-morrow; now highly inflamed, and now almost free from irritation ; at one time in a healing con- dition, and at another ready to commit the most destructive ravages. Out of these appearances, or varieties of appearances, have sprung the so-called inflammatory, diphtheritic, phagedenic, and sloughing chancres, with several others which it is unnecessary here to mention. Such occurrences constitute complications of disease rather than species and varieties, for they are liable to take place in all sores whatever their character, whether simple or malig- nant, specific or common. There is reason to believe that in syphilis the specific poison may sometimes undergo such a radical change as to adapt it, in an especial manner, for the production of these differences in the appear- ances of the local affection. Promiscuous intercourse with badly diseased women, particularly if these women are foreigners, and receive the embraces of a considerable number of men in rapid succession, would seem to be a powerful predisposing cause of these accidents. It was observed by the surgeons who accompanied the British army into Portugal, that many of the soldiers who had connection with the native prostitutes suffered severely from phagedenic and gangrenous ulcers, while the residents of the country expe- rienced very little trouble, and usually soon recovered from the effects of the disease. The French soldiers, during Bonaparte's campaign in Egypt, suf- 388 SYPHILIS. fered in the same manner. Similar phenomena are frequently witnessed in the inmates of the houses of ill-fame in crowded cities. Thus, in London, in Swan Alley, a narrow lane, celebrated as the residence of the humblest class of prostitutes, half-starved, badly clothed, nearly constantly intoxicated, and having frequent intercourse every day with filthy lascars and other vagabonds, many of the cases of chancre assume the worst possible type, running rapidly into phagedenic action, and often causing frightful ravages and even loss of life. Examples of a like kind came under my observation in this city, in 1827, 8, and 9, in the Philadelphia Almshouse, and in the numerous brothels which then existed among the low blacks and whites south of Pine Street. All chancres are inflammatory affections, and it is only therefore when the concomitant action assumes a grave type that it can be regarded as unnatural. Under such circumstances, the characteristic symptoms consist of inordinate pain and swelling of the parts more directly involved in the disease, accom- panied by an increase of discoloration, and an unhealthy aspect of the ulcer, which is the seat of a thin, ichorous discharge, more or less abundant, and generally a good deal irritating. Morbid erections are frequent, the prepuce is disposed to be cedematous, and the whole organ appears to be enlarged, especially the anterior extremity. When the inflammatory action transcends certain limits, it may pass into gangrene or destructive ulceration, as occa- sionally happens in common ulcers of the leg, and from similar causes, espe- cially from excessive indulgence in the use of ardent spirits, loss of sleep, bad air, an impoverished diet, and improper courses of mercury. Or, the overaction may be brought on by a plethoric state of the system, and a neglect of the requisite depletion. I have seen gangrene and phagedenic ulceration of the genital organs of both sexes occur at a very early period, in consequence, apparently, merely of too active a course of treatment soon after the establishment of the disease, and such cases are sometimes charac- terized by extraordinary rapidity of progress, the suffering parts being, as it were, overwhelmed by the disease. Gangrene, as a consequence of chancre, is more apt to invade the prepuce than the head of the penis, and, what is remarkable, the upper portion of this muco-cutaneous pouch is more frequently affected than the lower or lateral. Occasionally both structures are attacked simultaneously, or, if one suffer first, the other is soon attacked also, and in this manner the whole organ may gradually be involved, dropping off perhaps ultimately near the scrotum, or at its attachments to the pubic bones. The occurrence of gangrene is an- nounced by a blackish spot, preceded and accompanied by Fig. 83. a burning, smarting pain, and by an aggravation of all the other inflammatory symptoms. The system is extremely feverish, the pulse is frequent and irritable, sleep and ap- petite are impaired, or, more commonly, entirely destroyed, and the patient is often slightly delirious. When the pre- puce alone suffers, the whole of it may slough off, or, what is not unusual, it may be perforated at one or more points, the largest opening perhaps admitting the head of the penis, as seen in fig. 83. A common effect of gangrene, conse- quent upon chancre, no matter where situated, is the de- struction of the specific poison, thus effectually preventing inoculation of the system, provided that had not previ- _,, . .. ously taken place. The sloughing sore, 7-r, , l . the prepuce almost . Phagedena is a rare complication of chancre, especially gone; the gians go- in the better classes of subjects; it is analogous, in its worst ins- forms, to hospital gangrene, and is most liable to show itself in persons whose constitution has been ruined by intemper- ance and other debilitating influences. As already stated, it sometimes oc- CHANCRE. 389 curs as an endemic, and is then probably induced by a foul state of the atmosphere, as when the disease breaks out in the crowded wards of public institutions; or by some peculiar modification of the syphilitic poison, greatly heightening its virulence, as when it takes place in soldiers after having co- habited with foreign prostitutes. The morbid action deports itself variously; in general, it extends rather slowly, but continuously, gradually but effectually eroding the parts, and thus widening the breach as well as deepening it. Or, it may be that, as one portion of the chancre heals, another spreads. Or, the action may be very acute, extending with extraordinary rapidity, and commit- ting excessive ravages in an almost incredibly short time. Or, lastly, the ero- sion may be conjoined with gangrene, the textures dying both molecularly and in mass. The phagedena may begin soon after the appearance of the chancre, or it may manifest itself, as is most generally the case, at various periods of its progress. It may occur upon any portion of the genital organs, but is most common upon those parts of the mucous surfaces which are most plenti- fully supplied with follicles. In the male it is most liable to appear in the gutter upon the head of the penis, or at the point of reflection of the prepuce. The under surface of the penis, at the side of the frenum, is another favorite site, and when chancre occurs here it is almost certain to destroy this fold of mucous membrane. The appearances of the acute and chronic forms of phagedenic chancre are illustrated in figs. 84 and 85. Fig. 84. Fig. 85. The phagedenic com- plication is sometimes fol- lowed by grave hemor- rhage, the erosive action laying open an artery of considerable size, as the dorsal artery of the penis, from which blood may issue in such quantities as to induce severe, if not fatal, Acute phagedenaj bur. exhaustion. Ihe Scarlet rowing beneath the integu- Chronic phagedena; with great sur- hlie Of the fluid and the ments of the penis. rounding hardness. saltatory character of the stream will at once indicate its source. In some cases it oozes from the ulcerated surface from many points, as water oozes from a sponge. Chancres sometimes assume a serpiginous form, the erosive process, as the term implies, creeping about in different directions, generally in circles or semi-circles, one portion of the sore being perhaps cicatrized while the other is steadily advancing at the opposite point. The ulcer, although generally superficial, occasionally penetrates to a considerable depth, and, as its course is usually chronic, it often results in serious mutilation. Its surface, incrusted with grayish or drab-colored lymph, is bathed with ichorous fluid, and its edges are steep, ragged, and more or less everted. The serpiginous form of chancre is most common in persons of strumous constitution, especially such as are predisposed to phthisis, scurvy, and herpetic affections. It is generally remarkably obstinate, occurs almost exclusively in the skin, and manifests no disposition to burrow. When a chancre is covered with a thick layer of lymph, it constitutes what the French syphilographers have called the diphtheritic chancre; such an occurrence is very common in all ill-conditioned specific ulcers upon the genital organs, and is always denotive of an unusually irritable and inflamed condition of the part, the action of which altogether transcends the healthy limits, nature being incapable of converting the deposit into granulations, 390 SYPHILIS. and so throwing it off in the form of a slough, or as an effete substance. A considerable effusion of lymph is often observed in connection with the indu- rated chancre, but the soft chancre is by no means exempt from it. Diagnosis.— The diagnosis of chancre is often difficult and sometimes im- practicable, particularly in its earlier stages, before the disease has assumed its more distinctive features. The affections with which it is most liable to be confounded are herpes, eczema, balanitis, and simple excoriations, fissures, or abrasions, the result of friction and other accidents. Herpes, as will be seen in its appropriate place, is an eruption of the pre- puce and head of the penis, appearing in the form of little vesicles, hardly as large as the head of a pin, occurring in groups, closely set together, of a whitish color, and resting upon a florid base, with which they form a striking contrast. They are most frequent on the inner surface of the prepuce, in persons of red hair and tender skin, and often appear in successive crops, none of which last longer than six or eight days. They are characterized by a sense of itching and a slight serous discharge, manifest little disposition to extend, and usually promptly yield to very simple treatment. The resulting ulcer is always free from induration. Chancres never put on the appearance of herpes. The only approach to it is where the specific ulcers are seated in the raucous follicles, but in this case their circular form and excavated character will always serve to distin- guish them from common sores. Eczema is also an eruptive disease, but the little vesicles are more minute and diffused than in herpes, and there is also usually a greater amount of local irritation, the parts being swollen, hot, red, and itchy. When these vesicles burst, a thin watery fluid escapes, followed by the development of little deli- cate scales. The affection is apt to become chronic, and then little crevices generally form, increasing the irritation, and furnishing an acrid, sero-puru- lent, sanious, or ichorous discharge. Eczema is most common on the pre- puce, and is often particularly conspicuous at the free border of this muco- cutaneous covering. A careful examination of the affected parts, the history of the case, and the co-existence of the disease with eczema elsewhere will always lead to a correct distinction between this affection and chancre. It is probable that an inexperienced practitioner might mistake an incipient balanitis for a chancre, but no one who has ever seen the two diseases could possibly commit such an error. In balanitis the inflammation is generally widely diffused, often, indeed, over the whole surface of the prepuce and head of the penis, and the discharge is not only profuse but of a thick muco- purulent nature from the very commencement. There is no circumscribed ulceration as in chancre, and, indeed, no tendency whatever to destruction of tissue. These characters will always serve to prevent the disease from being confounded with chancre, which, whether indurated or soft, invariably presents itself as a distinct and well-defined ulcer. Simple ulcers, abrasions, or excoriations are liable to appear upon the prepuce and head of the penis, and may, unless great caution is exercised, be mistaken for chancres. They may proceed from a great variety of causes, as want of cleanliness, friction of the pantaloons, injury received during connec- tion, and intercourse with filthy females, especially such as are habitually the subjects of profuse and acrid discharges. However induced, such ulcers are always very superficial, and display no disposition to extend in depth, although they may spread considerably in diameter. The discharge which attends them is of an ichorous character, and they are usually surrounded by an inflammatory border, which is not the case in chancre. The most important diagnostic feature, however, by far, is that such ulcers always very promptly disappear under the most simple remedies, attention to cleanliness, with a cooling lotion and a mild aperient, generally sufficing to effect a cure in a few days. CHANCRE. 391 The site, size, shape, appearance, and course of chancre, considered sepa- rately, afford no reliable diagnostic evidence ; but viewed collectively they are of great importance as means of discrimination. Thus mere site and size are of no consequence, because a chancre may, like a common sore, occur on any portion of the penis and be very diminutive, as when, for instance, it occupies a mucous follicle ; but if, in addition to this, the ulcer is found to be excavated, to have a foul diphtheritic bottom, to pursue a chronic course, and to resist the ordinary means of cure, it is quite impossible to mistake its char- acter ; we conclude that it is specific, and nothing else. The indurated chancre is too well marked not to be recognized; it may, it is true, not be so easy to do this during the first few days of the disease, but it is altogether impossible to be deceived when the sore has attained its proper development, the hardened base to which it owes its name being then of itself sufficient to settle any doubts respecting the diagnosis. The history of the case often affords valuable information. If the patient is a married man, or if he has any other motive for concealment, he will be likely to deny that he has had impure connection, and even insist upon it that the sore on the penis is non-specific. Under such circumstances, it is not necessary to try to convict him of falsehood ; the surgeon examines the parts, and if he finds any suspicious looking ulcers, he will be very apt to conclude that they are syphilitic, and this opinion will be strengthened by the very de- nials of the patient, especially if he is noted for his gallantries. Young un- married men usually treat their attendants with entire candor, generally specifying with great particularity the time of the impure connection, and evincing no little anxiety to afford them all the light they can with a view of settling the diagnosis. We must, therefore, on the one hand, not believe that a man has not been exposed to infection simply because he says so ; and, on the other, it must not be taken for granted that every sore that may be found upon the penis is of a specific nature. Finally, in all cases of doubt the groins are to be examined with reference to the existence or non-existence of bubo. Iu the ordinary non-specific affections, above described, the occurrence of ganglionic enlargements is ex- tremely rare, and when it does happen it usually appears early in the attack, the bubo being small in extent, at the same time that it is comparatively transient. In chancre, on the contrary, bubo seldom comes on before the end of the third week, and the swelling, besides being generally considerable, is always per- sistent, frequently passing into extensive suppuration and ulceration. When the above means of diagnosis fail, which will seldom be the case if we are careful, the only other resource is inoculation, a small quantity of the suspected matter being inserted, upon the point of a lancet, in the skin on the inside of the thigh. If the operation is speedily followed by a vesicle, and this, in its turn, by a pustule, with a well-marked areola, there can be no doubt whatever respecting the true nature of the disease. Inoculation, if properly executed, cannot deceive, and is, therefore, after all, the only true and reliable test, although there are few surgeons of experience who will not, as a general rule, be able to determine the diagnosis without its aid. Treatment.—The treatment of chancre must be conducted with a twofold object; the prevention of the absorption of the specific poison into the sys- tem, and the rapid and effectual healing of the sore. If the poison be per- mitted to enter the lymphatic vessels, constitutional contamination will be inevitable, and the result of such a vice may be a long train of evils, which may continue during the rest of the patient's life, and, if he be married, even show themselves in his offspring. The prevention of the absorption of the virus constitutes what is called the abortive treatment, and should be an object of earnest solicitude in every case of the disease. Observation has proved that, if the specific character of a 392 SYPHILIS. chancre can be effectually eradicated before the end of the fifth day from the inoculation, the constitution will completely escape contamination, the chancre being up to this time a purely local affection. The matter secreted by the indurated chancre, which is the more common, although, as has been seen, not the only source of infection, does not possess any specific properties prior to this period, or, if it do, it does not appear to be amenable to absorption until the part has acquired a certain degree of development, of which the hardened and circumscribed base forms a most important and characteristic element. Up to tlris time it is almost certain that the matter may, by proper management, be prevented from reaching the system, and exerting any dele- terious impression upon it; but it is not equally certain that this procedure may not occasionally secure such immunity after this period, from the poison being unusually long delayed in the chancre, or, what is tantamount to this, from an indisposition on the part of the absorbents to carry it into the system. Hence, if there be no decided contra-indications, growing out of the exist- ence of severe inflammation, or inordinate size of the sore, the patient should have the benefit of the abortive treatment even after the lapse of the first week or ten days, although the chances of success will then undoubtedly be much diminished, as far as the security of the system is concerned. The abortive treatment is mainly of a local nature. The best plan of get- ting rid of the chancre is to dissect it out from the parts upon which it rests with a pair of forceps and a delicate bistoury, being careful to cut sufficiently widely around the diseased structures, so as to embrace the whole of them in the incisions. The operation requires some skill, but it is soon over, and, although a little painful, is rarely attended with any bleeding. Some caution is necessary, especially when the chancre has existed for an unusual length of time, to avoid inoculation of the wound ; a circumstance which might readily happen if the surface of the sore were permitted to come in contact with it. When the excision is completed, the part is to be treated with mild measures, like any common wound, and will generally heal in a very short time. If the patient be averse to the employment of the knife, or if the nature of the case be such as to induce the belief that excision cannot be effected without the danger of inoculating the raw surface, an attempt must be made to accomplish the object by means of escharotics. For this purpose several articles are in common use among the profession. The one most generally selected is a piece of nitrate of silver, cut to a very delicate point, and inserted into the ulcer, or broken vesicle, being held there until the infected tissues are brought thoroughly under its influence. The objection to this substance is its insufficiency; for, whether it acts simply as a neutralizer of the poison or as a destructive of the tissues, it is equally certain that it is generally un- reliable, and hence it ought never to be used in a case of such a serious nature. The article to which I have long given the preference, on account of its supe- rior efficacy, is the acid nitrate of mercury, prepared according to Bennett's formula, and applied either pure or variously diluted, according to the exi- gencies of each particular case. A good average strength is one part of the acid to double that quantity of water, applied with a piece of soft wood, the end of which is smooth and well rounded off. Such a contrivance is much better than a probe wrapped with lint or cotton, as the fluid can thus be brought in contact with the infected surface in a more concentrated and effi- cient manner. In order to prevent the solution from diffusing itself too widely, the parts should be previously well wiped, and immediately after bathed in pure water, or some weak alkaline lotion. The most suitable dress- ing will be an emollient poultice. When an escharotic is required, it is always better to make one free application than a number of imperfect ones. When the acid nitrate of mercury is not at hand, the cauterization may be effected with almost any of the mineral acids, especially the nitric and hydro- CHANCRE. 393 chloric. Some surgeons are in the habit of using caustic potassa, while others give a preference to the Vienna paste. Ricord has lately recommended a powerful caustic, composed of sulphuric acid and powdered vegetable char- coal, united iu the proper proportions to form a semi-solid mass. Of this a thin layer is applied to the chancre and the parts immediately adjacent, upon which it soon dries, forming a black adherent crust, which, on dropping off, as it usually does in eight or ten days, leaves a healthy granulating sore, rapidly followed by cicatrization. The objections to the carbo-sulphuric paste are the extreme pain which it produces, and its tendency to spread too far over the sound tissues. Conjointly with these local measures, it is necessary that the patient should be kept perfectly quiet for a few days, that his diet should be very light and non-stimulant, and that the bowels should be moved with some mild aperient. At the end of this time, unless there is evidence of undue inflammation, he may get up and go about his business. The abortive treatment having failed, or the time having passed for its successful employment, the question necessarily arises, How shall the case be managed in order to secure a prompt and satisfactory result? Supposing the chancre to be one of a simple character, unaccompanied by severe inflam- mation, the treatment ought to be of a correspondingly simple nature, all harsh and irritating applications being studiously avoided, inasmuch as they never fail to do harm, and thus retard recovery. From neglect of this pre- caution many a sore upon the genital organs that would, if gently managed, disappear in a few days, is often protracted for weeks, if not months, to the great detriment both of the part and system. Young practitioners, in par- ticular, are apt to fall into this error; their experience being limited, and their knowledge of the disease being derived from books rather than from clinical observation, they think they cannot do too much, and the consequence is that they fret and worry the sore until it places itself, so to speak, in a state of open rebellion, resenting all measures, local and constitutional, that are used for its cure. Instead of this, none but the most soothing means should be adopted, the object being to coax the disease, not to force it into terms. One of the first and most important points to be attended to, in every case, is cleanliness. This is best secured by frequent ablutions, or, what is pre- ferable, by immersion of the penis repeatedly during the twenty-four hours in tepid water, containing a little common salt, acetate of lead, or chloride of soda. If the chancre be concealed by a tight and inflamed prepuce, free use should be made of the syringe, as it will be impossible to effect retraction to an extent sufficient to accomplish the purpose. In the intervals of these local baths, which, while they serve to keep the parts nice and clean, contribute materially to the reduction of the concomitant inflammation, the ulcer should be kept constantly covered with a small piece of patent lint, wet with a weak solution of tannin and opium in compound spirits of lavender, yellow wash, or the dilute ointment of the nitrate of mercury, in the proportion of one part to six or eight parts of simple cerate. The tannin and opium constitute an excellent remedy, exerting at once an astringent and soothing influence, greatly promotive of healthy action. They form the principal ingredients of the aromatic wine, so much used in the French hospitals, and their efficacy has been well attested both in public and private practice everywhere. The yellow wash is also a very valuable remedy, but to obtain all the good which it is capable of yielding it should be employed very weak, as one-eighth of a grain of the mercury to the ounce of water, the strength being increased if it be found necessary on account of the slow progress of the case. The officinal preparation is much too strong and irritating, and must therefore be scrupulously abstained from. In my own practice I have derived great benefit 394 SYPHILIS. from the ointment of the nitrate of mercury, diluted as above mentioned, and applied either alone or in union with tannin and opium. In fact, there is no remedy which has done better or more efficient service in my hands than this in the treatment of simple chancre. I am aware that by many all greasy articles are denounced as being injurious, in consequence of their alleged tendency to become decomposed and rancid. Such objections, however, can only be considered as having any force when these applications are too long continued, or when there is a want of attention to cleanliness, the secretions being allowed to accumulate unduly, so as to promote putrefaction. All this may be readily obviated by changing the dressings every five or six hours, and taking care that the ointment shall always be very fresh. There is one important rule which applies here with as much force as in the case of common ulcers, and that is to vary the dressings whenever they are found to be unproductive of benefit, making them now weaker, now stronger, adding new ingredients, or omitting old ones, or changing the re- medy altogether. Much of the success, in every case, will depend upon the care with which this rule of practice is carried out. When the parts begin to granulate, the simplest dressings generally suffice; such as common ointment, Turner's cerate, diluted with five or six times its bulk of fresh lard, or merely a bit of dry lint carefully interposed between the contiguous surfaces. The latter application often promotes cicatrization with remarkable rapidity. When the head of the penis is swollen and painful, it must be kept constantly buried in an emollient poultice, made of powdered elm bark or ground lin- seed, and frequently changed. Or, instead of this, the warm water-dressing may be used, its efficacy being increased by the addition of laudanum and acetate of lead. It need hardly be added that the organ should be inces- santly maintained in an elevated position, just as any other part of the body in a state of inflammation. Constitutional treatment is important, and must therefore claim due at- tention, however simple the sore. Perfect quietude of mind and body is indispensable in every case. The effects of any disturbance of this kind are sure to be promptly seen in the aspect of the sore and the character of the secretion. The diet must be plain and simple, animal food and stimulants being carefully avoided; the bowels must be kept open by cooling purga- tives; and, if need be, free use must be made of the saline and antimonial mixture. Venesection will rarely be required, and then only in very pleth- oric subjects. If the local trouble be considerable, leeches may be applied to the groins or the inner surface of the thigh, care being taken to cover the bites, when the flow of blood has ceased, with collodion, in order to prevent their inoculation from the accidental contact of the chancrous matter. These animals should never be applied to the penis itself, much less to the parts immediately affected, as their secretions could hardly fail to come in contact with the little wounds, and so propagate the disease. If the ulcer belongs to the indurated variety, or if it be followed by a suppurating bubo, a mo- derate course of mercury will be proper; but as this is a subject which will come up for consideration by and by, it will not be necessary to enlarge upon it here. Chancre, complicated with undue inflammation, phagedena, gangrene, or excessive inactivity, requires some modification of treatment, adapted to the peculiar conditions of the part and system which are always present under such circumstances, and which may, therefore, be regarded, in the true ac- ceptation of the term, as so many exciting causes of the morbid action. It is only by bearing in mind the intimate relation subsisting between the local disorder and the state of the constitution, and the influence which they re- CHANCRE. 395 ciprocally exert upon each other, that the practitioner may hope to treat these epiphenomena with any immediate prospect of success. When chancre is accompanied by severe inflammation, as denoted by the swollen, discolored, and painful condition of the parts, and the feverish state of the system, recourse must at once be had to the vigorous employment of antiphlogistics, for the purpose of moderating, as promptly as possible, the violence of the disease. Bleeding at the arm, active purgation, light diet, and the use of antimonials, with absolute rest in the recumbent posture, cool- ing, anodyne, and mildly astringent lotions to the ulcer, and an emollient poultice or the warm water-dressing for the head of the penis, constitute the chief remedies in such an emergency, and must be carried to an extent com- patible with the powers of the system. Pain and morbid erections are re- lieved with opiates, administered in full doses. By these means the disease is soon brought under subjection, when it is to be managed in the same gentle manner as the milder forms of chancre already described. When the ulcer assumes a phagedenic character, manifesting a disposition to spread more or less rapidly both in depth and diameter, the principal addi- tion to the treatment, required in chancre complicated with undue inflamma- tion, consists in the increased amount of opium employed to soothe the part and system, which are generally excessively irritable in this variety of morbid action, and can only be successfully quieted by the most liberal use of this article. If the skin be hot and arid, the pulse excited, and the face flushed, the opium should be combined with antimony, or some cooling diaphoretic, so as to produce a decided determination to the surface. The diet and bowels must receive due attention; all stimulants must be avoided ; and the mind and body must be maintained in the most tranquil condition. If mercury has been given, its use is at once to be abandoned, experience having shown that, under such circumstances, it not only produces great harm, but that in many cases it is the principal cause of the phagedenic action. The local applications should all be of the blandest kind, consisting of warm water-dressing or emollient poultices, and of lint steeped in mucilage of gum arabic, or an infusion of elm bark, with the addition, to each ounce of fluid, of from two to three drops of nitric acid and one drachm of the vinous tincture of opium. If the disintegrating action is very rapid, the nicer should be touched freely with a solution of the acid nitrate of mercury, or a piece of solid nitrate of silver, its surface being kept constantly covered in the interval with the medicated lotion just mentioned. In some cases no- thing will arrest the erosive tendency so speedily as a weak solution of sul- phate of copper, in the proportion of from half a grain to a grain to the ounce of water, with the addition of from four to six grains of tannin and opium. The phagedenic form of chancre, however, does not always occur in the strong and robust; the system may be, and often is, in an adynamic condi- tion, requiring tonics and stimulants instead of depressants. The constitu- tion, degraded perhaps by long suffering or by all kinds of intemperance and starvation, must be brought up by quinine and iron, with porter, ale, or milk punch, a nutritious diet, and change of air, particularly if the patient be the inmate of a crowded and ill-ventilated hospital. The dissipated and ener- vated residents of large cities are particularly prone to suffer from phagedena during the progress of chancre, and the practitioner, therefore, cannot be too much upon his guard how he depletes this class of individuals. What is needed in such a state of the system is perfect tranquillity of mind and body, as secured by the liberal exhibition of anodynes, and a better condition of the blood, to enable the part to institute a more salutary action. If gangrene set in, the treatment must vary according to the concomitant state of the system, independently of any consideration growing out of the 396 SYPHILIS. presence of the specific virus. The question should simply be, is the action on the part of the system too high or too low ? If the former, antiphlogis- tics will be indicated, and should be promptly employed, although not with- out a certain degree of restriction, lest the powers of the constitution should suffer from the effect, and thus promote the spread of the disease. Bleeding and purgation must be used warily ; the practitioner must measure his ground and feel his way. The excitement may only be apparent, not real; and may, consequently, shortly subside, either spontaneously, or under very simple remedies. Most likely the action is typhoid from the beginning, or, if not, it soon will be ; hence, instead of a depletory, a corroborative course will be necessary, similar to that in ordinary gangrene in other parts of the body, our chief reliance, so far as constitutional means are concerned, being upon quinine, ammonia, brandy, camphor, and opium, with jelly and rich animal broths. As it respects the part itself the indications are, first, to arrest the gan- grenous action, and secondly, to promote the separation of the eschars. To fulfil the first of these objects, the affected structures are freely painted with the dilute tincture of iodine and wrapped up in an emollient poultice, medi- cated with laudanum and acetate of lead, while the dying tissues are well mopped with the acid nitrate of mercury, or brought under the full influence of the solid nitrate of silver. If any constriction exist, such as that produced by a tightened and retracted prepuce, it must be promptly relieved with the knife. The detachment of the sloughs may be promoted artificially, or, if not too large, be intrusted entirely to nature's efforts; at all events, all harsh interference must be carefully avoided. Fetor is allayed by the chlorides. The sloughs having separated, the next object is to invite the development of healthy granulations; and for this purpose the most available remedies will be found to be the nitric acid lotion, with tincture of opium, the oint- ment of the balsam of Peru, the aromatic wine, or the dilute ointment of the nitrate of mercury, with the warm water-dressing or an emollient cataplasm, as a general covering to the affected structures. Chancre attended with deficient action—the indolent sore of some syphilo- graphers—demands for its successful management a careful investigation of the nature of the exciting cause of this particular state of the part before recourse be had to direct treatment. In general, it will be found to depend upon some defect of the system, by correcting which the ulcer will speedily assume a healthy appearance, throwing out florid granulations, furnishing thick, laudable pus, and cicatrizing along its margins. Or it may be that the obstacle is of a strictly local nature, caused by want of cleanliness, by an undermined condition of the sore, or, finally, by the presence of a thick, semi- organized layer of lymph, firmly adherent to the surface of the chancre. Whatever it may be, it should, if possible, be promptly rectified; the consti- tution, if at fault, is improved, and the part is treated with special reference to the promotion of the granulating process. Particular attention is given to cleanliness, the hardened and shelving edges are trimmed off with the knife, and the incrusted surface, freely cauterized with the nitrate of silver or acid nitrate of mercury, is kept constantly covered with blue ointment or some stimulating lotion. The indolent form of chancre is frequently accompanied with an indurated base, which often continues a considerable period after the ulcer has become completely cicatrized, and constitutes a variety of primary syphilis peculiarly dangerous on account of its liability to be followed by constitutional symp"- toms. The idea now almost universally prevails that no person is safe from constitutional contamination so long as the part remains in this condition. It is an incontestable evidence that the specific virus still lingers at the original seat of the infection, and that, like a smothered fire, it may spring CHANCRE. 397 up at any moment into a full blaze, re-exciting ulceration, and endangering the system. It is to this form of chancre, more particularly, that mercurial- ization is applicable, very few patients thoroughly recovering without it. The manner in which it should be conducted has given rise to much discus- sion, and is deserving of special attention. My own opinion is that the more simple and gentle the mercurial course is the better. It should be carried just far enough to affect the gums, and no further. The object is not to cause profuse salivation, as was the wont of the older surgeons, but merely to produce slight soreness of the mouth, as an evidence of the constitutional impression, and to maintain this impression, in an equable, uniform manner, until the local affection has completely dis- appeared. The preparation which I usually prefer is calomel, in doses of from one to two grains three times a day, in union with a little opium, or, if there be dryness of the surface, with morphia and ipecacuanha. Blue mass is also a valuable article, and may often be employed as a substitute for the calomel, especially in the young and delicate. As soon as the medicine has produced a slightly salivant effect, or soreness of the gums, it is to be dis- continued, or given in smaller doses and at longer intervals. If the desired result be slow in coming on, the treatment may be aided by mercurial in- unction, from one to two drachms of the blue ointment being rubbed on the inside of the arms and thighs morning and evening. I prefer calomel, blue mass, and mercurial ointment to the more modern preparations of mercury, chiefly for the reason that they are less liable to gripe, and also because they are more certain and reliable in their effects. Iodide of mercury, the article usually resorted to by modern practitioners, nearly always causes intestinal irritation, and is, as I know, from ample ex- perience, generally very tardy and unsatisfactory in its action. The bichlo- ride, so valuable in the tertiary form of syphilis, is not a reliable medicine in chancre, except, perhaps, in cases of extraordinary chronicity, in which I have sometimes given it with much benefit, in doses varying from the twelfth to the eighth of a grain every eight hours. Mercury must not be employed, in any form, in the treatment of primary syphilis, if there be fever, or general excitement of the system. In such a case the patient must be subjected to a certain amount of preliminary treat- ment, consisting of rest, abstinence, purgation, and the use of salines and antimonials. A similar course is to be followed in phagedena and gan- grene, or even when there is merely an unusually irritable state of the consti- tution. Exhibited under such circumstances, the mineral never fails to pro- duce mischief, by increasing the local and general derangement. The great art of administering mercury in this and other diseases is to know when and how to give it; never to employ it sakelessly, or simply because it is mercury, but to give it for a good reason ; and in order to do this properly a great deal more judgment is required than is generally imagined. Upon the man- ner in which the article is used in primary syphilis will, in great degree, de- pend the future welfare of the patient. There can be no question that primary and even secondary syphilis are often curable without mercury. Every practitioner meets with instances where none but the most simple means are necessary to attain this object promptly and satisfactorily. For the last twenty years I have rarely given this mine- ral in any case of these two forms of the affection ; and, although tertiary symptoms have occasionally supervened upon this mode of treatment, I have, on the whole, had no cause whatever to regret it, but quite the contrary. The value of the non-mercurial treatment was fairly tested, in hundreds, if not thousands, of cases, by the British surgeons, during the Peninsular wars, and their results, as published by some of their most enlightened and reliable brethren, prove, in the most irrefragable manner, that primary syphilis may 398 SYPHILIS. generally be effectually relieved by ordinary antiphlogistic means. It was found that the average period occupied by the treatment of chancre unac- companied by bubo, without mercury, was twenty-one days, a little more than twice this period being required when the sore was followed by bubo. On the other hand, the cases that were treated with mercury required, for the cure of the chancre, an average of thirty-five days, and for the chancre and bubo fifty days. The results of the practice of certain hospitals are equally corroborative of the value of this treatment. Thus, in the various hospitals of Sweden, of 20,000 cases treated with mercury, the number of relapses amounted to thirteen and two-thirds in the hundred; whereas, in alike num- ber of cases treated by the simple method, the proportion of relapses was only seven and a half. In the Hamburg Hospital, out of 1649 patients, of both sexes, 582 were treated with mercury, and 1067 without mercury; the mean duration of the cure in the former was eighty-five days, and of the lat- ter, fifty-one days. At Strasbourg, 5271 persons were treated without mer- cury, with hardly any relapses and secondary affections. The above results are greatly in favor of the non-mercurial plan of treat- ment; and they deserve the more attentiou because it was formerly believed that the primary disease, when so relieved, is more liable to be followed by constitutional symptoms than when the patient gets well without the aid of the mineral. Finally, another fact developed by the British observers, and one repeatedly noticed in private and hospital practice since, is, that when mercury is exhibited in undue quantities, and especially in states of the sys- tem not properly prepared for its reception, the constitutional contamination is apt to be of the very worst kind, a sort of mercurio-syphilitic diathesis being established, which, in its remote effects, is more unrelenting and irra- dicable than the original disease, however severe. If hemorrhage arise during the progress of chancre, no time should be lost in arresting it; the patient may be already much exhausted by previous suf- fering, and a slight drainage of this kind might therefore prove eminently prejudicial to his recovery. When the blood issues unmistakably from an open orifice, it should at once be secured by ligature or the compressing for- ceps, a sufficiency of tissue being included in their bite to insure safe main- tenance. If, on the contrary, it proceeds from many points, the ordinary styptics will generally suffice for its arrest, especially if the system be promptly brought under the influence of opium. The morbid erections which so often accompany chancre", and which gene- rally so much impede the reparative process, must be treated in the same manner as in gonorrhoea; by the liberal use of anodynes by the mouth or rectum, and by soothing topical applications, either warm or cold, as mav be most grateful to the part and system If hemorrhage be present, they must be controlled at all hazards, on account of their tendency to tear open the bleeding vessels. Phymosis, complicating chancre, must not be interfered with, unless it act constrictingly, threatening destruction of the prepuce and the glans by mor- tification. In this event, the parts must be freely divided upon the grooved director, the edges of the incision being immediately cauterized with nitrate of silver or acid nitrate of mercury, to prevent inoculation. In ordinary cases, the tightened foreskin is permitted to retain its place, cleanliness and medication of the ulcer being effected by means of the syringe, as already stated. J ° ' J Paraphymosis is occasionally present, perhaps to a perplexing and even dangerous extent. The constriction produced by it may be such as to cause excessive oedema of the prepuce, and great engorgement, if not severe swell- ing, of the head of the penis; inducing a condition of things which, if not speedily relieved, may eventuate in extensive gangrene. These effects raay CHANCRE. 399 be brought about whether the chancre be situated on the glans or on the retracted prepuce, and, for the reason just mentioned, always demand prompt attention. An attempt should be made to restore the parts by manual ef- forts, aided by chloroform, to give the surgeon more perfect command over his movements. This failing, the only alternative is to divide the stricture, care being taken afterwards to keep the wound well coated with collodion. Chancre of the Urethra.—Chancre occasionally attacks the urethra; pro- bably much oftener than is generally supposed, although its relative frequency to chancre of the prepuce and head of the penis has not been determined. The fact that this disease is liable to occur here was not known, even to the most enlightened syphilographers, until within a comparatively recent period, and hence it is not surprising that many of them should have considered gonorrhoea as capable, in some cases, of giving rise to secondary symptoms. The chancre being concealed in the urethra, the discharge which attended it was regarded as being exclusively the product of gonorrhoea, and the igno- rance which existed upon the subject would probably never have been removed if it had not been for the practice of inoculation. The numerous experiments which have been performed upon the subject have proved, be- yond the possibility of doubt or cavil, that gonorrhoea is a mere local affec- tion, and that, whenever any constitutional syphilitic phenomena occur as a consequence of a urethral profluvium, those phenomena are due, not to the effects of gonorrhoea, but to those of a urethral chancre. Chancre of the urethra is generally situated just behind the meatus, or in that portion of the tube which corresponds with the glans; I have, however, repeatedly met with it on the lips of the external orifice ; and in the case of a young gentleman, recently under ray care, I found a well-marked indurated chancre at least two inches behind the anterior extremity of the tube. The disease occasionally, though very rarely, extends over nearly the whole of the urethra, as far back as the neck of the bladder. The period of latency of chancre of the urethra is much longer than in the ordinary form of the disease, which, on an average, does not exceed four or five days; here, on the contrary, it is rarely less than three and a half or four weeks. The reason of this would seem to be that the specific virus, being entangled in one or more of the lacunae of the tube, is incapable of exciting the same rapid influence as when it is brought in contact with an abraded surface upon the head of the penis. Moreover, it is extremely probable that only a very small quantity of the poison generally finds its way into the ure- thra, and that, consequently, it has great difficulty, not merely in effecting a secure lodgment, but in so multiplying itself as to enable it to produce ulti- mately an explosive effect upon the mucous and submucous tissues. The urine, passing along the tube soon after the intromission of the specific fluid, will, in general, either wash it entirely away, or, combining with it, effectu- ally neutralize its properties. The discharge attendant upon chancre of the urethra is generally less copious than in ordinary gonorrhoea; it is also more thin, and of a lighter color, unless the accompanying inflammation is unusually severe, when it may be both profuse and of a thick, bloody character, or thick and yellow with a greenish tinge. There is generally some degree of scalding in micturition, though hardly ever as much as in gonorrhoea, and the site of the chancre is nearly always indicated by a sense of hardness, or a kind of lump easily dis- tinguished by the thumb and finger. When the disease affects the anterior extremity of the tube, it is not uncommon to find great induration of the whole head of the penis with a red and phlogosed appearance of its mucous covering, and considerable tumefaction of the prepuce. Morbid erections are not only frequent but often very painful and troublesoiue. The disease is usually chronic, and rarely gives rise to fever, although it is liable to be fol- 400 SYPHILIS. lowed by secondary and tertiary symptoms. Bubo is not one of its ordinary effects; but a certain amount of contraction of the urethra nearly always is. The diagnosis of chancre of the urethra is often difficult. It is certainly easy enough when the ulcer is situated at the lips of the meatus, or just be- hind the orifice, the separation of the edges of which will then bring it fully into view, or, at all events, to an extent sufficiently satisfactory. When located farther back, its existence becomes a matter of doubt; for, although the induration which accompanies it raay be very distinct, yet as a similar condition may be present in gonorrhoea, in consequence of the development of an abscess, or the escape of a drop of urine into the submucous cellular tissue, no useful deduction can be drawn from it. Perhaps the most valuable rational symptoms are, the unusual latency of the poison, or the extraordi- nary length of time which intervenes between the impure connection and the outbreak of the disease, the remarkable obstinacy of the attack, resisting, as it generally does, all the various methods of treatment which are commonly directed for the cure of gonorrhoea, and, lastly, the slight scalding in micturi- tion, and the frequent variation in the nature of the discharge, which is now scanty, thin, and serous, and now profuse, thick, and yellow. The only real diagnostic character, however, is furnished by inoculation, which should be promptly resorted to in all cases of doubt on account of the selection of a proper and efficient course of treatment. The treatment of chancre of the urethra is to be conducted upon general anti-syphilitic principles. The remedies which prove so serviceable in gonor- rhoea are entirely inert here, except in so far as they may be instrumental in diluting the urine and depriving it of its acrimony. When within reach gentle cauterization with nitrate of silver will be beneficial, and, in obstinate cases, hardly any other direct application will be of much avail. In the intervals of the cauterization, or, in the more intractable forms of the disease, through- out the treatment, different kinds of injections must be used, especially weak lotions of sulphate of copper, tannin, and opium, acetate of lead, bichloride of mercury, and iodide of iron. If the sore be seated near the meatus, the opposite surfaces should be kept apart with a tent medicated with the dilute ointment of the nitrate of mercury ; or a small bougie smeared with this sub- stance may occasionally be introduced. If marked induration exist, early but gentle mercurialization must be employed, both as a means of promptly curing the chancre, and of protecting the system from contamination. Chancre in the Female.—Chancre in the female is most common upon the vulva, in the vagina, and upon the uterus, the relative frequency of the occurrence being in the order here stated. The perineum also sometimes suffers. The inferior portion of the vagina is much more liable to be affected than the superior, but both this part of the tube and the uterus are not nearly as often the seat of the indurated, or true Hunterian chancre, as was at one time supposed, owing probably to the fact that the infecting matter which covers the sore of the penis is wiped off during coitus before the organ has effected full penetration. The nature of the ulcer is easily recognized by its excavated shape, its steep, irregular edges, its foul, unhealthy-looking bot- tom, and its indurated base. In chronic chancre of the uterus, the hardness is generally wide-spread and most characteristic, the neck and mouth of the organ being almost of a stony consistence, deeply engorged, and of a florid hue. The soft or non-indurated chancre is much more comraon than the indu- rated, the two varieties of sore following, in this and other respects, the same laws in the female as in the male. The former is often multiple, and may acquire a large size ; the latter, on the contrary, is usually single, and almost always very small, its dimensions rarely exceeding those of a five cent piece. Both classes of ulcers are frequently the seat of excessive pain, especially BUBO. 401 when they attack the vulva and the inferior portion of the vagina. Their march is generally chronic, and their presence can only be satisfactorily de- termined by careful ocular inspection. In regard to their diagnosis, the sur- geon must be guided principally by the history of the case, the character of the patient, and the appearance of the ulcers. When the ordinary means of discrimination fail, inoculation must be practised. In the treatment of chancre in the female, the same general rules are to be observed as in the treatment of chancre in the other sex. Absolute rest in the recumbent posture, active purgation, the saline and antiraonial mix- ture, anodynes, diaphoretics, the warm bath, and light diet constitute the principal constitutional remedies. The most important topical means are frequent injections of cold water, or cold water impregnated with some mild anodyne and astringent articles ; cauterization with the solid nitrate of silver or the dilute acid nitrate of mercury; and isolation of the sores by tents of patent lint, medicated with aromatic wine, lotions of tannin and opium, yel- low wash, or some slightly stimulating unguent, especially the dilute ointment of nitrate of mercury. In obstinate cases, especially in the indurated chancre, a mild course of mercury will be necessary. 2. BUBO. Bubo is an enlargement of one or more of the lymphatic ganglions of the groin. It may proceed from a great variety of causes, tending to irritate aod inflame the lymphatic vessels leading to these glands; thus it may be occasioned by gonorrhoea, excessive sexual indulgence, fatigue from protracted exercise, injury of the inferior extremity, or the presence of a boil upon the nates, thigh, or perineum. Such swellings are particularly liable to occur in young subjects of a scrofulous temperament, in whom they often arise from the most trivial causes, and generally disappear without much, if any, treatment; the concomitant inflammation being usually very slight and seldom passing into suppuration. The syphilitic bubo, on the contrary, is a specific disease, the result of inoculation with the matter of chancre, and capable of furnishing a secretion similar to that by which it was itself pro- duced. An open syphilitic bubo is, in fact, a chancre, and nothing else. Hence, like the latter, it constitutes merely a form of primary disease ; for so long as the poison is limited to the glands of the groin there cannot, of course, be any true contamination of the system. It is only when it passes beyond this point that its operation can become general; up to that period syphilis is essentially a local affection. The true syphilitic bubo rarely arises until the end of the second week, or the beginning of the third from the appearance of the original sore; cases sometimes occur at an earlier period, as the seventh or eighth day, and, on the other hand, the attack may be postponed until the close of the first month. Some authorities, Puche among the rest, would have us to believe that the disease may occasionally not show itself until after the lapse of three years. Such a statement, although apparently credited by respectable au- thorities, is too ridiculous to be seriously entertained by any one. Nature undoubtedly constantly deviates from her established laws, but it is impossi- ble to suppose that she could be guilty of so great a departure as such an occurrence as this would imply. We must rather conclude that the fault lies in a want of correct observation than in such a flagrant violation of the laws of syphilis. Bubo may follow either the soft or the indurated chancre, but in order to do this it is necessary, as a general rule, that the sore should be free from phagedena and gangrene, or, indeed, from severe inflammation of any kind, inasmuch as the absorption of the specific virus and its transmission to the vol. i___26 402 SYPHILIS. groin are accomplished with great difficulty when the parts are overpowered by disease. An active, open state of the ulcer, and the smallest conceivable amount of inflammation in the structures immediately around, are, other things being equal, the conditions which are the most favorable to the devel- opment of the true syphilitic bubo. Considerable diversity exists in respect to the aptitude with which the two varieties of chancre produce bubo, as well as in regard to the characters of the bubo itself. Thus, the indurated chan- cre is always followed by bubo, the swelling, which usually involves several ganglions, being hard and chronic, and partaking more or less of the charac- ter of the parent sore, without much disposition to suppurate, although it is sure eventually to contaminate the constitution. The pus, moreover, which occasionally forms, is not generally specific, and is for the most part of a thin, ichorous nature. The soft chancre, on the other hand, is only now and then followed by bubo ; the disease, which attacks only one gland, always runs its course very rapidly, and soon terminates in the formation of an ab- scess, the fluid being both abundant and readily inoculable. However produced, the specific bubo will generally be found to occur on the same side as the chancre. Thus, if the ulcer exist on the right side of the penis, the right groin will be the one to suffer, and conversely. Now and then an exception to this rule is met with, depending, probably, upon an interlacement of the lymphatic vessels, those of the right side passing over to the left, and the reverse. A bad form of bubo occasionally occurs at the root of the penis, or upon the pubes, caused by the presence of an infected ganglion. Both sexes are liable to syphilitic bubo; but males suffer much more frequently than females, owing to the difference in the arrangement of the lymphatic vessels, those of the former passing in a much more direct manner than those of the latter from the seat of the disease. In chancre of the uterus and upper part of the vagina bubo is uncommon, and the same law holds good in chancre of the urethra in men. The relative proportion of bubo to chancre has not been settled ; while the indurated form of the disease is very generally followed by swelling of the inguinal glands, soft chancre does not perhaps produce such an effect oftener than in one case out of four. An opinion has extensively prevailed during the last twenty years, or more, that a bubo may form in the groin without the intervention or ante- cedence of a chancre, in consequence of the direct absorption of the specific poison from a mucous or cutaneous surface. It is maintained by the advo- cates of this doctrine that such an effect is possible, because, as they allege, bubo and even constitutional symptoms occasionally occur without any evi- dence whatever of their having been preceded by primary ulcers upon the genitals. ^ They assume that the matter in which the poison is entangled, or held, as it were, in solution, may be absorbed by the mucous or even the cutaneous surface of the penis in the same manner, and upon the same prin- ciple, as morphine, atropine, and other articles of the materia medica, and that, being subsequently conveyed by the lymphatic vessels to the groin, it is capable of infecting its glands in such a way as to form a true syphilitic bubo. Hence, the disease has been called the primary non-consecutive bubo, or, to use a French phrase, bubon d'emblte. The existence of this variety of inguinal enlargement was admitted by several of the older writers on syphilis, especially by Astruc and Swediaur, and has been dwelt upon at much length by Ricord and his disciples. Many of the most experienced practi- tioners, however, in all parts of the world, positively assert that they have never met with it, and, as for myself, I am quite sure that no instance of the kind has ever fallen under my observation. My belief, therefore, is that the occurrence is a mere chimera, explicable on the supposition that the chancre BUBO. 403 which precedes it is so small and evanescent as to elude detection. It is certain that such slight and transient ulcers often do appear on the genital organs of both sexes, and that, notwithstanding they do not attract any attention either on the part of the patient or his attendant, they are yet not unfrequently followed by the worst forms of constitutional contamination. An excellent observer, Dr. Bumstead, of New York, in his able work on venereal diseases, in speaking of this subject, makes the following very appo- site remarks:—"The existence of a bubon d'emblee, secreting inoculable pus and capable of infecting the constitution, is entirely inconsistent with our present knowledge of venereal diseases, and cannot now, as formerly, be admitted. The reported cases of this character are very far from being conclusive." Varieties.—Bubo, like chancre, is susceptible of a great variety of forms. Thus, it may, after having progressed a certain distance, remain stationary, perhaps even several months, manifesting no decided disposition either to advance or to recede. Conjoined with this indolent, passive, or inactive state is generally a certain degree of hardening, such as we so often observe in the chronic indurated ulcer upon the head of the penis. Such a swelling is always to be dreaded on account of the disposition which the specific poison has to lurk in the substance of the affected glands, from which, in time, there is great danger of its being conveyed into the system, so as to give rise ultimately to secondary and tertiary symptoms. The bubo, in fact, is a hot-bed, not merely for the temporary lodgment of the virus, but for its zymotic operation, and its gradual extension to other and more important structures. In another class of cases the enlarged glands, taking on inordinate inflam- matory action, pass into suppuration, the matter usually collecting in a solitary abscess, of an ovoidal shape, and from the volume of an almond up to that of a goose's egg. When the disease assumes this form, it generally runs its course with considerable rapidity, being characterized by severe constitutional disturbance, such as rigors, fever, and headache, and by in- tense local suffering, the pain being of an aching, throbbing character, the swelling great, the heat excessive, and the discoloration of a dusky livid red. If the matter, which is generally of a thick, yellowish appearance, inter- mingled with blood and cellular sloughs, be not promptly evacuated, it is apt to burrow among the neighboring tissues, causing extensive sinuses, which it is often extremely difficult to heal, and which occasionally lay open most important structures. In neglected cases I have seen such an abscess, more than once, pass high up over the abdomen, and low down upon the front of the thigh. Iu the indurated bubo, the result usually of an indurated chancre, the secretion is generally comparatively scanty, and of a thin, ichorous, sanious, or sanguinolent nature. Whenever the quantity of matter is unusually large, it may be assumed that it is furnished by the cellular tissue in which the affected glands are wrapt up rather than by the glands themselves. When the contents of the abscess have been discharged, whether sponta- neously or otherwise, the disease takes the name of an open or ulcerated bubo, a state in which it may remain, with very little change, for an almost indefinite period. The discharge from such a sore, which is always situated above Poupart's ligament, and which inclines from above downwards and inwards, may partake more or less of the character of laudable pus, or it may, as most generally happens, be thin, ichorous, and irritating, its quantity varying from several drachms to upwards of an ounce in the twenty-four hours. How long it may retain its specific properties is unknown. The edges of the sore exhibit very much the same appearances as those of a common chancre; thus, they may be very steep, hard, and ragged; everted, 404 SYPHILIS. inverted, or undermined; thick or thin; pale, reddish, dusky or purple. The bottom is usually incrusted with a dirty, greenish, or yellowish pulta- ceous substance, withhere and there a small, fiery looking, exquisitely sensi- tive granulation. Sinuses often extend from the main ulcer in different directions, and it is not uncommon, when the destruction has been at all extensive, to see some of the affected ganglions lying in a partially detached state at the bottom of the sore, perhaps adhering merely by a few shreds of cellular tissue. An ulcerated bubo may take on phagedenic action, extending more or less rapidly in different directions, just as in the case of a chancre occurring in an unhealthy constitution. This epiphenomenon may show itself soon after the swelling has been laid open, or not until after the lapse of several weeks or months. It is usually characterized by severe pain, by a thin, profuse, sanious discharge, and by a foul pultaceous state of the sore, along with an irritable condition of the system, want of appetite and sleep, and disorder of the alimentary canal. Finally, a syphilitic bubo raay become the seat of gangrene; sometimes before ulceration sets in, but usually not until afterwards. Such a termination is most apt to occur in the lower classes of patients, the inmates, of cellars, prisons, almshouses, and other filthy places, and often produces the most frightful ravages, causing extensive destruction of the skin and cellular tissue, as well as, in some cases, of the muscles of the abdomen. The symptoms are generally very severe, and the disease often proves fatal, the sufferer, mean- while, forming a most loathsome and disgusting object. Diagnosis.—Syphilitic bubo is liable to be confounded with bubo from other causes, and hence it is by no means always easy to determine the diag- nosis, desirable as it is that there should be no mistake upon a subject of such practical moment. There are a few points in connection with these two classes of swelling which are deserving of attention as means of discrimina- tion. In the first place, the surgeon must carefully consider the history of the case. If the bubo be of a syphilitic nature it will not, as a general rule, come on until the end of the second week from the primary disease, and in many instances, indeed, not until a considerably later period. In the common bubo, on the contrary, the swelling usually supervenes within a short time after the exciting cause has begun to act. Thus, a boil upon the nates, or a corn, bruise, or other injury of the toe, is usually followed by a bubo within the first three or four days after the local affection has sprung up. Secondly, useful information may be obtained from the duration of the swelling. A syphilitic bubo usually lasts a number of weeks, often, indeed, several months; an ordinary bubo, on the other hand, generally promptly disappears with the exciting cause that induced it. Thirdly, the specific bubo often suppurates and ulcerates; the comraon bubo seldom, if ever, and then only in persons of a scrofulous and broken constitution. Fourthly, the matter of the syphi- litic bubo is often inoculable; of the common, never. Finally, the syphilitic swelling is always situated above Poupart's ligament, affecting mostly only one gland; the non-syphilitic swelling, on the contrary, is usually situated below that band, or partly below and partly above, and generally attacks several ganglions, though rarely in an equal degree. The scrofulous bubo occurs only in persons of a scrofulous diathesis, mostly in children prior to the age of puberty. It commonly affects a considerable number of glands simultaneously, and they remain enlarged for a long time, being very hard and lobulated, and slowly tending to suppuration. The matter is of a yellow-greenish hue, and collects in several little abscesses, which, bursting, leave ill-conditioned ulcers, with thin, bluish, undermined edges, and a thin, sanious, irritating discharge, destitute of inoculable pro- perties. The bulk of the swelling is usually situated beneath Poupart's BUBO. 405 ligament, at the upper and inner part of the thigh; and traces of strumous disease generally occur in other parts of the body. Treatment.—The treatment of bubo must be conducted upon the same general principles as that of chancre, of which, as already stated, it is simply another form. If the disease be seen early, before there is much inflammatory action or any decided tendency to suppuration, the abortive treatment will come in play, consisting of the free application of tincture of iodine, and of concentrated compression, either with a truss, or a series of linen pads and the spica bandage. There are few cases of incipient bubo which can resist the combined influence of these remedies, if properly managed. If the com- pression, in the efficacy of which I have great confidence, proves painful, it must be moderated, or altogether pretermitted for a time. Occasionally the treatment is advantageously preceded by the application of leeches. If the disease has already made considerable progress, iodine and com- pression will probably prove insufficient, and then more active measures will be required. Of these, the most efficient is the formation of an eschar upon the most prominent portion of the swelling by means of the Vienna paste, applied as in making an issue, or a solution of bichloride of mercury, in the proportion of twenty grains to the ounce of alcohol. The skin having been previously elevated by a small blister, a compress wet with the lotion is firmly bound upon the raw surface, and retained for two hours, when it is replaced by an emollient poultice or the warm water-dressing. The pains produced by this application are excessive, and hence the paste usually deserves the preference, especially as it does not possess any special therapeutic advan- tages. The new action created by the caustic neutralizes or overwhelms the pre-existing, and rapidly destroys the specific disease. When suppuration is threatened, or inevitable, the process should be ex- pedited by the usual means, aided by recumbency and a relaxed position of the lower extremity. As soon as fluctuation is observed, the parts are freely divided, even if the matter be deep-seated, in order to give full vent to the confined fluid. A tent is kept in the opening to prevent closure of its edges. The incision should always be made in the direction of Poupart's ligament. If the bubo is chronic and indurated, the operation is sometimes attended with considerable hemorrhage, chiefly, however, of a venous nature, and con- sequently easily arrested by pressure and quietude. When the suppurative process is very slow and imperfect, as it sometimes is, especially in the variety of bubo just mentioned, the most appropriate application is a large blister, retained sufficiently long to produce thorough vesication, and dressed with an emollient poultice. When the accumulation of pus is very large, it has been proposed to effect its evacuation, not by incision, but by a number of punctures, on the ground that the procedure would be less destructive to the integument than the more common operation. I have not, however, found such a result to obtain in my own practice. On the contrary, the skin and cellular substance are generally so much detached and impoverished as to render it impossible to preserve them with any reasonable prospect of their ultimate reunion. Hence, I am always in favor of a free division; nor do I hesitate afterwards to remove such portions of integument as may seem to act obstructingly to the reparative process by overhanging the surface of the ulcer, and interfering with its medication. If sinuses form, they must be laid open in the usual manner: fungous granulations are repressed with escha- rotics, as sulphate of copper and nitrate of silver, or, what is better, the scissors. If the constitution is impaired by protracted suffering and confine- ment, tonics and change of air will be required; and in all cases proper attention is paid to the diet, the bowels, and the secretions. Should phage- dena or gangrene supervene, the same line of treatment will be demanded as under similar circumstances in chancre. The chronic indurated bubo will 406 SYPHILIS. rarely yield in a satisfactory manner until the system is brought gently under the influence of mercury. SECT. III.—SECONDARY SYPHILIS. 1. GENERAL CONSIDERATIONS. The term secondary is employed to designate that group of morbid pheno- mena which manifest themselves after the occurrence of primary syphilis, the period of their evolution varying, on an average, from five to eight weeks from the first outbreak of the disease. The structures which are most liable to suffer are the cutaneous and mucous, and these may be attacked either simultaneously or consecutively, or one may suffer and the other escape, ac- cording to the condition in which they may happen to be at the time of the contamination. Secondary syphilis is always preceded by chancre, for there is no reason to believe, as has been stated elsewhere, that the specific virus ever finds its way into the system by direct imbibition, or without the intervention of a breach of continuity of some kind or other. This fact is too well established to ad- mit of any doubt. Bubo, however, does not always precede it; in many cases, in fact, the inguinal glands remain completely intact, and yet the con- stitutional symptoms may be of the very worst character, occurring, perhaps, early after the primary disease, and exploding with peculiar virulence upon the cutaneous and mucous tissues. It would be interesting, in a practical point of view, if we could determine the relative frequency of secondary symp- toms and bubo, or how often in a given number of cases constitutional syphilis occurs with involvement of the inguinal glands, and, on the other hand, how often bubo exists without being followed by consecutive derangement. For the solution of this question, however, there are, unfortunately, no sufficient data. As was previously stated, the indurated chancre is nearly always suc- ceeded by constitutional involvement, occurring early in the disease, and generally giving rise to the most serious, if not to positively irremediable, effects. It has lately been insisted upon by certain authorities that the soft or non-indurated chancre is solely a local affection, and therefore never fol- lowed by any specific vice of the general system. Iu this doctrine I cannot agree, for I can see no reason, on general pathological principles, why an ulcer which furnishes an infectious virus, as the soft chancre is well known to do, should be capable of inoculating certain tissues and not others; why, in other words, it should be able to reproduce itself locally, and yet not be able to affect, implicate, or contaminate the constitution. To assume the possi- bility of such an occurrence would be, as has been remarked elsewhere, to suppose that there are two distinct poisons, a view which is contrary to all reason, science, and analogy, and therefore altogether untenable. But the observant practitioner is not driven to the adoption of so absurd a conclu- sion ; he appeals to his personal experience, and is satisfied that he has re- peatedly seen the very worst cases of secondary symptoms succeed to the soft chancre. I am sure it has repeatedly fallen to my lot to witness such effects, and I therefore regard this doctrine as a most pernicious one, calculated as it is, if practically followed, to throw the surgeon off his guard, and thus prevent him from adopting a suitable treatment for the relief of his patient. Secondary symptoms often come on before the primary have disappeared; a chancre, indeed, raay, so to speak, be in full bloom, and continue to furnish an abundance of specific virus, and yet the constitutional disease have already made considerable progress, the skin being perhaps covered with eruptions, the throat inflamed or ulcerated, and the tongue affected with tubercles, thus SECONDARY FORM. 407 showing thorough contamination both of the solids and fluids. Or, the chancre may have become cicatrized, but remain hard and tender, more or less of the specific poison lurking in the affected tissues, ready to ferment and break out anew from the most trivial causes. Or, the original sore may have got entirely well, but the bubo be still in action, either as an indurated swelling, or as an ulcer with more or less discharge. Or, lastly, and as is perhaps most commonly the case, the secondary complaint does not display itself until some time after the primary has completely disappeared, and the patient has perhaps imagined himself perfectly well. It is generally impossible to determine, in advance, what effect a chancre may exert upon the system; or, in other words, whether it will be likely to lead to constitutional contamination. There are certain circumstances, how- ever, which, like coming events, cast their shadow before them, and thus serve to enable the attendant to form at least a plausible conjecture, if not a positive conclusion, in respect to the future condition of the system. These circumstances may be arranged under the following heads :— 1st. It is now generally, if not universally, admitted that the indurated chancre is nearly always followed by secondary symptoms; often, if not usually, coming on before the primary sore is completely healed, and pro- ducing a degree of contamination which it is extremely difficult, if not im- possible, to eradicate completely from the system. The constitution, once affected, nearly always retains the peculiar impress which it has received from the virus, in so much that the disease is probably capable of being propagated from parent to offspring during a series of generations. 2d. The non-indurated chancre, if multiple or of great extent, will, other things being equal, be more likely to give rise to constitutional involvement than a single sore, especially if superficial and of small size. 3d. The site of the chancre probably exerts some influence upon the pro- duction of secondary symptoms. Thus, there is reason to believe that a specific ulcer seated upon the inner surface of the prepuce, or at the free border of this muco-cutaneous fold, will be more likely to lead to contamina- tion of the system than a chancre on the head of the penis, owing probably to the greater activity of the absorbent vessels in the former than in the latter. A chancre of the urethra is rarely followed by constitutional infection. 4th. Constitutional involvement is also influenced by the duration of the chancre. It has been conclusively shown that if a chancre, even if it pertain to the indurated variety, be cured or removed before the end of the fifth day from the time of the inoculation, there is, as a general rule, no risk whatever of systemic contamination ; and it is perfectly reasonable to suppose that the chances of absorption of the specific virus will be much diminished, in every case, whatever may be the nature or site of the sore, in proportion to the shortness of its duration. Hence the absolute importance of getting rid of such a sore in the most summary and thorough manner. 5th. The state of the patient's health greatly influences the production of secondary syphilis. If he be stout and robust, and, in every respect, well conditioned, both as it concerns his solids and fluids, the poison will be much less likely to be conveyed into the system than if he be feeble and exhausted by disease, or laboring under a strumous or scorbutic cachexia. 6th. The kind of treatment also produces a marked effect upon the occur- rence of a syphilitic diathesis. There is no doubt at all that, as a general rule, secondary symptoms are much more liable to declare themselves if mercury be given for the primary disease than when the cure is accomplished without it. The results of upwards of 80,000 cases, treated by the simple method in various parts of the world, conclusively establish this fact. 7th. The degree and character of the inflammatory action accompanying the chancre often greatly influence the occurrence or non-occurrence of con- 408 SYPHILIS. stitutional symptoms. When the inflammation is unusually severe, or of a highly phagedenic type, absorption will be kept in abeyance, and the system escape contamination. Gangrene, supervening early in the progress of the chancre, always prevents the absorption of the specific virus. Finally, it is not improbable that the occurrence of secondary accidents is materially influenced by individual peculiarity or idiosyncrasy. It is well known that some persons contract primary syphilis with great difficulty, and, on the other hand, there are some who can never touch an infected female without being inoculated. The same is true of secondary syphilis. Thus, one man whose penis is literally covered with chancres may escape constitu- tional contamination entirely, while another, who has only a small sore pre- cisely of the same kind, may suffer very severely. There must be great individual peculiarities in regard to the susceptibilities to the action of this poison, otherwise it would be impossible to account for the remarkable diver- sities which characterize the evolution and course of this disease in different persons. Secondary syphilis is not contagious, thus showing that the specific virus, after it has fully entered the system, undergoes changes which essentially modify its properties and disqualify it for the production of an inoculable disease. I am aware that a contrary opinion has been held by some very eminent authorities, and that the experiments of Vidal, Cazenave, and others, with the pus of syphilitic ecthyma, would seem to countenance such a view ; but it is impossible not to believe that these distinguished syphilographers, in their zeal to promote the interests of science, were deceived by accidental circumstances connected with the state of the system of those who were the subjects of their researches, causing it to give rise to an appearance similar to, but by no means identical with, that of a chancre or an infectious pustule. Indeed, if such an occurrence were possible it would manifest itself constantly during the progress of secondary syphilis in consequence of the secretions coming in contact with raw surfaces upon the skin and mucous membranes. But, although secondary syphilis is not contagious, it is transmissible from the parent to the offspring, probably not merely through one but through many generations, the result declaring itself in a great variety of affections, and often proving destructive to the new being, sometimes before birth and other times not until afterwards. The very stream of life is poisoned, and all those who partake of it are destined to suffer from its effects, this being at least one way in which "God visits the iniquity of the fathers on their chil- dren, down to the third and fourth generation." The very fact that the dis- ease is transmissible shows that the whole system of the individual is impreg- nated with the specific poison, every globule of blood and every particle of solid matter being impressed by it. It is this pervasive, universal influence that has led to the opinion, now very general on the part of the best educated members of the profession, that constitutional syphilis is seldom, if ever, completely eradicable. Once implanted in the system, its germ is probably indestructible. Secondary syphilis is usually ushered in by well-marked constitutional phe- nomena. Generally some days—frequently as many as eight or ten—before there is any evident local disease, the patient feels conscious that he is unwell, or that there is something wrong about him ; he is in a state of malaise, or in that uncomfortable condition in which a man is neither well nor yet decidedly sick. Prominent among these symptoms is his mental dejection ; he is gloomy and desponding, indulging in unpleasant forebodings, and unable to apply himself to business; his countenance assumes a dull, muddy appearance ; his hair becomes dry and rough ; his limbs and joints feel sore and stiff; his ap- petite is indifferent; the bowels are inclined to be costive ; the urine is scanty and high-colored; exercise soon fatigues; and the sleep, disturbed by fre- AFFECTIONS OF THE SKIN. 409 quent dreams, is unrefreshing. Gradually, after the lapse of a few days, or, it may be, all of a sudden, the patient is seized with chilly sensations, or actual rigors, followed by high fever, or by fever and profuse sweats. The attack, which constitutes what is called syphilitic fever, is manifestly an effort of the system to eliminate the specific poison, and the tissues upon which it usually explodes are, as was previously stated, the cutaneous and mucous, together with the posterior cervical ganglions, the morbid phenomena of the former exhibiting themselves in various eruptions, and of the latter in ulcers of the throat and tubercles of the tongue. The iris may also be enumerated as liable to suffer from secondary involvement. 2. AFFECTIONS OF THE SKIN. The syphilitic affections of the skin, the syphilid.es, as they have been termed by Alibert, manifest themselves under at least six varieties of form, the exanthematous, scaly, vesicular, pustular, tubercular, and papular. Of these, however, the last three, in consequence of the lateness of their appear- ance and the severity of their character, may be regarded rather as apper- taining to the tertiary order of phenomena than to the secondary. Of the other three, two are not unfrequently coincident with the primary disease, although, in general, they do not show themselves until some time afterwards. The syphilitic eruptions nearly always pursue a chronic course, are more or less circular in their form, and always exhibit a characteristic copper color, especially in their earlier stages ; for, after they have existed for some time, they are very apt to assume a grayish, muddy, or bronze appearance, owing to some modification in the coloring matter of the skin. Although occurring upon all parts of the cutaneous surface, they are usually most conspicuous upon the forehead, nose, cheek, back, and shoulder, together with the inside of the arm and thigh, and are followed or attended by thin, grayish scales, hard, thick, greenish scabs, narrow, superficial cracks, or well-marked ulcers. Syphilitic cutaneous diseases can generally be easily distinguished from ordinary skin diseases; first, by the history of the case, especially the exist- ence or absence of chancre ; secondly, by the concurrence of lesions of the cutaneous and mucous textures ; thirdly, by the copper color of the affected surface, the eruption, scale, or pustule being itself either of that complexion, or surrounded by a more or less distinctly defined border of it; and, lastly, by the total absence of itching in syphilitic affections, whereas that symptom is of very common occurrence in ordinary cutaneous maladies. 1. In the exanthematous form, the spots are of a dark copper color, of a circular shape, and from the size of a dime to that of a twenty-five cent piece, the intervening surface being of a muddy, dusky aspect. Although they sometimes cover nearly the whole body, yet they are generally most promi- nent on the trunk and extremities; they are never confluent, do not disap- pear under pressure, and usually pass off with a slight desquamation of the cuticle. There is a variety of this eruption in which the spots are of much smaller size, more irregular in shape, and of a brighter red, the color resem- bling that of a new copper coin. From this circumstance, and from the eruption being often somewhat confluent, like measles, it is generally known by the name of roseola. In neither of these forms is there any actual eleva- tion of the skin. The syphilitic exanthem often comes on before the disappearance of the primary disease, sometimes suddenly, and without any decided premonitory symptoms; at other times gradually, and with considerable pyrexial disturb- ance. As the eruption fades it loses its reddish tint, and assumes a dingy, dirty, dusky, or grayish aspect. Its duration varies from ten days to three or four weeks. Its gradual disappearance, and its coincidence with chancre, 410 SYPHILIS. bubo, cervical adenitis, and other marks of syphilis, either primary or second- ary, together with the absence of local distress, as itching and smarting, readily distinguish it from measles and other cutaneous affections. 2. The scaly variety of syphilis generally appears without any febrile dis- turbance, from six to ten weeks after the primary disease; it is always re- markably chronic, lasting frequently for months together, and is commonly associated with ulceration of the throat and palate, iritis, and affections of the bones and joints ; forming, in this case, a kind of connecting link between the secondary and tertiary stages of the constitutional malady. ^ The eruption manifests itself, as the name implies, in distinct scales, or thick and hardened portions of epidermis, of a dull, opaque, grayish appear- ance, resting upon a copper-colored base. It generally appears in separate patches, which, although they may occur on all parts of the cutaneous surface, are, nevertheless, most common on the forehead, scalp, face, forearms, palm of the hand, and sole of the foot, in the latter of which they often acquire a remarkable thickness. Each individual spot is from three to twelve lines in diameter, of a rounded shape, ordinarily isolated, rough, and somewhat ele- vated beyond the adjoining level. The scale is hard, whitish or grayish, and slightly adherent; the skin underneath has a tendency to ulcerate, or to form cracks and fissures, and when, by this means, its integrity is destroyed, the affected surface becomes covered with a thick, dry, brownish crust. When the part has cicatrized, a whitish spot, somewhat depressed at the centre, marks the original site of the disease. 3. The vesicular variety of syphilitic disease is of very uncommon occur- rence ; it is, iu fact, by far the rarest of all the syphilides. It usually begins coincidently with the latter stages of the primary sore, or soon afterwards, in minute, circumscribed pimples, scattered over different parts of the body, to which soon succeed small vesicles, occupied by a transparent, serous fluid, and surrounded by a reddish, copper-colored areola. Their progress is slow, and their contents are either absorbed, or they harden into thin scales, or scabs, which, falling off at different intervals, leave the part of a dingy, yel- lowish hue. The vesicles, which exist in distinct groups, are occasionally, though rarely, so numerous as to cover nearly the whole surface of the body. In general, they are most common on the neck, chest, and extremities, espe- cially the superior, their occurrence on the face and head being very infre- quent. They usually coincide with syphilitic disease of the throat, and nomadic pains in the bones and joints; a circumstance which, together with their copper-colored base, readily distinguishes them from ordinary vesicles. 4. Syphilitic pustules consist of circumscribed elevations of the skin, oc- cupied by pus, or sero-purulent matter, and possessing a strong tendency to terminate in ulceration. Although they occasionally co-exist with the pri- mary disease, they seldom appear until a long time after, and therefore generally appertain to the third order of symptoms, their presence being always denotive of profound constitutional contamination. Their size and figure are subject to considerable diversity. Sometimes they are as large as a hazel-nut; but ordinarily they do not exceed the volume of a pea, and in many cases they do not attain even that size. In their shape they are coni- cal, oval, pyriform, rounded, or flattened, with a minute central depression; and there are few instances in which these different varieties do not co-exist. Their number is often immense, hundreds being scattered over a small extent of surface; and, as they form successively, they may be seen and studied in every stage of their development. Each pustule reposes upon a hard, cop- per-colored base, and is apparently of a very complex structure, though its precise character is undetermined. After remaining for a short time, the contents of the pustule escape, con- crete, and form hard, thick scabs, of a dark color, pretty firmly adherent, and AFFECTIONS OF THE SKIN. 411 sometimes circularly furrowed. In the more simple cases, the scabs soon fall off, leaving merely a chronic induration, a livid, dusky, or grayish stain, or a small cicatrice; in the more severe forms of the disease, on the contrary, deep, circular, characteristic ulcers are exposed, with a foul, grayish bottom, and a hard, purple, and well defined margin. In cases of the latter descrip- tion, the scabs are frequently renewed, and are finally succeeded by round, indelible scars. There are two varieties of syphilitic pustules, the one, termed the psydra- cious, occurring in groups, and the other, the phlyzacions, disposed separately, without any tendency, as is sometimes the case with the other, to become confluent. Willan and some other dermatologists have described them under the generic appellation of syphilitic ecthyma. It is the matter furnished by these pustules that has been erroneously supposed by Vidal, Cazenave, and a few other observers, to be capable of transmitting secondary syphilis by inoculation. The pustular form of syphilis is not unfrequently associated with the tuber- cular and papular, but rarely with the roseolar and squamous. Severe con- stitutional disturbance is generally present, and, indeed, the suffering may be so great as to destroy life, the health being gradually undermined by the ex- cessive pain and irritation of the eruption and its sequelae. 5. In the tubercular variety of syphilis, the most formidable, if not also the most frequent of all, the eruption consists of small, red, copper-colored eminences, varying in size between that of a mustard-seed and an olive. Of a rounded, flattened, or conoidal shape, they are either isolated, assembled in groups, or arranged in perfect circles; they are smooth and polished, pro- duce little or no pain, and become covered, in a short time, with a dry, scaly incrustation, which is generally reproduced as fast as it falls off. In the more aggravated forms of this variety of syphilis, the tubercles are inordinately large, prominent, of a deep violet hue, from three to six lines in length, and encircled by a well-marked, copper-colored areola. After con- tinuing thus for some time, varying from a few months to several years, they inflame, suppurate, and are finally replaced by deep, foul, painful, irregular ulcers, reposing upon a hard, purple base. The thick scab which usually covers these erosions is repeatedly renewed, showing, whenever it is detached, that the sore is extending its ravages. When the tubercles are numerous, the ulcers, running together, often acquire a frightful size, and, on healing, leave disfiguring cicatrices. 6. Papular syphilis is characterized by the occurrence of small, hard, solid elevations, containing no fluid, and terminating almost always in desquama- tion, seldom in ulceration, or in the formation of scabs. There are two varieties of the affection, one of which is acute and primary, the other chronic and secondary. In the first variety, the eruption appears simultaneously on different regions of the body, and is completed in about forty-eight hours from the time of its invasion. The papulae are extremely small, disjointed, or grouped, of a red copper color, and of a slightly conical shape, being surrounded, here and there, by violet areola?, which are often confluent, and give the surface a characteristic yellow tinge. Ulceration rarely attacks these papula?; they disappear in a short time, and are followed by a furfuraceous desquamation of the cuticle. In the other variety, the eruption is developed in a slow and successive manner, being announced by small yellow spots, which are particularly numer- ous on the forehead, scalp, and extremities. The papulae, which are of a light copper color, are larger than the preceding, flat, of the size of small beans, grouped, and devoid of an areola. In time, the summit of each elevation becomes covered with a dry, grayish pellicle, which is regenerated as fast as 412 SYPHILIS. it desquamates, until the disease finally entirely subsides. Meanwhile, the skin between the agglomerated papulae undergoes important changes; it assumes a dingy yellowish color, has a dry, shrivelled aspect, and is the seat of a constant exfoliation of the cuticle. Treatment.—The treatment of secondary cutaneous syphilis may be divided into comraon and specific, the first being of a general antiphlogistic charac- ter, while the second has for its object the neutralization or destruction of the virus upon whose action the affection more particularly depends, and which, so long as it continues, exposes the system constantly to new out- breaks of the disease. In general, it will be found to be advantageous to begin the treatment with antiphlogistic remedies; for, although they may not always, or perhaps even very frequently, eradicate the poison, yet it is unquestionably true that the salutary impression which they make upon the system, by ridding it of its impurities, and restoring the secretions, greatly paves the way for the more prompt and efficient operation of any specific measures that may afterwards be deemed advisable. A disregard of this rule is probably one of the chief reasons why the mercurial treatment of syphilis is so often followed by severe tertiary symptoms, the system not being pro- perly prepared, by a course of dieting, baths, purgatives, and other remedies, for the reception and beneficial action of the mineral. Syphilitic fever should be combated upon the same general principles as any other kind of sympathetic fever. If the symptoms run high, as indicated by the state of the pulse and skin, and the patient is young and plethoric, blood may be taken from the arm, and the saline and antimonial mixture be directed, the bowels having been previously opened by a brisk cathartic. The action of the medicine should be promoted with tepid drinks, and, if there be much pain and aching in the back and limbs, a Dover's powder, or an anodyne and diaphoretic draught will probably be necessary. The dura- tion of the fever is usually very short, the disease often yielding to very simple measures. When eruptions appear upon the skin, the treatment which I usually adopt is the antimonial, having found it to answer an excellent purpose in a great majority of the cases of the disease that have fallen under my observation. The quantity of tartar emetic to be given at each dose must vary from the fourth to the eighth of a grain, repeated every three, four, or five hours, according to the influence of the remedy, decided nausea being hardly ever desired. The object is to produce only a sedative and alterant effect. It may be administered by itself, as in the milder forms of secondary cutaneous affections, or be variously combined with other articles, as sulphate of mag- nesia, when there is constipation, aconite, when there is much arterial ex- citement, or morphine, when an anodyne and diaphoretic action is desired. The salutary operation of the medicine will be greatly promoted by the daily use of the tepid bath, by diluent drinks, and by the strict observance of the antiphlogistic regimen. How tartrate of antimony and potassa acts in producing its salutary effects in secondary syphilis of the skin has not been determined. It is not impro- bable that it may, as mercury is supposed to do, neutralize the poison of the disease, by divesting it of its zymotic qualities ; or it may act simply as an eliminator, by furnishing an outlet for the poison through the various emunc- tories, upon all of which this medicine is known to exert more or less iufluence. Tartarized antimony, then, according to my experience, is the great remedy upon which our reliance is mainly to be placed in the treatment of secondary syphilis, especially of the skin, and, also, although in a less degree, of the mucous membrane. If the remedy fail, or the disease prove rebellious, recourse must be had to mercury, given in the same manner, and with the ALOPECIA. 413 same restrictions, as in the primary form of the disease. The use of the latter medicine may, I am satisfied, be limited to a very narrow circle of cases of secondary syphilis, and it will be found that, whenever it becomes necessary, its action will be immensely promoted by the previous employment of tartar emetic. 3. ALOPECIA. During the progress of syphilis it occasionally happens that the hair of the scalp falls off, constituting what is technically called alopecia. The accident generally comes on within the first six or eight weeks from the appearance of the primary sore, with which, consequently, it is not unfre- quently coincident, and usually occurs in circular disks, of variable size, and of a well-marked copper color, similar to the eruptive syphilides. The affec- tion is commonly partial, showing itself, as just stated, in distinct patches, of which several may exist simultaneously, or as fast as one gets well another may succeed, and thus the affection may proceed until it has travelled over the greater portion of the scalp; or, instead of this, nearly all the bulbs may suffer at once, and the hair drop off in great numbers, leaving the head ulti- mately nearly completely bare. When the system is, as it were, saturated with the specific virus, not only the hair of the scalp, but also of the beard, the eyebrows, and the rest of the body may drop off. I have seen two well- marked cases of this universal alopecia, both occurring in young men who had been the subject of indurated chancre upon the head of the penis ; in one the desquamation was associated with roseola and sore throat, and was never followed by a reproduction of hair anywhere. The patient, after having lingered for several years under the exhausting effects of rupia and nodes, died in a state of marasmus. In the second case, the alopecia was succeeded by syphilitic sarcocele; and in this the hair, in time, was regene- rated upon the scalp, although it always remained stunted, and was remark- ably coarse, stiff, and sparse. The first sign of baldness usually consists in a loss of the soft and glossy state of the hair, which becomes dry, stiff, and brittle, breaking off very easily in combing the head. After a little while it is observed to fall off in great abundance; and if the scalp be now examined it will be found to be remark- ably harsh and scurfy, and to be covered with muddy, dingy, or dusky, cop- per-colored blotches, generally of a circular shape, and apparently, though not in reality, somewhat elevated above the adjoining surface. Fever occa- sionally accompanies the affection ; and pains in the bones and joints, appa- rently of a rheumatic nature, generally characterize the progress of the case. Regeneration of the hair, partial or complete, may usually be expected, even under apparently the most adverse circumstances. Baldness, as an effect of syphilis, is a grave occurrence, and the practitioner cannot be too eager in his attempts to arrest it. The first thing to be done is to cut off the hair, not too closely, but just sufficiently to admit of the re- quisite attention to cleanliness and medication. Shaving of the scalp is not necessary in any case, however severe. The treatment, directed more espe- cially to the relief of the diseased hair-bulbs, must be essentially of a stimu- lating character, the object being to impart tone and vigor to the whole of the affected surface. In the more simple cases mild lotions of alcohol and spirits of hartshorn, eau de Cologne and compound spirits of lavender, or alcohol, glycerin, oil, and tincture of cantharides, either in equal, or in different propor- tions, may be used, according to the desired strength of the particular pre- paration. Another excellent wash is a solution of tannin and sulphate of copper in equal parts of spirits of wine and water, six grains of the former, and half a grain of the latter being used to the ounce of fluid. The applica- 414 SYPHILIS. tion should be made twice in the twenty-four hours, the friction being per- formed with the hand and fingers, and steadily continued until there is a glow upon the surface. The scalp should be washed every morning with warm water and Castile soap, and well combed immediately after to promote clean- liness and dislodge dandriff. If soreness of the scalp exist, or if there be eruptions, papules, tubercles, or numerous dry and adherent scales, the most eligible application will be a pomade of simple cerate and of the ointment of the nitrate of mercury, in the proportion of seven parts of the former to one of the latter, mixed with a few drops of the oil of jasmine and a little Cologne water, and thoroughly rub- bed into the roots of the hair night and morning. Along with these means special attention should be paid to the state of the system, and if the case threatens to be obstinate, or if the alopecia coexist with an indurated, indo- lent, or badly-healed chancre, measures should be adopted to bring the patient as promptly as possible under the gentle influence of mercury. 4. SYPHILITIC ABSCESSES. The subcutaneous cellular tissue is occasionally the seat of what might be termed the syphilitic abscess. It belongs to the third order of symptoms, and presents itself as a multiple affection. In the few cases that have fallen under my observation the abscesses were scattered over the body in immense numbers, being particularly abundant on the anterior portion of the trunk and on the inside of the arms and thighs. Their volume varies from that of a currant to that of a pea; they rest upon an indurated base, and are gene- rally grouped rather closely together. Their contents are of a white, yellow- ish appearance, and of a somewhat tough consistence, partaking very much of the character of a mixture of pus and aplastic matter. The progress of the disease is usually very tardy; the general health is a good deal disordered, and the abscesses are very slow in reaching the surface. In fact, under the use of iodide of potassium and mercury most of them gradually disappear without breaking. 5. CERVICAL ADENITIS. The posterior cervical ganglions generally suffer at an early period of the constitutional involvement, becoming enlarged and somewhat tender, though never very painful, and rolling, when pressed upon with the finger, like so many little elastic balls under the integuments. The swelling is generally most conspicuous in the glands situated along the upper two-thirds of the posterior border of the sterno-cleido-mastoid muscle, and along the root of the hairy scalp, extending frequently as far outwards as the mastoid process on each side. It is essentially of a chronic nature, often lingering for many weeks, and never terminating in suppuration. Diagnostically considered, this species of adenitis, from the constancy of its presence, is of great value, but from the want of practical tact to detect it, it is extremely liable to be over- looked by the surgeon. The number of glands involved seldom exceeds two or three, and in many cases the disease is apparently limited to a single one. Its occurrence is most common in young subjects, and it occasionally mani- fests itself at so late a period of the disease that it may then be considered as belonging rather to the tertiary than to the secondary order of symptoms. Cervical adenitis generally readily disappears under the treatment directed for the relief of other secondary affections. The enlarged glands may be rubbed twice a day with ammoniated liniment, or painted with dilute tincture of iodine. If much induration exist, the most eligible remedy will be gentle mercurial inunction. AFFECTIONS OF THE MUCOUS MEMBRANES. 415 6. AFFECTIONS OF THE MUCOUS MEMBRANES. Secondary syphilis of the mucous membranes generally declares itself within a short time after the cure of the primary sore, and sometimes even before this has completely disappeared; existing at one time in association with secondary affections of the skin, and at another, and perhaps more commonly, independently of them. From four to eight weeks is the average period of the evolution of the disease when it attacks these structures. What strikes one as very remarkable is the extent of surface over which it raay spread, there being no visible portion of the mucous membranes where it has not been observed. The parts, however, which are most prone to suffer are the tonsils, palate, pharynx, tongue, cheeks, and lips. It rarely extends into the windpipe. No dissections of a satisfactory nature have been made tending to show that the lining membrane of the stomach and bowels ever participates in the morbid action, but it is certain that well-marked signs of the malady have been repeatedly witnessed at the anus, as high up as the first inch or inch and a half from its verge, and of such a character as to be altogether unmistakable. In the male they sometimes appear upon the foreskin and head of the penis, while in the other sex they are liable to occur upon the vulva, the vagina and uterus. Their presence has not been detected in the respiratory and urinary organs, and is therefore altogether a matter of con- jecture, only to be settled by future observation. From the remarkable rela- tions existing between the skin and mucous membranes, and the fact that syphilitic affections of the former are liable to occur in all parts of its extent, it is not improbable that the latter may suffer in the same manner, though perhaps not in an equal degree, some portions almost entirely escaping, while others are peculiarly prone to receive and harbor the specific virus. Secondary affections of the raucous tissues occur in various forms; at one time, or in one place, as an erythematous disease, at another, as an elevation or tubercle, and again as a distinct ulcer, crack, or fissure; depending, doubt- less, upon some peculiar modification of the structure of the suffering part, some change in the action of the poison, or some idiosyncrasy of the indi- vidual. In the mouth and throat, where these affections are most common, it is not unusual to notice their coexistence, mere inflammatory redness with or without plastic deposit going on at one point, ulceration at another, and the formation of a tubercle at a third. Syphilitic erythema is observed chiefly in the throat, affecting the arches of the palate, tonsils, uvula, pharynx, and perhaps the root of the tongue. In rare cases it extends to the roof of the mouth. It may present itself as a diffused inflammation, or in the form of distinct patches, generally of a circular or oval figure, and from the size of a gold dollar to that of a twenty- five cent piece, the intervening surface being apparently quite healthy. The color, in the early stage of the disease, resembles that of a new copper coin, but it gradually loses its bright, fiery hue, shading off into dark bronze, in proportion as the morbid action declines. In cases of long standing and unusual severity, the discoloration is of a deep flesh-color and conjoined with marked thickening of the mucous membrane, and a tendency to ulceration. Deposits of lymph are not uncommon upon the inflamed surface, even when the disease is not at all active ; occurring in small aphthous-looking specks, in patches of considerable size, or in circular rings, more or less firmly ad- herent, and of a pale orange tint. This affection, which bears the closest resemblance to erythema of the skin, generally exists without the consciousness of the patient; there being no soreness in the throat or difficulty of deglutition, and no constitutional dis- turbance. All is quiet and passive, and the disease is perhaps discovered 416 SYPHILIS. altogether by accident. It of course denotes only a very slight taint of the system. It is apt to appear within the first four or five weeks after the pri- mary sore, and consequently not unfrequently before this is healed. Ulcers of the throat assume various appearances, and involve different structures, but particularly the tonsils and the back of the pharynx, affect- ing these parts either separately or conjointly. They occur principally in two varieties of form, the excavated and superficial. The excavated ulcer looks, as the name denotes, as if it had been made with a punch, or dug out of the tissues with a sharp instrument. Its edges are steep, everted, and ragged, like those of the Hunterian chancre ; and they are surrounded by a hard inflammatory, copper-colored base. The surface is usually incrusted with greenish, muddy, or yellowish lymph, which gives it a foul, unhealthy aspect. The discharge is thin and ichorous. The excavated sore is always most distinctly marked on the tonsils, where it sometimes ac- quires an immense size, and is generally accompanied by extensive inflamma- tion of the surrounding parts. It is often seen during the progress of the primary disease, especially the indurated chancre, and is liable to be associated with some of the earlier forms of cutaneous eruptions, particularly the exan- thematous and scaly. The superficial ulcer is often multiple, several frequently occurring together, either in close proximity, or scattered over the inflamed surface. Its appear- ance is either that of an abrasion, or of a cavity with well-defined, ragged edges, rather sharp, and often somewhat undermined; its surface being covered with a white or yellowish tenacious and adherent lymph : the parts around, although red and irritated, are free from induration. The most common sites of this variety of sore, which now and then assumes a serpiginous cha- racter, are the arches of the palate, uvula, and pharynx. It generally comes on early after the absorption of the specific virus, and often coexists with the primary sore. Secondary syphilitic ulcers of the throat are liable to take on phagedenic and gangrenous action, in the same manner as primary sores, and apparently from similar causes, the state of the system and mode of life of the patient mainly contributing to change their character. In consequence of the super- addition of this action, extensive destruction of the soft palate may result, followed by difficulty of deglutition and important alterations of the voice. Ordinary syphilitic ulceration of the throat, even when considerable, is not always attended by well-marked local and constitutional symptoms; the dis- ease, in fact, is often remarkably insidious in its approaches, and may there- fore have made great progress before its presence is even suspected. The excavated form of the affection is generally accompanied with extensive swelling, pain and difficulty in swallowing, and more or less febrile disturb- ance. When the tonsils are the seat of the lesion the tumefaction may be so great as to cause serious obstruction to respiration. Small ulcers, crevices, and fissures, of a secondary nature, are sometimes met with on the lips, especially at the corners of the mouth, the inside of the cheeks, and the tongue; generally superficial, indisposed to spread, and attended with but little uneasiness and discharge. Occasionally they have abrupt edges and a hardened base. Their diagnosis must necessarily be difficult, the only reliable sign being their co-existence with other marks of syphilis, either primary or consecutive. Mucous tubercles are most commonly found upon the tongue, the lips, and the inside of the cheeks, where they occur as slight elevations of the mucous surface, generally of an irregular oval or elongated shape, and of a whitish hue, as if the secretion of the part had been discolored with nitrate of silver or partially coagulated albumen. Upon taking hold of the swelling with the thumb and finger it is felt to be more or less hard, not unlike an indurated AFFECTIONS OF THE MUCOUS MEMBRANES. 417 chancre, and is generally quite tolerant of manipulation, even firm pressure rarely causing any decided pain. The size of the spots is variable, ranging frora that of a pea up to that of a twenty-five cent piece; they sometimes exist in considerable numbers, and then they occasionally become confluent. If unrestrained, they may give rise to ulceration, generally of a deep, exca- vated character, the edges of the sore being steep and callous. This variety of syphilitic affection finds its analogy in the condylomatous excrescences which are so liable to form about the anus and perineum, in con- sequence of the action of the syphilitic virus. As it usually comes on without any pain, its discovery is often purely accidental. The most reliable diag- nostics are the peculiar color and feel of the affected part above referred to, and the coexistence of syphilis in other localities, particularly the throat and skin. Not unfrequently traces of the primary disease will be found either in an open sore, or in the indurated cicatrice of a recently healed chancre. Treatment.—These mucous affections being all of a kindred character, their treatment must be conducted upon the same general principles. If the patient be at all plethoric, antiphlogistics will probably be necessary, blood being taken either by the lancet or by leeches from the vicinity of the inflamed parts, and the depletion followed by active purgation and the use of the anti- monial and saline mixture, rendered anodyne and diaphoretic by the addition, to each dose, of a small quantity of morphia. Light diet and perfect quie- tude are enjoined. In the milder cases of these diseases the most simple constitutional means will generally suffice, no drain upon the system of any kind being necessary. The most suitable local remedies are nitrate of silver, acid nitrate of mercury, and nitric acid, either pure, or variously diluted, and applied at longer or shorter intervals, according to the exigencies of each particular case. The solid luuar caustic is generally to be preferred when there is no breach of continuity, the affected surface being touched with great care and gentleness once every forty-eight hours, some mildly astringent gar- gle, or simple mucilaginous fluid, being employed in the intervals. When the part is ulcerated the caustic must be used more boldly, as well as oftener; though, under such circumstances, I usually give a decided preference to the acid nitrate of mercury, applied by means of a stick of soft wood, the end of which, being well rounded off, enables us to deposit just enough and not any too much of the fluid, as is so apt to happen when we employ a mop. Not only the sore but also the inflamed surface around should be treated in this way, and the application, in bad cases, should be regularly repeated every twenty-four hours until there is a very decided improvement iu the disease. I have found that hardly any secondary ulcer of the throat, palate, or tongue can withstand such a remedy beyond six or eight days, while in many cases it yields in a much shorter time. As soon as the reparative process begins, the acid is used less frequently and in a more dilute state. When the acid nitrate is not at hand, a good substitute will be furnished by nitric acid. The gargle which I usually prefer in ulcerated sore throat is the pyrolig- neous acid, in the proportion of from one to two drachms to half a pint of water, well sweetened with honey, and used five or six times in the twenty- four hours. Weak solutions of subacetate of copper and tannin, of nitric acid, and of chlorinated soda also answer an excellent purpose. Mucous tubercles generally yield to a few applications of the solid nitrate of silver, aided by astringent gargles, suitable purgation, and light diet. Similar means will usually suffice for the cure of superficial abrasions, exco- riations, and fissures of the lips and cheek. Mercurialization only becomes necessary in particular cases. In general, the remedy is called for when there is an excavated ulcer, or an ulcer pos- sessing an extraordinary degree of indolence, or indolence and induration. The simple, superficial sore rarely requires such a remedy; and it is of course vol. I.—27 418 SYPHILIS. withheld when there is a tendency to phagedena or gangrene in a broken, anemic state of the system. Under such,circumstances tonics, a generous diet, and nutritious drinks take the place of the mineral. SECT. IV.—TERTIARY SYPHILIS. 1. GENERAL CONSIDERATIONS. When the specific poison has deeply penetrated the system, and become, as it were, inlaid in its different structures, as well as thoroughly commingled with the blood, the effects which it produces constitute what is denominated tertiary syphilis, an order of sequence first distinctly asserted by Ricord, and now generally recognized by surgical teachers. The boundary line, however, between the secondary and tertiary groups of phenomena is not always well defined, the former affections often running, by gradual and insensible grada- tions, into the latter; an occurrence which cannot be too strongly impressed upon the mind of the reader, on account of its great practical importance. It is generally understood that those symptoms of the disease which show themselves before the fifth or sixth month from the commencement of the primary sore should be classed under the head of "secondary syphilis," while those which come on subsequently, or after this period, are considered as appertaining to the third order of phenomena, or "tertiary syphilis," the average period of their evolution ranging from six to eighteen months, although in very many instances they do not occur until a number of years after the appearance of chancre, or chancre and bubo. Thus, I have repeat- edly seen tertiary symptoms manifest themselves, for the first time, from twelve to eighteen years after the primary disease, the poison having lain all this time, like a hidden spark, in the economy. Once fairly roused, however, into activity, it extends through the system with great rapidity, completely over- whelming it in its progress, and exploding, with peculiar force, upon certain tissues, textures, or organs, these structures having apparently a kind of elec- tive affinity for it. The textures which are particularly prone to suffer in tertiary syphilis are the skin, raucous membranes, periosteum, bones, fibro-cartilages, aponeuroses, tendons, and testicles. All parts of the economy, however, are involved in the contamination, and it is extremely probable that, in the worst cases, hardly any organ or structure entirely escapes. The affections of the internal viscera, however, although alluded to by many of the older syphilographers, have only of late attracted serious attention, and hence the amount and nature of their participation in this poisoning process have not been satisfactorily ascer- tained. Enough, however, has been determined to produce conviction that the changes in the lungs, brain, heart, liver, and other organs are often of a grave character, liable to be followed by the worst results, because so insidi- ous are their approaches and progress that even their existence is hardly ever suspected during life, to say nothing of the impossibility of arresting them by any known treatment, or combination of remedies. The most common of these internal lesions, which have, strangely enough, been termed secondary, are foul, ragged-looking abscesses, with imperfectly elaborated contents, soft- ening and pulpy degeneration, and tubercular deposits. Attention has not yet been sufficiently directed to the alterations of the ovaries of females who die of tertiary syphilis ; but from the resemblance which exists between these organs and the testes, both in structure and function, and from the fact that the latter are so often involved in the disease, it is highly probable that it will be found, as our pathological researches are extended, that they frequently seriously participate iu the morbid action. GENERAL CONSIDERATIONS. 419 Tertiary syphilis is not invariably preceded by secondary symptoms ; on the contrary, there are many cases where the disease passes directly from the first to the third order of phenomena, the structures usually implicated in the secondary attack escaping entirely. Again, it is well known that tertiary syphilis is not always preceded by bubo. Tertiary symptoms are most liable to occur in persons of intemperate habits, and of a broken dilapidated constitution, with an impoverished state of the blood. A scrofulous or scorbutic condition of the system also acts as a predisposing cause. The nature of the chancre doubtless exerts considerable influence upon the production of the disease. Thus, there can be no hesitation in affirming that tertiary syphilis is more apt to follow an indurated than a non-indurated chancre. The duration of the primary disease is also to be taken into the account; it being reasonable to suppose that a chronic chancre, which retains its specific poison, will be more likely to give rise to constitutional syphilis than one that is acute or rapidly healed. Finally, the occurrence of tertiary symptoms is influenced by the nature of the general treatment. It is well known, as stated elsewhere, that when the primary sore has been treated without mercury there is much less likelihood of the development of remote constitutional symptoms than when this re- medy has been used, especially when its effects have been carried to an in- ordinate extent, as evinced by profuse salivation. The occurrence of tertiary syphilis, under such circumstances, is not only probable, but the chances are that, if it do break out, it will show itself in the very worst form, by estab- lishing a sort of mercurio-syphilitic diathesis, which it is extremely difficult, if not impossible, to eradicate completely from the system. The immediate development of tertiary syphilis is often remarkably influ- enced by the habits and state of health of the individual. It is impossible to say how long the specific virus might lie dormant in the system if the subject of it were entirely free from the prejudicial influences of surrounding agents. Exposure to cold is usually accused of being one of the most com- mon exciting causes of the complaint, and yet it is notorious that the inhabi- tants of the South Sea Islands and other tropical regions are extraordinarily prone to all kinds of constitutional syphilis. There can be no doubt, however, that the poison is often fanned into activity by the hardships of our northern winters and by a residence in damp cellars, or moist, ill-ventilated, under- ground apartments, especially when this mode of life is conjoined with all kinds of dissipation and intemperance, loss of sleep, and an impoverished diet. Although it is extremely probable that no state of the system, how- ever near it may approach to the normal standard, can ever entirely prevent the development of tertiary syphilis, when once the poison has taken posses- sion of it, yet there can be no doubt that an individual so circumstanced will, other things being equal, be much less likely to suffer than one who is differ- ently situated, or who gives himself up to the unbridled indulgence of his passions. The matter furnished by ulcers, abscesses, and suppurating surfaces, con- sequent upon tertiary syphilis, is not inoculable ; the specific virus has been completely changed in its properties, and no case has ever occurred where it was capable of infecting the tissues of a healthy person by direct contact. It is also believed that the disease is not hereditarily transmissible ; but although this be true in the ordinary sense of the term, yet it is extremely probable that the offspring of such an individual are, if not actually imperfectly de- veloped, naturally predisposed to various kinds of cachectic affections, parti- cularly to scrofula and scurvy, by which life is rendered miserable and often cut off prematurely, the constitution being unable to endure the hardships incident to ordinary pursuits. 420 SYPHILIS. The prognosis of tertiary syphilis is always grave. Whatever form it may assume, it is extremely difficult to dislodge it effectually from the system, or to effect a radical permanent cure. Relapses are of constant occurrence from the most trivial exposure, or the least disorder of the digestive organs, and few patients, however skilfully they may have been treated, are afterwards ever entirely free from rheumatic pains, proneness to cold, and stiffness of the joints. In fact, although recovery undoubtedly occasionally does take place, yet in most cases the constitution remains in an enfeebled and crippled condition, remarkably subject to attacks of other diseases. Tertiary syphilis often proves fatal, although not nearly as frequently as prior to the discovery of the use of iodide of potassium, death generally occurring from local irritation and constitutional exhaustion. Many of those who recover are horribly disfigured, some from pock marks, some from the loss of the nose and palate, and some from anchylosis of a joint. 2. SYPHILIS OF THE THROAT AND MOUTH. Tertiary affections of the throat and mouth are by no means uncommon ; they supervene at an indefinite period after chancre, and manifest themselves in characteristic ulcers, which, if permitted to go on, gradually spread to the palate and maxillary bones, which, together with the soft parts, are some- times destroyed to a most frightful extent, the buccal and nasal cavities being perhaps laid into one immense cavern. In some of these cases large portions of the alveolar process of the maxillary bone are necrosed, followed by the loss of many of the teeth, and a similar fate may be experienced by the ascending process and ungual bone, thus implicating and endangering the lachrymal sac and its canals. The nature of the disease is readily ascer- tained by ocular inspection and the altered state of the voice. Tertiary syphilis of the tongue generally appears in the form of ulcers, or fissures, the latter of which are soraetimes of enormous extent and depth, reaching far into the substance of the organ. Specific ulcers are usually situated upon the side of the tongue, at or near its middle, and exhibit the characteristic features of venereal sores in other structures, having a deep excavated form and a foul surface, with marked induration of the base, the parts feeling, on being pinched, like a mass of fibro-cartilage. Only one such cavity generally exists ; when large and irritable, it may give rise to swelling of the lymphatic glands at the base of the jaw. The history of the case, the foul, excavated character of the sore, aud the existence of syphilitic disease in the throat, nose, or other parts of the body, will always distin- guish the lesion from other affections. The following case will convey a good idea of syphilitic fissures of the tongue:—Frederick Saxe, a blacksmith, aged twenty-eight years, presented himself at the Clinic of the Jefferson Medical College in July, 1857. His tongue, which was of the natural length and breadth but much increased in thickness, and excessively hard at the sides, especially the left, was covered with numerous fissures, of varying size and depth, overhung by steep indurated edges, which at first sight concealed them almost completely from view. The largest groove, which resembled a deep furrow, extended along the centre of the organ, from a short distance in front of the root to within a few lines of the tip, its depth being nearly half an inch. The bottom of each fissure had a clean, smooth appearance ; the raucous membrane of the tongue generally was somewhat redder than natural, but there was an entire absence of pain and even soreness under rough manipulation. The starting point of the dis- ease seemed to have been the throat, which had been inflamed for a long time; the uvula had become elongated, and had been cut off weeks ago. The arches of the palate and tonsils were still a good deal discolored and con- SYPHILIS OF THE NOSE AND LARYNX. 421 gested. The tongue had been in its present condition for the last three months, having resisted various kinds of treatraent, without the disease ap- parently manifesting any tendency to spread. A small painful node existed on the right tibia, and there was a vesicular eruption with some itching on the face. The man denied that he had ever had syphilis, but the history of the case and his present condition clearly proved that he was mistaken, or tried to deceive me. He rapidly recovered under the internal use of iodide of potassium with bichloride of mercury, and the local application, every other day, of the solid nitrate of silver. 3. SYPHILIS OF THE NOSE. Syphilitic disease of the nose, or syphilitic ozaena, as it is occasionally called, is another tertiary symptom, depending upon ulceration of the pitui- tary membrane, and the several bones of the nasal fossae, including not unfre- quently the proper bones of the nose. The morbid action, which is generally associated with marks of a constitutional taint in other situations, usually sets in at a very remote period after the primary sore, and lingers on obstinately for many years, notwithstanding the best directed efforts to arrest it, until it has caused the most extensive havoc, piece after piece dying and dropping off until every one has disappeared. When the proper nasal bones are in- volved, the whole organ, bridge, cartilage, and skin, may be destroyed. The disease is attended with an abundant fetid and bloody discharge, and the voice has a peculiar characteristic, muffled twang. The septum of the nose is very prone to suffer in this form of syphilis, giving way, first, at the cartilaginous structure, and afterwards at the osseous. The consequence is that the part is perforated by an opening of variable size and shape, with sharp, irregular edges, which have a constant tendency to spread until the greater portion of the septum is destroyed. A similar effect sometimes follows scrofula, and considerable difficulty may therefore attend the diagnosis. The chief points of distinction are the history of the case, and the fact that the ulcerative action is generally much more rapid in the former than in the latter disease. 4. SYPHILIS OF THE LARYNX. Syphilis of the larynx seldom comes on until a long time after the primary disease, and may therefore justly be classed among the tertiary phenomena. In most cases, indeed, it does not declare itself before the end of the second year, and often not until much later. It is generally, but, I think, erroneously ascribed to an extension of disease from the palate, tonsils, and pharynx, by continuity of structure; on the contrary, there is reason to believe that it is usually an independent affection, commencing in the larynx, and thence soraetimes passing into the throat. However this may be, its coincidence with syphilis in other parts of the body, particularly of the skin, bones, and fibrous membranes, sufficiently stamps its character, and renders it easy of diagnosis. The disease, beginning in inflammation, soon terminates in ulceration, which often continues for months and even years together, the erosive action being at one time stationary, or on the very verge of healing, and at another steadily advancing. Confined originally to the mucous membrane, it at length invades the arytenoid cartilages, the vocal cords, and even some of the muscles of the larynx. Portions of the thyroid cartilage occasionally perish, and a not uncommon occurrence is the partial destruction of the epi- glottis. In some of the cases of this disease that have come under my ob- servation, nearly the whole of this fibro-cartilage was eaten away, nothing 422 SYPHILIS. Fig. 86. but a thick, narrow, stump-like remnant being left to cover the glottis, as illustrated in fig. 86, from a preparation in my private collection. The cri- coid cartilage rarely participates in the disease. The ulcers are seldom numerous, unless they are follicular, when the affected surface may literally be studded with them; in general, we do not find more than one or two, which are then pretty large, both as it respects their depth and superficial area. They are of a circular or oval shape, with indurated edges and a foul bottom, and, in the more severe and protracted cases, they sometimes penetrate very deeply, opening, perhaps, externally. Such an occurrence is most likely to happen when there is extensive destruction of the thyroid carti- lage. Occasionally the mucous membrane, instead of being ulcerated, is the seat of granulations, or syphilitic warts, of a red, fleshy appearance, and from the size of a small pin-head to that of a mus- tard-seed, their number varying from half a dozen to fifteen or twenty; they are usually most con- spicuous around the vocal cords, and apparently consist in a hypertrophous condition of the mucous crypts which naturally exist in the interior of the vocal tube. The symptoms of syphilitic disease of the larynx are generally well marked, particularly when it has made considerable progress, or when it presents itself in the form of ulceration. Besides the wan, emaciated, and cachectic appearance of the patient, which is itself almost sufficient to point out the nature of the affection, there is a hoarse, husky, characteristic state of the voice, which, in time, is re- duced to a mere whisper, and eventually completely The larynx feels tender on motion and pressure ; deglutition is difficult painful; and the slightest vocal exertion is productive of severe suffering. Cough is always present, frequently to a most harassing extent; and in attempting to swallow fluids the patient is frequently seized with symptoms of impending suffocation. The matter which is expectorated is excessively fetid, often bloody, and occasionally mixed with fragments of cartilage, its quantity being frequently very copious. As the disease progresses, the°local and constitutional irritation increases; the emaciation becomes extreme; the sweats are copious; and the patient at length dies completely exhausted, the immediate cause of his death being, perhaps, inanition, suffocation, or hemor- rhage from the sudden giving way of an artery of considerable size. Long before this event, however, the lungs, pleurae, and bronchial tubes become seriously involved, and thus serve materially to hurry on the fatal crisis. 5. SYPHILIS OF THE EYE. ^ Iritis belongs to the more advanced stages of syphilis, being usually asso- ciated with tubercular, papular, or pustular eruptions, rupial sores, nodes, and rheumatism of the bones, and ulceration of the throat, palate, and nose. It is characterized by a fixed and contracted state of the pupil, which is generally filled with lymph and displaced upward and inward ; by the ap- pearance, upon the anterior surface of the iris, of reddish-brown tubercles, or minute yellowish abscesses; and by severe nocturnal pains, situated deep in the eye, forehead and temple. The disease coramonlv attacks both organs Syphilitic ulceration of larynx. lost and SYPHILIS OF THE EAR AND SKIN. 423 either simultaneously or successively, and always rapidly extends to the other structures, as the cornea, choroid, and retina, involving them in its ruinous consequences, few persons recovering without loss of sight. As allusion will again be made to this affection in the chapter on the eye, no further notice need here be taken of it. In April, 1858, Dr. Addinell Hewson read before the Pathological Society of Philadelphia, the history of a case of supposed syphilitic retinitis, in a stout man, thirty-one years of age, who had contracted primary syphilis up- wards of two years previously. He had subsequently labored under loss of flesh and strength, alopecia, and sores on the skin, afterwards followed by violent pain in the left temple, and dimness of vision in the left eye. There had been no iritis. Under the ophthalmoscope, the lens and vitreous humor appeared to be perfectly clear, but the retina was defective in translucency and of a dirty tint, its surface being extensively sprinkled with small white, yellowish-white, or reddish points, of a globular shape, and strongly resem- bling the condylomata of syphilitic iritis. The optic nerve was changed in color, and the vessels of the retina were somewhat varicose. 6. SYPHILIS OF THE EAR. Syphilis of the ear is uncommon. Patients of a broken-down constitution and of intemperate habits are most liable to suffer. The disease frequently comes on in the form of sudden deafness, attended with aching pain, and evidently consists of inflammation of the tympanal membrane, which, upon inspection, is found to be red and abnormally vascular, and, in time, to be- come more or less opaque. If the morbid action be not soon arrested it may eventuate in ulceration, followed by complete destruction of the membrane, and permanent deafness. In the worst forms of the disease, the Eustachian tube, the middle ear, and even the petrous portion of the temporal bone become involved. The diagnosis is usually sufficiently easy, the most reliable points being the coexistence of syphilis in other parts of the body, the comparative slight- ness of the pain, which is much less than in ordinary myringitis, and the amenability of the disease to specific treatment. The affection evidently ap- pertains to the earlier tertiary group. Syphilis of the ear must be managed upon the same general principles as syphilis of other organs. The great remedies are mercury and potassium, aided by leeches, blisters, and mildly astringent injections. 7. SYPHILIS OF THE SKIN. Ulcers of the skin, or rupial sores, may be a sequence of secondary syphilis, but in general they are among the more remote effects of the tertiary form of the disease, coming on, in most cases, several years after the primary affection. They usually coexist with nodes and rheumatic pains, or with ulceration of the throat, nose, and larynx, or with all these ailments combined, and are nearly always preceded by scaly eruptions, pustules, papules, or tubercles. Persons of a broken, infirm, and cachectic constitution are their most common subjects, and those in whom they commit the greatest ravages. Much diversity exists in regard to the situation and character of these cutaneous ulcers. They are most frequently found on the extremities, espe- cially the inferior; they are also sufficiently common on the forearm and elbow, and on the scalp, forehead, and temple. Their size ranges from that of a split pea to that of the crown of a hat, their shape being usually circular or oval, although sometimes it is extremely irregular from two adjoining sores being connected or running into each other. The edges are nearly always 424 SYPHILIS. callous, everted, and more or less ragged ; the surface is excavated, covered with a greenish, pultaceous matter, and exquisitely sensitive; while the dis- charge, which is often very profuse, is thin, ichorous, and offensive, frequently excessively so. It is not often that we notice anything like a distinct, well- defined areola ; such an occurrence is seen only in rare cases, but in most instances there is marked inflammation with redness and induration in the parts immediately around. The largest of these ulcers generally occur on the shoulder, side, and buttock, and it is amazing what an immense size they raay attain. Numerous small ulcers of this kind occasionally exist in groups, giving the surface a peculiar worm-eaten appearance. In some cases, again, the ulcers have a serpiginous arrangement; in another class of cases they are, perhaps, very much undermined ; and now and then two large ulcers are connected together by a sort of cutaneous bridge. In fact, there is no end to the diversities of their configuration. Finally, they may be quite super- ficial, or so deep as to involve the subjacent cellular tissue, and even the fasciae, muscles, tendons, and bones. Rupial ulcers often continue for an indefinite period, sometimes partially cicatrizing, now spreading, now indolent or stationary. Frora local causes, as well as constitutional, they may take on almost any kind of action; when the patient is in an exhausted, irritable condition, they are very apt to be- come severely inflamed, and to assume a phagedenic, sloughing character, spreading often with immense rapidity, both in diameter and depth. The system generally actively sympathizes with these sores; the skin is dry and hot, the pulse small, quick, and frequent, the appetite impaired, the sleep destroyed, and the loss of flesh and strength excessive. The patient has an old, superannuated, care-worn look, with all the signs of a deep-laid syphilitic cachexia. The scars left by the healing of these ulcers are abnormally white, and retain for a long time a remarkable hardness, with a tendency to constant furfuraceous desquamation. They are sometimes very rough, and prone to reopen frora the slightest causes. The diagnosis of syphilitic ulcers is generally sufficiently easy, the only affection with which they are liable to be confounded being the common non- specific sore. There is generally an appearance about a specific ulcer of the skin which at once stamps its character. In the first place, it is generally circular or oval, and of an excavated shape, with hard, everted edges, and a foul surface, destitute of granulations and of healthy discharge ; the surround- ing surface is indurated, and generally somewhat discolored, the tint often resembling that of copper. Secondly, the sore is often multiple, occurring in groups, and also on different parts of the surface; a circumstance which is generally of itself sufficient to denote its nature; for the ordinary ulcer is usually solitary, and is most common on the lower extremity. Thirdly, the disease of the skin nearly always coexists with syphilitic disease in other structures, especially the periosteum and bones. Finally, the effects of the treatment afford important aid in doubtful cases ; ordinary ulcers disappear- ing, or soon assuming a healthy, granulating appearance, under simple anti- phlogistics, rest, and light diet, whereas specific ulcers always require the use of iodide of potassium and mercury, the latter often both internally and ex- ternally. These syphilitic affections of the skin are admirably illustrated in fig. 87. The diagnosis is unmistakable. ^ The syphilitic eruptions are soraetimes attended with onychia, or inflamma- tion of the matrix of the nails, the latter of which gradually become dry and black, and eventually drop off, leaving a foul, excavated, painful ulcer, with hard, steep edges, and a very fetid, ichorous discharge. If the raorbid action be very severe, or if it be not soon arrested, the matrix will be completely destroyed, when there can of course be uo reproduction of the nail; most SYPHILIS OF THE OSSEOUS SYSTEM. 425 commonly, however, a part of its substance survives, and afterwards makes a feeble effort at the formation of a new nail, which, in general, however, is merely an ill-shaped, stumpy, horn-like excrescence, altogether different from Fig. 87. Syphilitic rupia. the original structure. The diagnostic signs of the disease are the copper- colored appearance of the surface immediately around the ulcer, and marks of syphilis in other regions of the body. The lesion occasionally does not appear until may months after the primary sore, thus bringing it, properly speaking, under the head of tertiary symptoms. 8. SYPHILIS OF THE OSSEOUS SYSTEM. Affections of the periosteum and bones belong to the latter order of tertiary syphilis, and they may declare themselves in various forms, of which the most important are nodes, or soft tumors, inflammatory hypertrophy, exosto- sis, caries, and necrosis. These affections may come on at any time after the eighteenth month from the date of the primary sore, but in the great majority of cases they do not show themselves until after the lapse of at least twice that period. They are most liable to occur in persons of a scrofulous and cachectic constitution, and in those whose health has been destroyed by habit- ual intemperance, constant exposure, and deficient alimentation, leading to an impoverished state of the blood and protracted derangement of the secre- tions. The idea is now generally prevalent that diseases of the periosteum and bones, especially in their more severe forms, are, in great measure, limited to those persons who have undergone severe courses of mercury for their cure; and in this opinion the results of my experience induce me fully to concur. Of the many cases of tertiary syphilis of the osseous tissue that have fallen under my observation nearly all had taken mercury in large quan- tity, and the few who had been treated without that remedy had suffered comparatively little, except where there was a marked strumous diathesis, which never fails, I think, to aggravate the effects of the ingrafted disease. It would thus appear, at first sight, that this metal, by combining with the specific poison, was capable of essentially modifying its action, if not of form- ing a new virus, more potent and destructive than the original. But it is not necessary to have recourse to such an explanation ; it is sufficient to know that the action of mercury, when carried to an inordinate extent, is a most powerful depressant, the effect of which is felt, for a long time, by the whole system, by the blood not less than by the solids. A species of physical de- gradation of the entire organism is thus engendered, which cannot fail to predispose it, in no slight degree, to the injurious operation of morbific agents, whether acting within the system, or impressing it from without, through the medium of the cutaneous and mucous surfaces. Instead, there- fore, of supposing that a new poison, or a sort of a syphilitico-mercurial virus, is formed under these circumstances, it will be found to be more in accordance with the established facts of pathology to conclude that the fright- ful ravages so often committed in tertiary syphilis, after the inordinate use of 426 SYPHILIS. mercury, upon the osseous tissue, are the result, exclusively, of the deterio- rating influence of this metal upon the general system, whereby the more feebly organized structures, as the bones and their investing membrane, are rendered peculiarly prone to a bad form of inflammation, which, if not early checked, often leads to the most serious consequences. Tertiary syphilis is met with only in certain bones, chiefly in the superfi- cial, or in those least protected by soft parts, as the tibia and fibula, the ulna, clavicle, and bones of the skull, nose, palate, and upper jaw. In rare cases, almost every piece of the skeleton is involved, either simultaneously or suc- cessively ; some in nodes, some in caries, some in necrosis, and some in exos- tosis. Nodes occur chiefly upon the tibia, ulna, and skull, particularly the frontal and parietal bones. They present themselves as circumscribed, semi-solid swellings, of an ovoidal shape, somewhat elastic to the touch, and from half an inch to an inch and a half in diameter. So far as we are able to deter- mine, they always begin beneath the periosteum, upon the surface of the bone, as an inflammation, which is soon followed by the deposition of a remarkably gummy substance, of a light, turbid, or greenish hue, and of the nature of cacoplastic lymph. In many cases this is the only substance found in the swelling; in others, however, it contains, in addition, a considerable quan- tity of serum or of pus, or the gummy matter may be entirely absent, and the tumor be occupied by an imperfectly elaborated pus. The periosteum and bone, at the seat of the node, are both inflamed, softened, and ulcerated ; and as the turaor extends, the superincumbent structures, participating in the morbid action, become red and painful, and ultimately yield at the most prominent point, thus allowing the pent-up fluid an opportunity of escaping, although generally in a very imperfect manner, and not without severe suf- fering. A node is essentially an abscess of the fibrous and osseous tissues, the con- sequence of a specific inflammation, and occupied by an imperfectly elaborated pus, or a mixture of pus and plasma. Its course is always chronic, and the pain which attends it is peculiar, being of an intermittent, neuralgic cha- racter, subject to violent nocturnal exacerbations. The general health is always disordered, and, if the swelling is large, considerable constitutional disturbance is apt to be present. In many cases, nodes co-exist in different pieces of the skeleton. The skull is sometimes studded with them. A node may not only ulcerate, but also mortify; and after it has become an open sore, it may take on an almost endless variety of morbid actions, in- cident to syphilis in other structures. Thus, it may be excessively irritable, be invaded by phagedena or gangrene, burrow extensively among the sur- rounding tissues, be complicated with serious disease of the osseous tissue, or, lastly, be indolent and indisposed to heal. Caries of the bones is most commonly met with in the long bones of the extremities, as in the tibia and ulna, in the skull, and in the palate, maxil- lary, nasal, turbinated, and ethmoid bones, together with the vomer; in all of which it is not unfrequently conjoined with necrosis, whole pieces dying and sloughing away, so as to cause the most frightful mutilation and disfigure- ment. These ravages are generally most conspicuous about the countenance, especially when the disease attacks and destroys the proper bones of the nose, which then cave in, and cause that remarkable flattening of the face so characteristic of the effects of tertiary syphilis. In many cases the turbi- nated bones, the ethmoid, and vomer are separated, so as to convert the nasal fossae into one immense cavity ; and instances occur where, in conse- quence of the destruction of the palate and maxillary bones, the mouth and nose communicate with each other. In the long bones of the extremities, the caries and necrosis are generally superficial, the dead portions coming SYPHILIS OF THE OSSEOUS SYSTEM. 427 away in the form of exfoliations, the central parts of these pieces seldom participating in the morbid action to an extent sufficient to cause their de- struction. The adjoining cut, fig. 88, from Druitt, affords a graphic illustration of caries of the bones of the skull, which, as in a case that came under my observation many years ago, are sometimes completely riddled, so as Fig. 88. to give them, throughout, a cribri- form appearance. Syphilitic hypertrophy of the os- seous tissue is extremely common, and sometimes involves the greater number of pieces of the skeleton ; the bones, however, which are most liable to be attacked are the tibia, fibula, femur, ulna, radius, and cra- nium. The lesion occurs either as an exostosis, or as a diffused swell- ing, which, when it affects the whole length and thickness of a bone, as- sumes the name of general hyper- trophy. The mode of formation of a syphilitic exostosis presents nothing peculiar, and need not, therefore, claim any special atten- tion ; it evidently takes its rise in a deposit of plasma, which serves as a nidus for the future growth, the ossific process passing through the same phases as in the natural skeleton. The tumor is usually knobby and irregular, with a broad base, and a rough scabrous surface. In cases of long standing, it is nearly always of a hard, ivory consistence. The more common variety of hypertrophy is the diffused or general, of which the best specimens are usually seen in the bones of the leg, thigh, and forearm, which are often nearly twice the natural thickness and of extraor- dinary weight and firmness. A section of such a piece, seen in fig. 89, from a specimen in my cabinet, shows that the spongy substance has been com- Fig. 89. Syphilitic caries of the skull. General syphilitic hypertrophy of the femur; internal structure. pletely, or almost completely replaced by solid osseous matter, that the medullary canal has been obliterated, and that the compact structure has acquired a closeness of texture almost equal to that of ivory. The Haver- sian tubes are for the most part obliterated, or greatly changed in their size and shape, and the outer surface of the bone, as seen in fig. 90, is remark- able for its roughness, its appearance bearing a striking resemblance to that of a worm-eaten tree. The skulls of persons laboring under tertiary syphi- lis are sometimes astonishingly hypertrophied. In a specimen, presented to me several years ago by Dr. Cochran, of Louisiana, the cranial bones are 428 SYPHILIS. throughout at least half an inch in thickness ; the different pieces are com- pletely fused together without any trace of suture or of diploe, and their consistence and density are almost equal to those of ivory. Fig. 90. General syphilitic hypertrophy ; external characters. The periosteum is variously affected in syphilitic diseases of the bones; iu the more inflammatory lesions it is generally very vascular, soft, and spongy, at the same time that it is considerably thickened, and easily detached from the subjacent surface. In hypertrophy, especially the diffused form, the principal alterations are thickening and induration, with a tendency, here and there, to ossification. Instead of being easily separated from the affected bone, as it is in the more acute affections, the membrane always adheres to it with extraordinary firmness. The various syphilitic affections of the bones, but especially diffused hyper- trophy, are all attended with more or less disturbance of the general health, and deep-seated, excruciating pains. These pains, frora the fact that they are always worse at night, have earned for themselves the title of nocturnal, although they are rarely entirely absent even in the day; they are also fre- quently called syphilitic rheumatic pains. They are generally of a dull, heavy, aching, or gnawing character, and begin to increase in severity the moment the patient becomes warm in bed ; they may continue all night, or go off in a few hours, but while they last the patient has no sleep or comfort of any kind. Not unfrequently they are of a neuralgic nature ; excessively keen, darting, and coming on in nightly paroxysms. While they exist, the affected bones are generally exquisitely tender and intolerant of manipulation. 9. SYPHILITIC ORCHITIS. Syphilis of the testicle must be classed among the tertiary symptoms, since it rarely comes on until a long time after the primary sore. The average period, in the cases that have fallen under my notice, was frora two to four years; but it not unfrequently happens that the enlargement does not show itself until after the lapse of eight, ten, or even twelve years. It is usually associated with syphilis of other parts of the body, particularly the bones, joints, throat, nose and skin, the latter of which is often extensively ulcerated and otherwise disordered. These complications, which are seldom entirely absent in any case of syphilitic orchitis, are especially liable to occur when the tertiary affection breaks out long after the primary one, and they are always denotive of an infirm cachectic state of the system, induced by long suffering, neglect, or bad treatment, or all these causes combined. The disease almost always involves both testicles, either simultaneously or successively, although seldom in an equal degree ; and, as it proceeds, it is sure to extend to the epididymis, so that, in time, the two structures form one inseparable mass. The swelling is characterized by extraordinary weight and hardness, the affected organ resting upon the hand like a heavy solid body, and requiring constant support to prevent it from causing a sense of SYPHILITIC ORCHITIS. 429 dragging. When the disease has reached its maximum, the testicle is often six or eight times the normal bulk. The surface of the swelling is variable, though in general it will be found to be rather smooth, or but slightly knobby. The induration is uniform, except when there is, as not unfrequently happens, an accumulation of water in the vaginal tunic, in which case the correspond- ing portion will be soft and fluctuating. The spermatic cord usually partici- pates in the disease, being unnaturally hard and thickened. When the disease is of long standing, the affected structures lose their normal characters com- pletely, either at particular points, or throughout, the seminiferous substance being replaced by fibrous tissue. In the worst forms of the malady tubercular deposits occur, which, breaking down and disintegrating, lead to the forma- tion of unhealthy abscesses, and, when these discharge their contents, to the establishment of fungus. Syphilitic sarcocele is always a remarkably tardy and painless disease. It is only, as a general rule, when there is much water in the vaginal tunic, constituting the complication called hydrosarcocele, and causing constant pressure upon the inflamed and degenerating tissues, that the patient will be likely to suffer much, and then chiefly at night and in damp states of the atmosphere. When the swelling is very large, considerable inconvenience is usually experienced from the weight and bulk of the organ. The subjects of this form of syphilis are always thin, pale, and anemic, the appetite is greatly impaired, the strength is wasted, and the sleep is interrupted by nocturnal rheumatism. Their whole appearance, in fact, is indicative of a worn-out, miserable state of the system. When both organs are extensively diseased, the individual must necessarily be impotent. A remarkable feature of this form of syphilis is its tendency to recur, perhaps again and again, after being apparently relieved by treatment. Syphilitic orchitis can always be easily distinguished frora common orchitis ; first, by the tardy, indolent, and persistent character of the swelling; secondly, by the simultaneous, or successive involvement of both organs; thirdly, by the co-existence of syphilitic disease in other parts of the body, especially of nodes, and ulcers of the skin, nose, and throat; fourthly, by the gradual but certaiu destruction of the textures and functions of the testicle; and, lastly, by a careful consideration of the history of the case, particularly of the cha- racter of the patient. In obscure cases, before resorting to extirpation, the surgeon should make a faithful trial of anti-syphilitic remedies, otherwise he may have occasion to lament his rashness. The subjoined case, which I treated at the Clinic of the Jefferson Medical College, in the winter of 1857, affords an excellent idea of the nature, pro- gress, and termination of syphilitic orchitis, with the changes experienced by the affected organ. It was drawn up by Dr. S. W. Gross. A man, aged 29, had a fungus of the right testicle, which had commenced four months previously, as a small pustule on the scrotum. He had con- tracted chancre and bubo nine years before, and was laboring at the time of his admission under syphilitic rheumatism, ulceration of the tibia, and a slight eruption upon the face. The right testicle began to enlarge, and to become hard and painful three years ago. The left organ was also diseased, but in a less degree. The general health was much impaired. The fungus, above alluded to, was about the size of a half dollar, and the seat of an offensive, ichorous, and profuse discharge, as well as of severe pain, especially at night. Being satisfied, from a careful examination, that the organ was hopelessly destroyed, I had no hesitation in removing it. The dissection verified the cor- rectness of my diagnosis. The tubular structure was completely annihilated, a fibrous substance, of a pale yellowish color and dense consistence, occupying its place. At the posterior part of the epididymis was an abscess, about the volume of a small hickory-nut, filled with a tough, yellowish, cheesy-looking 430 SYPHILIS. matter, bearing a close resemblance to tubercular deposit. The wound soon healed, and under the use of iodide of potassium and bichloride of mercury, aided by a nutritious diet, the patient rapidly improved in health and spirits A year previously to this, I performed a similar operation upon a middle-aged raan, who had also labored for a long time under tertiary syphilis. The fungus was of large size, and the testicle was completely degenerated into fibrous tissue. Whenever syphilitic orchitis is of long standing, whether it is accom- panied or not by fungus, it will generally be found that its tubular substance is irretrievably destroyed. 10. CONDYLOMATOUS GROWTHS. Condylomata of the skin, or of the skin and mucous membrane, usually described by the French syphilographers under the name of mucous tuber- cles, occasionally arise as a consequence of venereal contamination. They consist in the development of various sized excrescences, of a flat and rather broad appearance, occurring either in groups or in isolated tubercles, and dependent essentially upon a hypertrophied condition of the integuments. It is difficult to assign to this disease its precise rank in the order of syphilitic phenomena, or even to affirm, with certainty, that it is always plainly of a syphilitic character. There are not wanting surgeons of great eminence who do not hesitate to assert that these condylomata may be produced by the contact of gonorrhceal matter, or by acrid vaginal and other secretions not specific in any way. On the other hand, it has been alleged that they pertain, not to one form of syphilis, but to all three, now following chancre, now secondary syphilis, and now tertiary. As for myself, I am inclined to regard them as of a constitutional character, depending upon the absorption of the syphilitic virus, and displaying themselves at a period more or less remote from the primary sore; as belonging, in fact, rather to the third order of phenomena than to the second, and under no circumstances whatever to the first. The idea of the constitutional origin of these bodies is strongly cor- roborated by the acknowledged fact, that they always require a course of constitutional treatment for their permanent eradication. These excrescences are sometimes a result of hereditary syphilis. Of this rare occurrence, I have witnessed not less than five cases. The first was a boy, eight years old, whose father had himself had a similar affection several years previously, in consequence of tertiary syphilis, attended with nodes and a scaly eruption. The tubercles existed in great numbers around the anus, and upon the lower part of the perineum, and could not possibly have been better characterized ; the child was pale and somewhat emaciated, but there was no other evidence of constitutional contamination. The mother had given birth to three infected infants, two before, and the other at the full period; the former were cast off dead, and in a putrid condition, and the latter died at the age of three months from marasmus, the whole body having been covered with scaly eruptions, which were particularly conspicuous on the forehead, hands, and feet. All the other cases were equally well marked. The most common sites of condylomata are the scrotum, vulva, perineum, anus, and buttocks, as exhibited in fig. 91. They also occur, though unfre- quently, on the penis, and in the folds of the thigh, in the axilla, and in the ear. They seem to have a particular predilection for parts which are habi- tually hot and moist; for it is there that they are not only most frequently found, but that they acquire their greatest and most rapid development. Their size and shape are very various. Thus, they may not be larger than a pin-head, or a mustard-seed ; but on the other hand, they often acquire the volume of a filbert, and even of a small almond. In shape, they are usually flat with a broad base, though not unfrequently the free portion is much CONDYLOMATOUS GROWTHS. 431 larger than the adherent, a circumstance which gives the growths a pedicu- lated aspect. When they occur in groups, as is very apt to be the case, they often coalesce, forming thus considerable masses, tuberculated on the surface, Condylomata. irregular in shape, of a reddish color, and of a firm, fibrous consistence. The largest and worst of these tumors always occur at the margin of the anus, and on the perineum, vulva, and other parts which, from the contact of the opposing surfaces, are habitually subjected to friction, heat, and moisture, which, as already stated, are greatly conducive to their development. In these localities, the tumors are always humid, exhaling a thin, muco-purulent fluid, often quite abundant, and always excessively fetid. In those parts, on the contrary, where they are more exposed to the air, they are dry, insensible, of a darkish color, and partially incrusted with scabs. Condylomata often coexist with other evidences of a syphilitic taint, espe- cially affections of the bones, rupial sores, tubercles, and scaly eruptions. Their course is variable; sometimes steadily onward, at other times stationary, and now and then even retrogressive. Exercise and friction always irritate them, causing them to become sore, and sometimes so exquisitely sensitive as to deprive the patient of the power of locomotion. When they are large and numerous, the discharge is generally copious and almost insupportably offensive. They are rarely accompanied by febrile symptoms. It has been supposed that the discharge furnished by these excrescences is contagious, and, consequently, capable, by inoculation, of producing a similar disease. A great deal of plausible testimony has been adduced in favor of this opinion, by surgeons holding the highest position as observers and men of talent; but the notion has always appeared to me to be untenable, on the ground that these bodies, being always the result of a constitutional vice, are not capable of yielding any specific virus. When they coexist with chancre, the occurrence of infection during sexual intercourse is easily explicable. The diagnosis of condylomata cannot be mistaken. The situation of the excrescences, their peculiar shape, their chronic character, and their fetid secretion all serve to give them a distinctive character. Corroborative testi- mony is often furnished by the history of the case and the coexistence of syphilis in other parts of the body. 432 SYPHILIS. TREATMENT. The treatment of tertiary syphilis reposes upon broad, scientific, and philo- sophical principles, and may therefore generally be pursued with a positive certainty of affording great relief, if not of ultimately effecting a radical cure. Even the worst cases may usually be immensely benefited in a very short time under the modern system of treatment; and I have repeatedly seen patients, apparently on the very verge of the grave, who had not enjoyed a comfortable night's sleep for years, and whose bodies had been sadly deformed and racked by pains, raised to health and usefulness by a few doses of medi- cine. The remedy to which we are indebted for these wonderful effects is the iodide of potassium, which, if there be such a medicine as a specific, is unquestionably entitled to that distinction. Experience has shown that it is capable of performing for tertiary syphilis what quinine is for intermittent fever, or arsenic for neuralgia. It is the remedy par excellence in tertiary syphilis; a modern discovery of stupendous consequence to the human race; a remedy without which it would be impossible to treat this disease with any prospect whatever of success in almost any case, however simple. Let me not, however, in making these broad statements, be misunderstood. I do not wish to assert that iodide of potassium is absolutely infallible; like quinine and other great remedies, it occasionally disappoints expectation; but we may safely claim for it a degree of certainty which no other article of the materia medica possesses, as an antisyphilitic agent in the tertiary stage of this affection. I therefore ask for it, as has been done by many others, an undoubted confidence in its efficacy, and a fair trial of its use. The exhibition of iodide of potassium may usually be commenced without any preliminary treatment; it is only when there is great disorder of the secretions that any preparation of the system will be necessary, and then it need not generally extend beyond a single dose of purgative medicine, and the administration of a full anodyne. The proper mode of exhibition is that of solution in distilled water, either alone, or with some bitter infusion or tincture, as hop, gentian, or quassia, such a combination being particularly desirable in the event of a gentle tonic being required. The dose of potas- sium has been a prolific source of dispute. Long experience has taught me that, while less than ten grains will rarely do much good, there are few cases in which more than this quantity is really ever needed. I have therefore found this to be a good average dose, repeated three times a day, at intervals of eight hours, the most favorable period for the administration being soon after eating. When a rapid effect is required, as when there is unusual urgency of the symptoms, an additional dose may be given, but this will seldom be necessary. I have occasionally exhibited twenty, twenty-five, and even thirty grains at a close thrice daily, but the effect, instead of being gratifying, has generally disappointed me, the medicine seeming to act as an irritant rather than as a calmative, as it always does wheu it agrees perfectly with the system. I have never given drachm doses of the article, as is done so often by others, and I should regard such practice as altogether unmean- ing, if not positively prejudicial. We cannot take the disease by storm ; the treatment must be chronic, in conformity with the malady which it is intended to cure ; hence it requires patience, regularity, and perseverance rather than a display of strength and heroism. The remedy must not be abused. The practitioner should be intent upon accomplishing a certain amount of good every day, until he succeeds in eventually expelling the implacable foe effect- ually from the system. Conducted upon this plan, a most rapid and decided amendment generally occurs; the sleep, appetite, and strength daily improve; TREATMENT OF TERTIARY SYPHILIS. 433 the countenance loses its wan, cachectic appearance ; and in less than a fort- night, often indeed in less than a week, the patient looks and acts like a new being, his whole condition, physical and mental, evincing the astonishing change wrought by the medicine. Iodide of potassium, especially when given in large doses, occasionally signally disagrees with the system, rendering it necessary either to suspend its use altogether, or to administer it in a modified form, or in smaller quan- tity. The most comraon effect which it induces is an irritable condition of the air-passages, with a sense of fulness in the head and frontal sinuses, a thin watery discharge from the nose, more or less sneezing, vascular injection of the conjunctiva, and a general feeling of discomfort, the symptoms strongly resembling those of a rather severe coryza. This effect sometimes declares itself after the exhibition of only a few doses of the medicine ; at other times it does not appear until after the lapse of eight or ten days, or until the system has been pretty well saturated with it. In some cases, depending evidently upon a strong idiosyncrasy, the smallest quantity almost is sufficient to produce excessive discomfort, and an invincible repugnance to the further use of the remedy. Among the more uncommon effects to which the iodide of potassium may give rise are, gastric irritation, diarrhoea, salivation, glos- sitis, vesicular eruptions of the skin, excessive diuresis, hemorrhagic dis- charges from the urethra and vagina, and cerebral excitement not unlike that occasioned by alcoholic drinks. The best mode of counteracting these disagreeable effects of the medicine is to combine it with an anodyne, as a small quantity of morphia, or from five to ten drops of acetated tincture of opium with each dose. In some cases I have found the free use of strong hop tea to answer the purpose, while in others a mere diminution of the dose was sufficient. I do not remember an instance in which I have been compelled, on this account, to abandon the use of the article altogether. The length of time during which the potassium should be continued must, of course, vary in different cases and under different circumstances, and does not therefore admit of any definite statement. In the great majority of cases it should be exhibited for many weeks and even for a number of months, with an occasional intermission of three or four days, in order to afford the system a short respite, which is always found eminently beneficial whenever a medi- cine has to be used chronically. An invariable rule with me is to continue the remedy for several weeks after all disease has apparently vanished ; and afterwards to give it for eight or ten days at a time at intervals of a month, on the same principle that we administer quinine periodically and for a long time, for the radical cure of intermittent fever. Iodide of potassium may sometimes advantageously be combined with carbonate or muriate of ammonia, the two articles being given in solution, iu equal proportions, thrice a day. An eminent Italian practitioner, Dr. Gamberini, of Bologna, recommends, as a substitute for iodide of potassium, iodide of sodium and iodide of ammonium. The latter preparation has lately been very frequently employed by Professor Blackman, of Cincinnati, and, as he informs me, with the most gratifying results. He prescribes it in doses of about five grains, three times in the twenty-four hours, using along with it, when there is much emaciation, cod-liver oil and generous diet. Although I have no hesitation in declaring that iodide of potassium alone will often cure tertiary syphilis, yet I am quite satisfied, from personal experi- ence, that its efficacy is generally remarkably augmented by the addition of a small quantity of mercury. Indeed, so thoroughly am I convinced of the decided superiority of this course that I have of late years almost invariably employed it, thus greatly abridging the treatment, and much more completely eradicating the disease. The plan is particularly beneficial when the affection vol. i.—28 434 SYPHILIS. is of long standing, when it has deeply penetrated the system, as shown by the existence of nodes, nocturnal pains, and ulcers upon the skin, and when the patient has been fruitlessly subjected to frequent courses of the iodide alone. An infirm, broken state of the system is no bar to the use of mercury in this mode of combination ; on the contrary, it often affords the medicine an opportunity for its best display. The form of mercury which I prefer, and to which I have become much wed- ded, is the bichloride, which is readily made soluble by the iodide, and may be given in doses varying from the eighth to the sixteenth of a grain three times a day. I usually begin with the twelfth of a grain, gradually increas- ing the quantity, if necessary, on account of the obstinacy of the case, to the eighth or sixth of a grain, which should rarely, if ever, be exceeded in any case. The effects of the remedy are of course carefully watched, the slightest tendency to ptyalism being a sign for its suspension, or, at all events, its more guarded use. In general, I have found it beneficial to continue the mineral until there is slight tenderness of the gums, with a metallic taste in the mouth, and to keep up this action afterwards for several weeks by repeat- ing the dose occasionally as the effect begins to flag. In short, chronic mer- curialization is wished for, not acute, which never fails to do harm, sometimes immense and irreparable. After the mercurial course has been sufficiently persisted in, the cure may be completed by the iodide of potassium, now given by itself, and perhaps in reduced doses, simply to maintain a slight constitu- tional impression. When the bichloride disagrees, which, however, is seldom the case, a good substitute, although of inferior value, will be found in the blue mass, the gray powder, or the protiodide. Donovan's solution, a compound of mercury, iodine, and arsenic, may sometimes be advantageously exhibited, the dose being from six to eight drops three times a day. It often proves serviceable in relieving rheumatic pains and swellings of the bones and periosteum. When the system is much dilapidated, the object is best attained by inunc- tion, fumigation, or the vapor bath, the remedy, when thus introduced, acting often much more beneficially and kindly than when administered by the mouth. The topical application of mercury is particularly to be commended when the syphilitic disease is of unusually long standing; when the surface is covered with irritable, painful, and intractable sores ; when there is deep involvement of the bones, as declared by the existence of nodes, diffused swellings, or caries and necrosis; or when the system is greatly exhausted by protracted suffering, want, and exposure, or long and injudicious courses of mercury by the mouth. Thus employed, its effects frequently display themselves in the most striking and efficient manner, in the rapid and extraordinary improve- ment that follows in the character of the several local affections and the con- dition of the general system. The article which is usually employed for inunction is the simple mercurial ointment, from a drachm to a drachm and a half being rubbed upon the in- side of the thighs and arms once a day until the constitutional effects of the medicine become apparent by the state of the gums, breath, and saliva. I usually add a small quantity of powdered camphor, with a view of rendering the ointment more soluble, and thereby facilitating its introduction into the skin. The friction should be very thorough, and be continued until the oint- ment has disappeared from the surface. Mercurial fumigations may be conducted in a very simple manner, and with hardly any expense. All that is necessary is a large comfort, long enough to extend from the floor to the patient's neck, to which it is carefully secured with a piece of tape, so as to prevent the fumes from escaping into the room and entering the sufferer's lungs. For want of this precaution, suffocation TREATMENT OF TERTIARY SYPHILIS. 435 has occasionally occurred, as in an instance which took place, many years ago, at the Louisville Hospital, in a man affected with tertiary syphilis. Or, in- stead of this, the body may be surrounded with a cloak of oil-cloth. The patient, completely stripped, is seated in a large arm chair, or upon a stool, beneath which is placed the fumigating apparatus, consisting of a common dinner plate, and a spirit lamp, arranged in such a manner as not to endanger the safety of the person. The mercurial preparation usually employed is the red sulphuret, of which from half a drachm to a drachm is put upon the plate prior to the ignition of the lamp. The operation, which should not be re- peated oftener than once a day, lasts from ten to twenty minutes, at the end of which the patient should retire to bed, and cover himself well up in order to maintain the perspiration usually so auspiciously begun during the fumiga- tion. Great prostration, however, may follow this sweating process, and hence care should be taken not to carry it too far, or to renew it too frequently. The length of time during which the fumigation should be continued must depend upon circumstances; in general, it will not be short of two or three weeks. Another mode of employing mercury topically is by a combination of fumi- gation with steam, constituting what Mr. Langston Parker, of Manchester, terms the mercurial vapor bath. It is applied after the same method as ordinary fumigation, with this difference, that, while the cinnabar or sulphu- ret is volatilized by means of a spirit lamp, the steam of hot water is con- veyed from a boiler under the patient's mantle as he sits in his chair. I can testify from considerable experience to the beneficial effects of these two methods of mercurialization, having effected some very extraordinary cures with them after all other rational means of treatment had failed. I recollect, in particular, the case of a young gentleman of Arkansas, who was under my charge, in 1855, on account of tertiary syphilis of many years' standing, attended with an enormous amount of rupial action of the skin, one of the sores being fully as large as a dinner plate, and with an infirm, cachectic state of the system, who was promptly cured, comparatively speak- ing, by daily fumigations with sulphuret of mercury, conjoined with the fre- quent use of the tepid bath, a nutritious diet, and stimulants, after a great variety of other means had been fruitlessly employed. My impression is that this mode of treatment is not sufficiently appreciated by the profession of this country. It certainly deserves the highest encomiums. WThen there is much disorder of the secretions, derangement of the alimentary canal, or a feverish state of the system, a short course of preliminary treatment will generally be necessary before commencing the fumigation process, as this will greatly augment its efficacy. In all cases the object should be to bring the mercurial vapor as fully as possible in contact with the syphilitic sores. Simple and medicated baths often prove serviceable in tertiary syphilis, not only as means of cleanliness, but by the direct soothing and healing influ- ence which they exert upon the part and system. They are particularly beneficial in rupial ulcers and in rheumatic pains of the bones and joints. The emollient bath, prepared by mixing a basinful of thick gruel, or twice that quantity of wheat bran, with a suitable quantity of tepid water, gene- rally proves most grateful. The common salt-water bath, or a bath contain- ing a small quantity of carbonate of potassa, or chloride of sodium, is an excellent detergent and stimulant in the foul ulcers of the skin and bones so common in the advanced stages of syphilis. Occasionally the water may be advantageously impregnated with bichloride of mercury, from three to ten grains of the salt being added to the gallon of fluid, and the immersion con- tinued for at least twenty or thirty minutes. Much caution, however, is required, especially when the surface is considerably denuded, otherwise severe ptyalism may arise. Baths containing nitric, hydrochloric, or acetic 436 SYPHILIS. acid, are sometimes used, though of late they have gone much out of vogue, chiefly, perhaps, because they are inconvenient, and liable, if proper care be not taken in their preparation, to cause severe pain. Besides mercury and the other means above mentioned, there are certain remedies which, although usually considered as being merely auxiliary, are, nevertheless, of great consequence in a curative point of view in the treat- ment of syphilis. At the head of these may be placed a properly regulated diet, tonics, sudorifics, and anodynes, which deserve the greatest attention in every case of the disease. It is impossible to insist too strongly upon a well regulated diet in the treat- ment of this affection, when it is recollected how much its progress and viru- lence are influenced by the exhausted and impoverished condition of the system which generally attends it in its more advanced stages. No medicine can possibly produce its full and legitimate effects under such circumstances, without the aid of good, wholesome, and easily digestible food, stimulating drinks, especially brandy and whisky, and an abundance of fresh air. The blood must be enriched and the solids rebuilt before it will be possible to eradicate the specific virus from the system. Tonics are nearly always indicated ; and quinine with iron will usually be found to answer better than any other combination. The bitter extracts, as gentian and quassia, are generally of no account, except in so far as they may conduce to improve the appetite. Occasionally benefit accrues from the use of some of the acids, particularly the nitric and hydrochloric, either alone or conjointly, and diluted with a large quantity of water. Formerly, power- ful anti-syphilitic properties were ascribed to these articles, but it is probable that all the good they do is solely dependent upon their tonic virtues, and not upon any agency they possess in neutralizing the syphilitic poison. When much emaciation exists, with want of assimilative power, or a feeble diges- tion, there is no article which holds out greater promise of usefulness than cod-liver oil, given in doses suited to the state of the stomach and the gene- ral condition of the system. Sudorifics have long held a high rank in the treatment of syphilitic affec- tions, under a supposition, at one time quite rife, that they aided in carrying off the venereal poison, thus ridding the system of its noxious influence. Without conceding to them such a virtue, which they certainly do not pos- sess, there is no question as to their general usefulness in all states of the economy attended with obstructed perspiration, so often present in the ad- vanced stages of syphilis, particularly when there is serious involvement of the skin. The object for which such medicines are usually prescribed raay be readily obtained by the warm, hot, or steam bath, assisted by tepid drinks, and various kinds of diaphoretics, as Dover's powder, antimony and morphia, and similar articles. Some caution is necessary in the use of sudorifics, lest injurious debility be induced. But of all the auxiliary remedies now described, the most important, in every respect, are anodynes; their employment is absolutely indispensable, and it is therefore impossible to assign to them too high a rank. They are, up to a certain stage of the treatraent, of more consequence even than food and drink. The patient is not only not able to sleep, but his body is literally racked with pain and surcharged with irritability. To look for any sub- stantial improvement, under such circumstances, from ordinary remedies, would be worse than idle; it would be absurd. The first thing to be done is to quiet the system and induce sleep; and to accomplish this, anodynes must be exhibited in large and sustained doses, a grain of morphia, or its equivalent of solid opium, laudanum, or black drop being given every eight or twelve hours, according to the effects of the article. The manner iu which anodynes are borne, in the worst forms of tertiary syphilis, is often astonish- TREATMENT OF TERTIARY SYPHILIS. 437 ing, and can only be explained by the irritable condition of the nervous system. I have not made any reference to sarsaparilla in the enumeration of the above remedies, simply because I am not sure that its employment in my hands has ever been productive of any appreciable benefit. Whether this has arisen from bad luck, or from the use of an inferior article, it is not in ray power to affirm ; I raay state, however, that I have employed it in every form and mode of combination in which it is used in this and other countries, and am therefore inclined to believe that it has been invested with virtues which do not belong to it, or which are due mainly, if not solely, to its asso- ciate ingredients. Finally, persons laboring under tertiary syphilis should live in a pure, dry atmosphere, and be well protected against cold. When it is remembered how easily the disease is provoked by exposure to cold, and by living in damp, underground, and ill-ventilated apartments, the importance of atten- tion to this injunction cannot fail to be fully appreciated. The body should be well covered with flannel, both in summer and winter, and the patient should not be permitted to sit in the draught. The above general treatment is applicable, to a greater or less extent, to all forms and cases of tertiary syphilis whatever ; it is only necessary, there- fore, in concluding this branch of the subject, to refer to the topical measures, and to such modifications of treatment as are likely to grow out of the ana- tomical relations of the individual structures and organs liable to suffer from this disease. There are certain rules of treatment which are applicable to all local affec- tions, whatever raay be their site or extent. Thus, the surgeon does not hesitate to remove dead bone, open abscesses, trace out sinuses, divide fasciae or aponeuroses, and trim off the ragged, undermined and impoverished edges of cutaneous ulcers, so as to place them in a more suitable condition for speedy reparation. All this is self-evident, and only requires mention to secure at- tention. Cleanliness is of paramount importance in all cases, as it contributes not merely to personal comfort, but also, in a powerful degree, to recovery. Fetor is allayed by the free use of the chlorides. Ulcers, fissures, eruptions, papules, and tubercles of the skin often get well with very little topical treatraent; simply, in fact, under the use of iodide of potassium, or potassium and mercury, with attention to cleanliness and other hygienic observances. When much inflammation is present, with a foul ap- pearance of the part and a tendency to spread, the dilute tincture of iodine will come in play, with emollient cataplasms, or the warm water-dressing, simple or medicated. Touching the sores lightly once a day, or every other day, with dilute acid nitrate of mercury or the solid nitrate of silver, gene- rally astonishingly promotes the cure. Unguents are not always as bad as they have been represented to be in these cases. I have often employed them with excellent effect, especially the opiate cerate, the balsam of Peru ointment, and the ointment of the nitrate of mercury, mixed with six or eight times its bulk of simple cerate. The mercurial ointment, much diluted, and mixed with opium, often makes an excellent dressing in the indolent form of rupial ulcer. Syphilitic onychia is, strictly speaking, a rupial ulcer, and should therefore be treated in the same manner as similar sores elsewhere. If abscesses form under the nail, they must be punctured; and if the nail die, it must be removed, or trimmed, if it overhang and injuriously compress the diseased parts. The topical treatment of tertiary ulcers of the throat, mouth, and tongue is restricted principally to applications of the acid nitrate of mercury and solid nitrate of silver, made at first once a day, and subsequently every third, 438 • SYPHILIS. or fourth day, according to the condition and progress of the sore. Weak gargles, or washes of acetic acid, tannin and sulphate of copper, chlorinated soda, or of the cyanuret of mercury, in the proportion of frora ten to six- teen grains of the salt to a pint of some bland, mucilaginous fluid, as linseed tea or infusion of elm bark, may be employed three or four times a day in the intervals. In the treatment of syphilis of the nose, our chief reliance is upon injections of weak lotions of iodide of iron, sulphate of copper and tannin, tincture of myrrh, and chlorinated soda, particularly the latter, as it imparts not only a healthy stimulus to the affected surfaces, but effectually allays fetor, so dis- tressing and disgusting in this class of nasal complaints. Mercurial prepa- rations are, as a general rule, improper, being extremely prone to pass into the stomach, and thus occasion salivation ; but for this they would often be most beneficial. In using injections for the nose, a large syringe with a long, perforated nozzle is required, the object being to bring the fluid in contact with every portion of diseased structure. They should not be repeated more frequently than thrice a day, and especial care must be taken that they do not distress by their severity. In fact, an injection of the nose should never smart beyond a very few minutes, and then only in a very slight degree. If it pains longer, it is an evidence that it is too severe to be beneficial. If the affected parts are within reach, regular and steady medication may be effected with lint smeared with some suitable ointment or wet with some slightly stimulating lotion. In all cases the nasal cavities should be fre- quently inspected with a view to the early detection and removal of dead bone. In syphilis of the larynx direct medication may be attempted by means of the mop wet with a weak solution—from ten to twenty grains to the ounce— of nitrate of silver, introduced once every third or fourth day, the patient being at the moment partially under the influence of chloroform so as to render the parts more passive, and, consequently, more tolerant of the opera- tion, which is otherwise very apt to prove a complete failure. When the disease is extensive or the case urgent, as when there is deep ulceration with excessive difficulty of deglutition and frequent spasm of the muscles, or oedema of the glottis, nothing short of laryngotomy will suffice, and should be had recourse to without delay. Direct medication may then be made with acid nitrate of mercury or with any other article that may seem expedient. If warty excrescences be present, they may be clipped off with the scissors, repullulation being prevented by escharotics or sorbefacients. Dead carti- lage is removed in the usual way. The great remedy for syphilitic iritis is mercury pushed in such a maimer as to produce a most rapid and decidedly salivant effect. No time is to be lost; the treatment must be prompt and earnest, with a view to the one result, or the eye is lost. If the patient be young or plethoric, blood is freely taken frora the arm or by leeches and cups frora the temple. Opium is given to allay pain and prevent the mercury from running off by the bowels. Affections of the bones and periosteum of the extremities are treated upon general antiphlogistic principles. The local pain and swelling are often immensely benefited by tincture of iodine, leeches, and blisters, although in very many instances they readily yield to the internal exhibition of iodide of potassium and mercury. A node should not, as a general rule, be opened so long as it is very small, and unproductive of serious annoyance; when the reverse, however, is the case, it should be freely incised, and so also if it be the seat of distinct fluctuation, denotive of the existence of matter. A good rule, under such circumstances, is to make the knife graze the bone, imper- fect division of the parts being generally worse than useless. If the resulting ulcer be slow in healing, it should be well blistered, or dressed with mercurial TREATMENT OF TERTIARY SYPHILIS. 439 ointment, or some stimulating and anodyne lotion. Sometimes the pain and tension of a node may be promptly relieved by subcutaneous incision, effected by means of a delicate bistoury, carried about in different directions and in such a manner as also to divide the periosteum. Necrosed bone must be removed as soon as it is sufficiently detached to admit of its easy separation ; while carious bone must be scraped and otherwise managed to put it in a condition capable of undergoing reparation. Diffused hypertrophy rarely requires any other than constitutional remedies. Exostosis, properly so called, is usually free from mechanical inconvenience ; should it act obstruct- ingly, the best remedy will be the saw or pliers. Syphilitic sarcocele is treated, topically speaking, upon the same general principles as swelling of the testicle from gonorrhoea, by rest of body and elevation of part, leeches, astringent and anodyne fomentations, and mild mercurial inunctions. When the enlargement is indolent and rebellious, strapping may be employed, either with common adhesive plaster, mercurial and ammoniac plaster, or the plaster of Vigo. The cure is often retarded in these cases by the presence of a considerable quantity of serum in the vaginal tunic, compressing and irritating the diseased organ. The proper remedy is a free incision, or repeated punctures. If abscesses and fungus form, they should be treated in the ordinary manner. When the testicle is fungous, ulcerated, and completely disorganized, the only resource is removal, no treatment, either general or local, proving of any service in such a case. But, before so serious an operation is ventured upon, it should always be understood that the organ is really, and not merely apparently, past recovery. The treatment of condylomatous growths must be conducted upon general and local principles. It is true, topical means alone will often cure them without difficulty ; but to effect permanent riddance constitutional treatment is generally indispensable. The most efficacious remedy, for this purpose, is the iodide of potassium in union with the bichloride of mercury, administered as in tertiary syphilis, the diet, bowels, and secretions being at the same time suitably regulated. The specific treatment should be prolonged, in a modi- fied manner, for several weeks after all disease has apparently disappeared, the object being to break up all tendency to recurrence. In regard to the topical treatment, cleanliness is a matter of primary importance, hardly less on account of the attendants than of the patient himself. Free use must be made of tepid water, impregnated with the liquid chlorinated soda, and applied by means of a sponge or syringe ; if there be much discharge, the dressings and the bedclothes should be frequently sprinkled with the solution. Another important element of treatment is perfect rest with isolation of the affected parts, their contact having, as stated previously, a tendency to foster growth and secretion. To repress the tumors, various remedies may be used, the best of which is chromic acid, applied once in the twenty-four hours, until they are shrivelled and dried up, as they generally will be in a few days. Nitrate of silver, nitric acid, and acid nitrate of mercury, so commonly recommended, are all extremely severe, besides being very uncertain. In the intervals of the applications, the excres- cences should be kept well covered with some desiccating substance, such as three parts of prepared chalk to one of carbonate of zinc, calomel, or dry lint. Under this management rapid improvement soon follows ; the tubercles be- coming dry, shrivelled, and less sensitive. In the minor cases, prompt relief generally follows the application, several times a day, of pulverized savin, with a small quantity of tannin and a minute portion of sulphate of copper, or equal parts of powdered savin and alum. Great attention should be bestowed upon cleanliness for a long time after the excrescences have disap- peared. 440 SYPHILIS. SYPHILIS IN THE INFANT. Infants are subject to syphilis, and there are two modes in which they may become infected. First, they may suffer from direct inoculation, and, secondly, the disease may be communicated by either parent; by the father in the act of copulation, or by the mother during the process of pregnancy. It has also been supposed that a child may be contaminated by the milk of an un- sound nurse, but if this be true, the facts have not been presented in such a light as to induce general conviction of their accuracy. Direct, primary syphilis may be contracted, as, indeed, it most generally is, by a child in its passage through the soft parts of the mother, by the surface of the body coming in immediate contact with a chancre in the vagina, or on the vulva, or, at all events, with the secretions of such a sore. In this man- ner an eye may become inoculated, or the mouth, or, in short, any mucous surface that may entangle and retain the specific virus sufficiently long to ad- mit of its absorption; for in so young a subject as this it is probably not necessary that there should be any actual solution of continuity in order to produce the effect, the mucous tissues being so delicate, and the lymphatics so active as to enable the poison to enter these vessels by direct imbibition. When the disease attacks the skin, however, it is generally, if not always, the result of direct inoculation from the matter being brought into contact with an abrasion on its surface. A nurse having a chancre upon her nipple may impart the virus to the infant's lips in the act of suckling, but such an occur- rence, although possible, must be extremely uncommon. In whatever manner the infection is caught, the resulting disease pursues the same course as when it occurs in the adult, whether from sexual inter- course or artificial inoculation. The child may perish from the local irritation, or, if it survive the primary affection, it may afterwards suffer from constitu- tional syphilis, the impression manifesting itself in cutaneous eruptions, mucous tubercles, sore throat, ulceration of the nose, and rheumatic pains in the bones and joints. In the great majority of cases of infantile syphilis, however, the disease is communicated either through the seminal fluid of the father, in the act of pro- creation, or by the mother through her blood after the ovum has taken up its residence in the uterus. That the contamination may occur in both these ways has been incontestably proved by numerous observations, conducted with such care as not to admit of any reasonable doubt. The semen is a living fluid, and in a man laboring under constitutional syphilis the probability is that every spermatozoon is completely impregnated with the specific poison ; hence it is only necessary that it should be mixed with the material furnished by the mother in order to produce thorough vitiation of the new being. Thus, the very fountain of life is poisoned in the very act of conception, and it is therefore not surprising that all its sources should participate in the evil thus inflicted. The time at which a female with secondary symptoms may communicate the poison to her offspring cannot be accurately stated. The probability is that it is very short. This is proved by the circumstance that such a woman fre- quently aborts within a few months after conception, evidently in consequence of the deleterious effects of the virus upon the foetus. I suppose that the contamination is coeval with conception, occurring at the moment of the commingling of the two seminal fluids; for if it be assumed, as we have a right to do from the facts of the case, that the male can communicate the poison in this manner, why should a similar faculty not be ascribed to the female ? She, too, furnishes a fecundating substance—a seminal liquor— SYPHILIS IN THE INFANT. 441 which can no more escape contamination when her system is affected with secondary syphilis than the seminal fluid of the male. In both cases, the blood, the source of life, growth, and nutrition, is completely empoisoned, and hence all its products, whether solid or fluid, must necessarily participate in the evil effects to which such a state must give rise. But in the female these effects must be still greater than in the male; the whole function of the male, in the process of reproduction, consists in the deposition of a certain amount of semen, perhaps a solitary spermatozoon, while the female is also obliged not only to furnish a fluid, but after conception has occurred, she is compelled to nourish the new being, the most intimate connection being esta- blished between them by means of the placenta. It has been alleged that a healthy child, or a child born of healthy parents, may be infected by a nurse affected with secondary syphilis; the milk being tainted, and capable of communicating the disease. Of the possibility of such an occurrence I entertain, I confess, great doubt; my own practice has certainly not afforded me any examples of it, while it has fallen to my lot to see several cases where the converse was the fact, healthy children having sucked infected women, and yet they remained perfectly sound. It has been a contested point whether a child, laboring under constitutional syphilis, can infect its nurse by communicating the disease through the nipple, and the question, as might have been expected, has been answered differently by different writers. Those who have espoused the affirmative side of the question, rest their assertion upon the result of personal observation, the most reliable testimony of all, one would suppose, in a controversy of this kind; but it is not to be forgotten that observation is fallacious, and that all men, however competent to practise medicine and surgery, are liable to be deceived by their patients, especially in relation to venereal affections. Not only do the abettors of this doctrine assert the possibility of this mode of transmission, but they go further and allege that a nurse so affected has, in turn, infected her own offspring. In a case related by Mr. Hunter, and upon which great stress is usually laid by authors, it is stated that the diseased infant, in this way, successively inoculated three wet nurses, two of whom afterwards conceived, and were delivered of syphilitic children. Now, in- stead of looking upon this case in this peculiar light, I should be inclined to infer one of two things, either that this diseased child had had a chancre upon its lip, or, what is more probable, that the three nurses had all been previ- ously infected. Those, on the other hand, who contend that such a mode of contamination is impracticable, base their conclusions upon the fact that the matter of secondary syphilis is destitute of inoculable properties, no well authenticated case, or one entirely free from objection, having yet been observed of the transmission of the disease through its intervention. Now, if this be true, as undoubtedly it is of the adult, it ought to be equally true of the infant; and hence, although the child should have a specific sore upon the lip or tongue, and the mother a fissure, crack, or ulcer upon the nipple, yet, inasmuch as the secretion of the former is innocuous, no constitutional contamination can be caused by its contact with the exposed surface of the latter. There is another question which closely connects itself with the preceding, aud it is this: Is there any evidence, of a positive kind, that a husband labor- ing under secondary syphilis may communicate the disease to his wife through the agency of the semen ? So far as I am aware, there is none, and yet the affirmative side of the question has met with some very warm advocates. It is absurd to believe that this fluid, when injected into the vagina and uterus, is ever absorbed, even supposing that it were retained for a considerable length of time, which, however, it rarely, if ever, is. There is certainly no satisfactory proof of such an event, and we must, therefore, at least for the 442 SYPHILIS. present, reject it. It is different when impregnation occurs. Here, as already seen, the semen mixes directly with the corresponding fluid of the female, to which it at once imparts its deleterious properties, thereby effectually tainting the new being in the very act of its creation. Hereditary syphilis is generally a grave disease ; for, unless it be judi- ciously treated, it nearly always proves fatal. A great majority of the neg- lected cases terminate in abortion, the foetus often perishing as early as the end of the third month, and frora thence on death may occur at any period up to the full term of gestation, the child being usually thrown off in a putrid and horribly offensive condition. The number of successive abortions is sometimes remarkable; in one instance, communicated to me by one of my own patients, it amounted to thirteen, the woman never having brought forth a healthy infant. Cases of three and four successive abortions have repeatedly come under my observation. Now and then a woman will abort several times in succession, and then be delivered of an apparently healthy child; I say apparently healthy, for, although the new being may be perfectly plump and fat, and exhibit all the outward signs of the most perfect integrity, yet generally, in a very few weeks, it is found to present unmistakable marks of decay and disease. The first thing that is usually noticed is that it loses flesh and strength, becoming gradually thin and puling, and looking as if it had been withered by the sudden drying up of its juices. The skin has a dingy, muddy, shrivelled appearance, and hangs about in loose, soft folds. The countenance is shrunken, wan, and ghastly, and resembles that of a raan of seventy-five or eighty, instead of that of an infant a few weeks old. The voice is husky; the respiration is snuffling; the throat is sore; the gums are red and spongy; the lips and anus are fissured; and the body is covered with copper-colored eruptions, usually of the scaly kind, and intermixed with tubercles. Purulent ophthalmia is not uncommon, the inflammation usually coming on within two or three days after birth, and generally ending in total blindness. In some cases numerous superficial ulcers are found upon the surface, attended with a thick, tenacious discharge, and a hard, reddish, cha- racteristic base. The hair often drops off in large quantity, both on the scalp and on the rest of the body. The well-developed node and orchitis are of rare occurrence in infantile syphilis. Death, under such circumstances, is seldom protracted beyond the first three or four weeks after birth. Occa- sionally, the child may reach the end of the second or third year, and in a few instances life is prolonged until after the period of puberty, the individual having a stunted, sickly growth, and being the subject of deep ulcerations of the throat, palate, nose, and skin, with, perhaps, caries of the bones of the extremities, and stiffness of some of the principal joints. Such, in a few words, is an account of the most comraon effects of this direful form of the disease. Few children recover, and those who do are doomed to drag out a miserable existence, generally amidst the most loathsome and disgusting de- formities. Infantile syphilitic eruptions are liable to be mistaken for some of the more common affections of the skin incident to early childhood, aud the diagnosis is not unfrequently environed with no little difficulty in consequence. Iu obscure cases, our chief reliance is to be placed upon the history of the attack, and other concomitant circumstances. From three to four weeks after birth is the average period of the appearance of the cutaneous affections, the sole of the foot, the buttock, scrotum, face, chest, and inside of the thigh and arm being the parts originally involved. The surface immediately around the eruptions is of a coppery or reddish-brown color, a condition very different from what is observed in ordinary diseases, especially eczema, lichen, prurigo, and lepra, with which they are most liable to be confounded. Besides this, which is always a most important symptora, diagnostically considered, the SYPHILIS IN THE INFANT. 443 general appearance of the infant shows that it has received a severe shock ; it is thin and emaciated, and progressively fails to an extent, and in a manner altogether unusual in common cutaneous maladies. The old, withered and shrivelled look of the child is almost, of itself, characteristic of the disease; the snuffling is another important element in the discrimination of the case, and too much stress cannot be laid upon the mottled, dingy, or muddy state of the skin. The history of the case will usually show that the parents have been the subjects of syphilis, or that they are actually suffering under it at the time. Much stress has recently been laid upon the condition of the teeth as a diagnostic sign in hereditary infantile syphilis, attention having been first directed to the subject by Mr. J. Hutchinson, of England. The disease oc- curs chiefly in connection with, or as a result of, specific stomatitis, and dis- plays itself more particularly in the upper incisors, although the lower inci- sors and even the canine teeth occasionally participate in the morbid action. The first evidence of the disease is generally a dirty, dingy or light brownish appearance of the enamel of the central and afterwards of the lateral incisors, which soon begin to soften and crumble away, the child ultimately becoming edentulous. Both sets of teeth are cut prematurely as well as very irregu- larly, as it respects their position in the jaw ; and, unless the constitutional taint is early eradicated, the permanent are doomed to share the same fate as the temporary, although they are destroyed less rapidly. The characteristic appearances of infantile syphilitic teeth are well illus- trated in the annexed sketches, figs. 92, 93, borrowed from Mr. Erichsen. Fig. 92. Fig. 93. Syphilitic temporary teeth. Syphilitic permanent teeth. Treatment.—The treatment of infantile syphilis must be prophylactic and curative. If the mother be suspected to be laboring under a constitutional taint, as she justly may be if she has had several consecutive abortions or miscarriages, or if she is in infirm health, with eruptions upon the skin, a plen- tiful discharge from the vagina, aud an ulcerated condition of the neck of the uterus, she should be promptly put upon a course of mercury and a properly regulated diet, in order to prevent the ill effects of the contaminated state of her blood upon the foetus, and thus enable the latter to attain its full growth, and the full period of gestation. The mercurial course should be chronic, not acute, aud as gentle as possible, lest it should excite abortion ; and in most cases it will be beneficial to associate the metal with the iodide of potas- sium and some preparation of iron, with a view to a tonic effect upon the general system, which, as already stated, is usually in an impaired and cachectic condition, and therefore requires great attention to bring it up to its normal level. The diet should be mild and nutritious, the clothing should be warm, and the patient should have the full benefit of fresh air. As soon as the child is born it should be taken from its infected mother, and confided to a sound wet-nurse, as an appropriate diet is absolutely es- sential to its preservation. If no suitable wet-nurse can be obtained, it should have an abundant supply of fresh cow's milk, or, what is better, of 444 SYPHILIS. the milk of the ass, which approaches nearer to the human milk, in some of its more important properties, than that of any other animal. The body and limbs should be well protected with flannel, and frequent recourse should be had to the tepid bath, impregnated with bran, or mucilage, especially if there be eruptions, fissures, or ulcers upon the skin. An abundant supply of pure air will be indispensable. The fact is, too much attention cannot be paid, in every case, to the observance of the rules of hygiene. Cod-liver oil will prove a valuable adjuvant in all cases where it agrees with the stomach. The most important internal remedy is mercury, and it is here that this article often displays its effects to the greatest advantage in neutralizing the specific virus. If any one should doubt the efficacy of this medicine, as an antisyphilitic agent, his scepticism will soon vanish if he will take the trouble to watch the progress of the treatment and the good results that will follow it. If it is not positively a specific, it approaches as nearly this property in this disease as anything well can, quinine in intermittent fever hardly ex- cepted. The form of exhibition is the bichloride, in doses varying from the fortieth to the fiftieth of a grain three times in the twenty-four hours, dis- solved in distilled water, or, when there is need of a tonic, in a few drops of Huxham's tincture of bark. This should be steadily continued, with now and then a few days' intermission, for a number of weeks, not only until all disease is apparently gone, but for a considerable period after; and it will be well for the sake of the more complete eradication of the poison, to recur to the remedy occasionally until the child is several years of age. When the disease proves obstinate, the bichloride may generally be advantageously conjoined with the iodide of potassium, from the fourth to the eighth of a grain being given with each dose of the salt, according to the age of the child. When the body is covered with sores, pustules, or tubercles, a gentle course of mercurial fumigation will be advisable, but great care must be taken not to carry it to such an extent as to induce debility or to suffocate the child. Mild dressings may be used in the intervals, and of these the best will be very weak preparations of oxide of zinc or of the nitrate of mercury, in the form of unguent. Cases sometimes occur where the bichloride of mercury does apparently either no good, or where it proves positively prejudicial; under such circum- stances trial may be made of mercury with chalk, or, what is preferable, because not liable to cause gastro-intestinal irritation, of inunction with mercurial ointment, frora half a drachm to a drachm being rubbed upon the inside of the thigh once a day, the surface being kept constantly covered with a piece of flannel. The treatment is continued for several weeks, until all evidence of the disease has disappeared. SYPHILIZATION. Within the last few years, attention has been directed, in various quarters, to the subject of syphilization, or the cure of syphilis by inoculation with the virus of chancre. As early as 1844, Dr. Turenne, in attempting to trans- fer syphilis from man to the monkey, was struck with the fact that, when the inoculation was repeated a number of times, the tissues to which the matter was applied were at length rendered completely insusceptible to its influence. To the condition thus obtained, he applied the term syphilization. Sup- posing that the treatment might be advantageous to the human system, he accordingly instituted some experiments upon men, but the results of his ob- servations were not given to the profession until after the publication of the SYPHILIZATION. 445 memoir of Dr. Sperino, of Turin, in 1851. In this memoir numerous ex- periments are detailed, going to show that constitutional syphilis may be successfully cured by repeated inoculation. More recently the subject has engaged the attention of other observers, especially of Dr. Boeck, of Nor- way, the results of whose labors have been widely disseminated through the medical press of Europe and America. I am not aware that any experi- ments upon syphilization have been performed in this country. According to Dr. Boeck, syphilization is justifiable at all periods of life, but it should only be resorted to after the development of secondary symp- toms ; for, as long as the disease is in its primary stage, inoculation would be improper, as no one can positively determine beforehand whether the con- stitution will become tainted or not. The earlier the treatment is commenced, the better, and the effect will always be the more prompt and decisive, when the patient has not been subjected to any previous mercurial course, which ren- ders the system more stubborn to its influence, and more prone to relapses. The inoculation is performed with the virus of chancre, and it is imma- terial whether the matter be taken from the indurated or the non-indurated sore. The parts selected for the operation are the trunk and the inside of the thighs and arms. In a few days pustules will form, the matter of which must be inserted into the skin, until no further effects result, when the virus of the primary sore must again be employed, and the same course be pursued as before, until it is found that no further impression can be made upon the system. It will sometimes require the use of a new virus five or six times, before complete constitutional immunity can be secured.. The symptoms, as a general rule, begin to abate in from four to six weeks, but it may take a whole year before the disease is perfectly eradicated. It will be found, upon every repetition of the inoculation, that the pustules and ulcers become less and less, and, also, that they gradually lose their specific appearance and character. In regard to the value of this treatment, it is obviously impossible, at pre- sent, to form any definitive conclusions ; further observation alone can en- able us to do this. The practice is, to say the least, exceedingly filthy and disgusting; a circumstance which, added to the tediousness of the cure, will probably serve as an effectual bar to its general adoption. Besides, a sur- geon may, in consequence of its employment, render himself liable to prose- cution and heavy fine, as iu a case which recently occurred in France. 446 GENERAL DIAGNOSIS. CHAPTER XII. GENERAL DIAGNOSIS. Diagnosis is the art of distinguishing and identifying diseases and acci- dents, or, in other words, of determining their seat, nature, and effects. Its study is of paramount importance to every practitioner, and he should there- fore omit no opportunity of improving his knowledge of it. Its value, prac- tically considered, has been felicitously expressed by Louis, the illustrious secretary of the French Academy of Surgery. " The science of diagnosis," says he, "holds the highest rank among the different branches of the healing art, as it is at once the most useful and the most difficult. The discernment of the peculiar character of each kind of disease and of its different species constitutes the source of all curative indications. Without a clear and exact diagnosis, theory must always be at fault, and practice frequently uncertain." It is by his knowdedge of diagnosis that the practitioner acquires a command over disease which he who is destitute of it can never attain. It should therefore form the great object of his inquiry in every case of disease and accident; for to be able to locate and define their seat and character is almost to be able to cure them. To be incapable of doing this is literally to grope about in the dark; or to be tossed to and fro, like a mariner without a helm, upon an ocean of uncertainty. To disentangle truth from error; to give to disease "a local habitation and a name;" to distinguish one injury from an- other ; and to base upon the knowledge thus derived a proper course of treatment, calculated to restore the sufferer to comfort and health, are among the highest attributes of the practitioner, and require an amount of talent, tact, and experience such as few men possess. The very first thing that a surgeon does when he is called to a case of dis- ease is to set up an inquiry into its true nature; to ascertain where it is situated, or what structures it involves ; how it has been brought about; what progress it has made ; and what are its essential characteristics, or in what particulars it differs frora other lesions. In order to do this with any tole- rable degree of success, it is necessary, in many cases, literally to interrogate every important organ and tissue of the body, with a view of ascertaining which of them are more directly implicated in the disorder, which are free from suffering, and which are affected only sympathetically. Such a step is generally indispensable when the lesion is of spontaneous origin, or when it arises without any appreciable cause. When the converse is the case, a less elaborate exaraination will usually suffice to supply the requisite light. Not unfrequently the nature of the complaint is perceived at a glance. SECT. 1.—EXAMINATION OF THE PATIENT. To examine a patient well, so as to elicit all the light that may be neces- sary to a thorough comprehension of the nature of his malady, requires gene- rally great tact and an extensive knowledge of morbid and healthy anatomy, physiology, pathology, and animal chemistry, not to say anything of micro- w EXAMINATION OF THE PATIENT. 447 scopy, now so much employed as a means of diagnosis. Any one may make a superficial investigation, and in the more ordinary cases such a mode of procedure may perhaps be all that is required; but under opposite circum- stances, where everything is shrouded in obscurity, nothing short of the most patient and elaborate exploration will usually answer the purpose. Know- ledge and tact alone, however, will not insure success ; they may go very far, it is true, in enabling the practitioner to solve the mysteries of a case, but unless they are aided by a nice faculty of observation, and by a just sense of discrimination, he will never be able to analyze and group the facts presented to him in such a manner as to render them fully available when he comes to apply his therapeutic agents. Unfortunately, however, the power of observa- tion is a rare gift, which few possess, and still fewer use to advantage. Sur- geons, like physicians, have eyes, but they do not always see, and ears, but they do not always hear. Another fault, of which, unfortunately, too many, even among the most sagacious and best informed, are frequently guilty, is the hasty manner in which examinations are made, and, hence, no wonder that so many disgraceful and fatal blunders are daily committed by men who, if they would only give themselves proper time, might see disease as clearly as if they were looking at it in a mirror. Hasty examinations commonly lead to hasty deductions, and hasty deductions to hasty generalization and slovenly practice. All practitioners do not of course require the same amount of time to arrive at a correct judgment respecting the diagnosis of their cases ; some literally jump at conclusions ; others reach them only by a slow and tedious process of examination and induction. Of the two, the latter are generally the safest practitioners. The object of an examination is often seriously interfered with, if not en- tirely frustrated, by the want of co-operation of the patient, in consequence of his timidity, his want of intelligence, or the perverseness of his disposition. Much adroitness is therefore often required to bring out the desired result; fully as much as the lawyer is obliged to expend in the examination of a wit- ness who is incapable of appreciating the responsibility of his position, or of making a proper use of his knowledge. To gain the confidence of a patient is one of the first duties of a practitioner, as this is often necessary not only to a full development of the history of his case, but to its successful manage- ment. A gentle word, an agreeable tone, a winning manner, are well calcu- lated to effect this result, and are attributes of the highest value, the more so as but few persons in our profession possess them. Age, occupation, climate, and habits of life, being so many circumstances calculated to modify morbid action, should be among the first objects of in- quiry at the bedside of the sick. There are many diseases which occur only at particular periods of life. Thus, scrofula is most comraon in children, scirrhus in elderly persons, chronic enlargement of the prostate in advanced age. The influence of occupation in the production of disease is well shown in hemorrhoids, varix, and ulcers of the legs, and, to go no farther, in necrosis of the lower jaw in persons engaged in the manufacture of lucifer matches. Gout, rheumatism, pneumonia, and pleurisy are most common in northern latitudes, while dysentery, hepatitis, and fever are most frequent in southern. Individuals of dissipated habits are particularly prone to erysipelas, boils, and carbuncles, and are often attacked with delirium tremens, when they become the subjects of severe injuries, as lacerated wounds, fractures, and dislocations. Particular inquiry should be made into the previous history of the case; whether there is any hereditary predisposition to disease; whether the suffering organ was ever similarly affected before; how the present attack came on, how long it has been in progress, and what have been its chief symptoms. A careful examination of this kind cannot fail to elicit important and valuable 448 GENERAL DIAGNOSIS. information, which, if properly applied, may go far in saving the patient's life, or in cutting short his disease. A knowledge of the causes of a disease often throws valuable light upon their diagnosis. Thus, the knowledge that a youth affected with urethritis recently had connection with a lewd female, at once leads to a proper com- prehension of the nature of the case; and in the same manner important aid may be obtained in deciding between a specific and a non-specific ulcer on the head of the penis. The diagnosis of a malignant pustule upon the hand is generally determined at a glance by a surgeon of experience ; but one of an opposite character will hardly arrive at such a result without being told that the patient a few days previously was engaged in flaying a cow, or in handling green hides. During the existence of endemic and epidemic dis- eases, all persons brought within their influence are liable to their attacks, and the similarity of the symptoms is consequently sufficient to stamp their character. The knowledge that pyemia frequently follows upon severe inju- ries and capital operations is of the greatest value to the practitioner, as it enables him at once to interpret correctly the symptoms which attend that peculiar affection, the nature of which was so long a mystery. In accidents, a knowledge of the manner of their occurrence is often a matter of great moment in a diagnostic point of view. Thus, if a man, in the act of falling from a considerable height, has alighted upon the vertex, and is immediately rendered insensible, and particularly if he remains in that condition for a long time, the inference is strong that the base of the skull is fractured, and that he will perish from the effects of the lesion, although there may be no apparent injury upon the portion of the head which received the blow. In railroad accidents the leg may be severely hurt, and yet not sufficiently so to account for the extraordinary depression of the system ; in- quiry discloses the fact that the body was violently compressed between the car and a post, and a more thorough exploration leads to the discovery of rupture of the spleen, liver, bowel, or bladder; a circumstance which at once establishes the diagnosis, and prevents the patient from being subjected to useless amputation. When the patient is unconscious, whether from disease or accident, valuable information respecting the nature of the affection may often be obtained from his nurses and friends ; or, in the latter case, from the by-standers, who thus become important witnesses of what transpired at the moment in regard to the manner in which the injury was inflicted, the previous state of the intel- lect, and the condition of the person immediately consequent upon the receipt of the lesion. In the more obscure cases of diseases and accidents, the diagnosis can be arrived at only after the most patient, thorough, and systematic examination; a random exploration will be worse than useless. Every organ must be questioned, and even then it is often extremely difficult to determine what the lesion really is. In my own examinations I usually begin with the ali- mentary canal, from which I pass on, successively, to the abdominal and pelvic viscera, the lungs and their envelops, the heart, brain, and spinal cord, and, finally, the external surface, carefully noting everything of importance as I proceed. In this manner, it is difficult for any serious disease to escape detection, if the practitioner is at all endowed with the faculty of correct observation. EXAMINATION OF THE DIFFERENT ORGANS. In general, very useful diagnostic information is afforded by the state o the tongue in surgical affections. In traumatic fever, abscesses, rheumatism, and gout, the organ is usually unnaturally dry, and covered with a thick, white EXAMINATION OF THE DIFFERENT ORGANS. 449 fur, at the same time that its tip and edges are abnormally red. A narrow, pointed, or acuminated appearance of the tongue is also frequently observed under these circumstances, especially in young subjects. In profuse hemor- rhages, the tongue is generally very pallid, soft, flabby, and indented at the edges. A dry, brownish, and tremulous state of this organ, with difficulty of protrusion, is generally denotive of the existence of a typhoid condition of the system, and, in connection with other symptoms of exhaustion, is to be regarded as an unfavorable occurrence. It is the kind of tongue which commonly attends gangrene, malignant erysipelas, and the latter stages of traumatic fever. The appearances of the tongue sometimes afford useful hints respecting the state of the digestive apparatus, and even of the general system. Thus, aphthae upon this organ, or small ulcers scattered over its surface, are usually denotive of chronic gastric disorder, or derangement of the stomach and liver, by correcting which the disease promptly vanishes. In constitutional syphilis, the existence of mucous tubercles upon the tongue affords at once a satisfac- tory solution of the nature of the complaint. The presence of an excavated ulcer upon this organ, or upon the tonsils, with a copper-colored border and a foul bottom, is generally equally diagnostic of a contaminated state of the system. A thick and tumid upper lip is generally denotive of a scrofulous taint of the system, or of a vitiated state of the alimentary canal depending upon the presence of worms, and disorder of the hepatic and follicular secretions. A cracked, chapped, or fissured state of the lower lip is often an accompaniment of general plethora, over-feeding, and gastro-enteric derangement. A pale prolabium is indicative of a deficiency of the coloring matter of the blood, and is generally an evidence of the necessity of tonics. Useful information is sometimes derived frora an examination of the gums. A red, spongy, and tumid state of them is usually denotive of a scorbutic diathesis, especially if it be conjoined with frequent bleeding and hemorrhagic spots in different parts of the body. An eroded appearance of the gums is generally indicative of an accumulation of tartar, while the presence of sordes is expressive of a typhoid state of the system. Pain in the throat and difficulty of deglutition are evidences of tonsillitis, and of disease or mechanical obstruction of the oesophagus. A careful inspection of the fauces and the introduction of the probang usually readily determine the precise locality of the affection, as well as its nature. In the former case, the tongue is carefully depressed with the handle of a spoon, or a tongue-holder, the mouth being widely opened as the patient sits upon a chair in a strong light; in the latter, the surgeon, standing behind the patient whose head rests upon his chest, carries the instrument gently and cautiously along the tube until it comes in contact with the obstruction, which is not passed all at once, or forcibly, lest undue violence should be inflicted, perhaps eventuating in rupture or ulceration of the oesophagus. No examination in any case of disease, if at all serious, whether surgical or medical, can be considered as at all complete without a thorough explora- tion of the condition of the stomach and bowels. When it is recollected that disorder of the secretions of these organs, the presence of irritating ingesta, or the accumulation of fecal matter, is frequently a source of disease in other parts of the body, as well as in these organs themselves, the importance of an attentive examination of them cannot be too much insisted upon. The in- sertion of the finger into the rectum, and the use of the speculum, often lead to the most useful knowledge of the condition of the anus and lower bowel. An examination of the alvine evacuations not unfrequently reveals important information in regard to the state of the liver, as the presence, absence, or vol. I.—29 450 GENERAL DIAGNOSIS. quality of the bile, and the action of the mucous follicles of the alimentary tube, and should never be omitted in any case of serious disease or accident. Intellect.—The intelligence is often remarkably altered in disease and acci- dent. Delirium and incoherency are common effects of all lesions attended with high arterial excitement. Their character, degree, and duration vary much in different cases, and are greatly influenced by surrounding and intrinsic circumstances, as the nature of our treatment, the intensity of the morbid action, the importance of the affected organ, and probably also by the idiosyncrasy of the individual. In general, as they are of a purely sym- pathetic character, they rapidly disappear with the excitement that induced them ; coming and going perhaps several times in the twenty-four hours, especially during the vesperal and nocturnal exacerbations which are so liable to distinguish most febrile attacks, whether traumatic or idiopathic. In organic disease of the brain and its envelops, on the contrary, a different order of things usually occurs. Here the delirium, once fairly begun, con- tinues uninterruptedly, although it may be characterized by intervals of re- mission ; and, as the morbid action progresses, it generally lapses into stupor, and this, ere long, into deep coma, which is but too often the immediate fore- runner of dissolution. In compression of the brain, whether from extravasated blood, excessive congestion of the cerebral vessels, effusion of serum, or de- pression of the cranial bones, the intelligence is commonly completely abo- lished; the patient is deprived of all sensation and volition, and cannot be roused by the most powerful stimulants. He is, in fact, a mere automaton, dead to all surrounding impressions. If, from any cause, inflammation of the brain or of its membranes arise, the face soon becomes flushed, the eye suf- fused, the pupil contracted and impatient of light, the skin hot and dry, and the pulse quick, hard, and frequent. Delirium soon sets in ; the mind be- comes incoherent, and, although questions may still with some effort be an- swered rationally, yet the patient speedily lapses into his former condition, knitting his brows, tossing from side to side, withdrawing his hand from the attendant, muttering constantly, and falling gradually into a more unconscious state. Rigors generally occur early in the disease, and are always denotive of great danger. If effusion of serum, lymph, or pus take place to any con- siderable extent, convulsions and deep coma are sure to follow, soon terminat- ing in death. ^ Countenance.—The state of the countenance is always a subject of inquiry with the intelligent practitioner. The mirror of the soul, it reflects, to a greater or less extent, alike the sensations of pleasure and of pain, of joy and of sorrow, and is thus capable of supplying important diagnostic'indications in a great variety of diseases and accidents. To call attention to all the de- tails which necessarily connect themselves with the study of the physiognomy under these circumstances, would be out of place in such a work as this and I shall therefore content myself by referring to a few of the more frequent and conspicuous. Excessive pallor of the countenance, especially of the prolabia, is generally denotive of great loss of blood, or of extreme shock of the nervous system. In the latter case it is often associated with a peculiar withered and shrunken expression of the features, reminding one sensibly of the decay of a leaf in autumn. In apoplectic affections of the brain, the face is turgid, flushed and paralyzed on one side, thus causing serious distortion, the angle of the mouth being drawn to the opposite side, while the eyelid on the affected side has a drooping appearance, descending hardly half way over the ball. In general inflammatory fever, whether the result of accident or of internal causes the countenance is red and tumid, the eye is suffused, and the ala of the nose is rapidly dilated and contracted by the hurried inspiration. When the breath- ing is much embarrassed, as when there is deep congestion of the lungs or EXAMINATION OF THE DIFFERENT ORGANS. 451 mechanical obstruction to the entrance of the air, as when a foreign body exists in the larynx or trachea, the face is livid and often remarkably puffy, particularly when the affection is of long standing, and accompanied by oedema of the subcutaneous cellular tissue. All painful affections of these organs are characterized by an anxious expression of the features, attended by an unusual dilatation of the nostrils during each act of inspiration, and by a peculiar heaving movement of the chest. " In inflammation of the abdomi- nal viscera," observes Dr. Marshall Hall, "attended with severe pain, the muscles of the face are in a state of continued contraction ; the features are unnaturally acute, the forehead is wrinkled, and the brows knit. The nostrils are acute and drawn up ; the wrinkles, which pass from them obliquely down- wards, are deeply marked; the upper lip is drawn upwards, and the under one frequently downwards, so as to expose the teeth. The state of the fea- tures is aggravated on any increase of the pain frora change of position or external pressure. When the abdominal pain arises from spasm, the muscles of the face are exceedingly contracted and distorted during the paroxysms of pain; but in the intervals of the paroxysms the countenance assumes a calm and placid aspect." The diagnostic value of the Hippocratic countenance has long been recog- nized by practitioners. Its presence is always denotive of extreme danger, and is commonly associated with other symptoms of an untoward import, as twitching of the tendons, high delirium, a dry tongue, sordes on the teeth and gums, and excessive prostration. It consists in a peculiarly sharp, re- tracted, and withered appearance of the features, and generally attends the closing scenes of all typhoid states of the system, whatever may be their cause or character. Voice.—The state of the voice often furnishes useful information respecting the nature of the lesions of the larynx and trachea. Its peculiarity in croup is well known, being either sharp and shrill, like the crowing of a young cock, or low, hoarse, and almost extinct, especially if the disease has made con- siderable progress. In oedema of the glottis, without being always hoarse, it is generally reduced to a mere whisper; and in thickening of the vocal cords and ulceration of the mucous membrane of the larynx, partial loss of voice, and ultimately complete aphonia, generally attend. Respiration.—The respiration should always be attentively examined. In all acute diseases, attended with unusual vascular excitement, it is increased in frequency, short, and laborious. In pneumonia and pleurisy it is generally diaphragmatic, the intercostal muscles being almost completely quiescent, with hardly any perceptible elevation and depression of the ribs. The patient, alarmed and anxious, breathes with great difficulty, dilating his nostrils at every inspiration, and raising the shoulders and upper part of the chest, so as to draw in as much air as possible at each effort. In inflammation of the abdominal viscera, on the contrary, the diaphragm is nearly stationary, while the intercostal muscles are in full play, the act of inspiration being short and panting, lest the descent of the diaphragm should produce an aggravation of suffering by rudely compressing the affected organs. In affections attended with cerebral congestion, effusion of blood, or depression of the skull, the breathing is slow, labored, and irregular; often stertorous, and accompanied by a peculiar whiff. In spasmodic diseases of the respiratory organs, the in- spiration is quick and imperfect, as if the patient was unable to dilate the chest, and is usually accompanied with a characteristic wheezing sound, often audible at a considerable distance, during expiration, which is, at the same time, labored, and protracted. Short, difficult, and anxious breathing, aggra- vated by muscular exertiou, as in ascending a hill, or rapid talking, is gene- rally denotive of hydrothorax, and of organic disease of the heart and great arteries. 452 GENERAL DIAGNOSIS. Heart.—The diagnostic signs manifested by the heart and arteries deserve careful consideration. In examining the pulse, the exponent of the great central organ of the circulation, particular attention should be paid to its frequency, volume, and force, as these constitute the leading features by which the practitioner judges of the state of the system, or, in other words, of the character and effects of the morbid action. To do this properly requires not a little knowledge and experience, for nothing varies more than the condition of the pulse in health and disease. Hence it is not surprising that it should have been pronounced by one of the older physicians to be the most fallacious of symptoms. Pidse.—In traumatic fever the pulse, as a general rule, is quick, frequent, and hard, and similar qualities usually characterize it in idiopathic affec- tions. The increase in the number of its beats ranges from ten to thirty and even forty in the minute; they are performed with a peculiar sharpness and rapidity, and the blood is sent into the arteries with such momentum as to cause their coats to rebound under the finger, offering thus a decided resistance to its pressure. When this is the case, the pulse is said to be hard. Hard- ness, quickness, and frequency are often associated with fulness, especially in very plethoric subjects, laboring under intense inflammatory excitement; but such a coincidence is by no means always necessarily present; on the con- trary, instances occur where the pulse is so exceedingly small and thready as to require some care to detect it. This is generally the character of the pulse in peritonitis, from whatever cause arising, and therefore affords valuable diagnostic information. In certain affections of the brain, as in compression, whether a result of apoplexy or external injury, the pulse is slow, full, and laboring, as if the heart were oppressed by a heavy load which it found diffi- cult to carry or to shake off. The pulse after hemorrhage is strikingly pecu- liar, although it is not easy to define its character; it may be described as being very sharp, quick, and thrilling, as if the blood were sent into the artery with a kind of jerk, imparting thus a vibratory sensation to the finger. Once felt, it is impossible ever to forget it. An intermittent pulse is generally denotive of organic disease of the brain, or of the heart, lungs, or great vessels; sometimes, however, it appears to be the result altogether of func- tional disease, as dyspepsia, or gastro-intestinal irritation. In examining the pulse with a view to its diagnostic value, it is to be re- membered that it may be naturally slow or frequent, hard or soft, full or small, strong or feeble, depending upon idiosyncrasy, or the effects of pre- vious or existing disease. The time and mode of examining the pulse require some attention. As a general rule, the surgeon should not put his hand upon the wrist immediately after he has sat down by the side of the bed, as such a course would be likely to cause alarm, and thus lead to erroneous inferences. Nor should he use a watch for the purpose of counting it, especially if the patient be very sick and nervous, as this also might excite injurious apprehension. In fact, it is impossible to conduct the examination too carefully; for unless this be done, the intention of the practitioner will often be completely thwarted, simply in consequence of his awkwardness. At least two fingers should be placed upon the radial artery, and the application should be continued sufficiently long to enable him to determine fully the character of its beats, particularly their frequency, volume, and power of resistance. Kidneys.—The renal secretion should claim particular attention in every severe case of accident and disease. A very superficial inspection will gene- rally at once detect remarkable deviations from the normal standard, both as it respects the color, quantity, and consistence of this fluid, as well as any tendency it may manifest to the formation of deposits after having stood for some time in the receiver. But if a more thorough investigation be deemed MENSURATION. 453 necessary, as when organic disease of the kidney is suspected, or with a view to the detection of the existence of any particular calculous diathesis, a more minute and elaborate examination, conducted with the microscope and chemi- cal tests, will be required ; and it need hardly be added that such a procedure generally calls for an amount of knowledge, skill, and experience such as few professional men possess. As this subject will receive special consideration in the chapter on the urine and its deposits, no further allusion to it need be made here. Finally, the practitioner must not neglect to examine the state of the skin, noting particularly the character of its temperature, the presence or absence of moisture, the degree of its contractility, and any change of color it may have experienced; the condition of the limbs, as to the existence or non- existence of paralysis or injury ; and lastly, the state of the genital organs, if, upon inquiry, there is reason to suppose that they are either the seat of the morbid action, or that they deeply sympathize in the disorder of other parts of the body. SECT. II.—MENSURATION. An examination of the dimensions of a part occasionally affords valuable aid in determining the diagnosis of its lesions. Such a mode, of investiga- tion is particularly serviceable in fractures and dislocations, in coxalgia, and in affections of the chest, especially in pleuritic effusions, so common after accidents and diseases. The best contrivance for ascertaining the amount of shortening in an in- jured or diseased limb is the graduated tape, used by seamstresses and tai- lors, and inclosed in a metallic case, so as to admit of its being carried in the pocket. It is a yard in length by half an inch in width, and being composed of oil-cloth it is perfectly inextensible, thus rendering it admirably adapted to the object. In order to attain perfect accuracy of result, it is necessary that the sound and affected members should be placed as nearly as possible parallel with each other; for if there be the slightest variation in their incli- nation it must proportionably impair the value of the examination, if not com- pletely destroy it. Thus, for example, in trying to ascertain the amount of overlapping of the fragments of a broken femur, the two thighs should not only be placed parallel with each other, but great care should be taken that they, as well as the buttocks, rest evenly upon the bed, table, or floor on which the patient lies. Finally, in order to perform the operation in the most unexceptionable manner, the additional precaution should be taken of main- taining the head, chest, pelvis, and extremities all in a straight line until the measurement is completed. After the limbs and body have been adjusted as here described, two fixed points are selected, between which the tape is stretched. Thus, to take the thigh again as an illustration, the two proper points are the anterior supe- rior spinous process of the ilium and the inner border of the patella. The distance between these two prominences having been ascertained upon the affected member, the tape is next stretched between the same points on the sound limb, the difference in the length between the two being the sum of the shortening of the injured bone. Where no fixed points can be obtained, a mark may be made upon the skin either with ink, or nitrate of silver. The graduated tape may also be employed for measuring the diameter of a limb, as in disease of an important joint, or a suspected morbid growth. Or, instead of this, recourse may be had to the graduated compass of Mayor, which, however, notwithstanding its ingenious mechanism, really pos- sesses no real advantages over the tape. This instrument consists of four 454 GENERAL DIAGNOSIS. pieces, the central one, which is a flat rod, being marked by a scale of inches and lines. Mensuration of the chest is often practised in pleuritic effusions, although such a means of diagnosis is seldom necessary in the hands of an intelligent and skilful surgeon, auscultation, percussion, and inspection being quite suf- ficient for the purpose in almost every instance coming under his observation. When more than ordinary care is desired, the graduated tape, extending from the middle of the sternum to the centre of the spine, will readily supply the requisite information. The plumb-line is occasionally used for determining the existence of cur- vature of the spine ; such an expedient, however, can only be necessary in the earlier stages of the malady, before marked deformity has set in. When the disease is fully established, such a mode of investigation would savor alike of affectation and stupidity. A ready method of determining the angle of an object, as, for example, that of a broken bone, has been suggested by Malgaigne. It consists in ap- plying a sheet of paper, by its edge, to the limb so as to represent its vertical axis. At the point where the axis changes its direction, the paper is so folded as to follow it exactly; the result will be that the salient angle thus formed will necessarily give the entering one caused by the fragments of the deformed bone. In order to determine the degree of this angle, a sheet of paper is folded in four, which " makes a right angle, or 90° ; folding again one of the sides affords an angle of 45°; adding this angle of 45° to the unchanged right angle, gives an angle of 135°, and so on. Applying now this extemporaneous quadrant to the already ascertained angle of the frac- ture, we obtain, without trouble, or loss of time, as accurate an estimate as possible." SECT. Ill—ATTITUDE OF THE PATIENT. The attitude of the patient and the position of the affected part are va- riously and often remarkably changed in diseases and accidents, and afford, in many cases, valuable diagnostic indications, not attainable in any other way. The study of the variations in the configuration of the body is of much greater moment, as a means of distinguishing different lesions, than is generally imagined, and has received less attention than its importance merits. In some affections, the diagnosis absolutely hinges mainly, if not entirely, upon the attitude assumed by the patient in consequence of the morbid ac- tion. We need only instance the peculiar distortion of the body in tetanus, caused by the continued and violent contraction of the muscles, drawing the trunk, in one case, powerfully forwards, in another backwards, and in a third to one side. No one that has ever witnessed this change of configuration can possibly mistake it in a similar attack ; for there is no other lesion capa- ble of producing it. In caries of the vertebrae, usually known as Pott's dis- ease, and in lateral curvature of the spine, the result of irregular muscular action, the distortion of the body is characteristic. In coxalgia, the flatten- ing of the hip, the elevation of the pelvis of the affected side, the retraction of the heel, and the effacement of the femoro-gluteal fold are among the most valuable diagnostic signs of the malady. In diseases and injuries of the chest, the position of the patient is often highly characteristic. In inflammation of the lungs and pleura, attended with slight effusion, he generally lies either on the affected side, or else upon his back, not on the sound side, as the weight and pressure of the diseased organ would seriously impede respiration and excite violent coughing. In hydrothorax, with large accumulations on both sides, the patient is obliged ATTITUDE OF THE PATIENT—EXTERNAL CHARACTERS. 455 to raise his head and shoulders very much, or even to sit up in bed, in order to obtain the requisite supply of air. When he lies down, the effused fluid is diffused over a larger portion of lung, an occurrence which is instantly fol- lowed by increased difficulty of breathing, and by the necessity of a change of posture to prevent impending suffocation. " When out of bed, he is often observed to sit with the arms placed along the side, and the hands fixed and pressing forcibly on the chair or sofa on which he rests ; in other cases he leans a little backwards, still supported by the arras and hands, which are pressed behind his back." The attitude assumed by the patient in inflammation of the abdominal and pelvic viscera is generally very striking and characteristic. Unable to shift his position, he lies constantly upon his back, with his head and shoulders considerably elevated, the knees raised, and the thighs partially flexed, the object being to relax the abdominal muscles in the greatest possible degree, so as to take off their weight and pressure from the inflamed surface. In spasmodic affections, on the contrary, the position of the patient is altogether different; instead of observing dorsal decubitus, he lies at one time on this side, and then on the other, now on the back, and next on the belly; and instead of avoiding pressure he actually courts it, not feeling comfortable without it. Hence, he often doubles himself up, and twists and contorts his body in almost every possible manner, in order to obtain relief. In stone of the bladder impeding the flow of urine, the attitude of the patient is frequently very singular. Sometimes he is compelled to assume a stooping posture; at other times he crosses or separates his legs, inclines his body to one side, lies down, rests on his elbows and knees, or lies on his back, and throws up his buttocks. In traumatic and other affections, attended with typhomania, retention of urine may be suspected, if the patient lies on his back with the limbs retracted. Iu acute inflammation of the kidney, the body is generally inclined a little forwards and towards the affected side, so as to relax the lumbar muscles, and take off any pressure they might other- wise exert upon the diseased organ. The nature of an accident is not unfrequently revealed by the attitude of the part and body ; sometimes by the one, sometimes by the other, and oc- casionally by both. Thus, the manner in which the patient inclines his head and supports his arm in fracture of the clavicle is so peculiar as to be ab- solutely, in great degree, pathognomonic of the nature of the lesion. Dis- locations of the shoulder, hip, and other joints, are denoted by striking, if not characteristic, changes in the attitude of the body and limb. The exist- ence of a fracture is often revealed by a peculiar change in the conformation of the affected member, consisting either in a marked shortening, or in a peculiar alteration in the axis of the part. The disease called wry-neck de- rives its name from the peculiar twist of the neck by which it is distinguished. SECT. IV.—EXTERNAL CHARACTERS. Important diagnostic data are sometimes furnished by the color, form, con- sistence, mobility, pulsation, temperature, crepitation, sensibility, or odor of a part, and by the spots, scars, or ulcers existing upon its surface. A mere glance at these different topics will serve to show their value as means of distinguishing morbid action, whether it be considered simply in reference to its nature, or its nature and degree. Thus, as stated under the head of inflammation, the color of the diseased part may be scarlet, as in inflammation of the mucous membrane of the fauces ; lilac, as in sclerotitis; grayish, or brick-colored, as in iritis. When the redness occurs in the form of a streak, extending up the arm or leg, it is 456 GENERAL DIAGNOSIS. denotive of phlebitis, or of angeioleucitis. Diffuse discoloration character- izes erysipelas; circumscribed discoloration, boils and carbuncles. A scarlet hue implies great vascular activity, such as exists in acute inflammation ; a purple hue, on the contrary, denotes partial stasis of the blood, which, if not soon arrested, may lead to gangrene. Change in the form of a part may be caused by swelling, as in inflamma- tion attended with effusion, or it may depend upon the presence of a new growth, or it may be the result simply of hypertrophy. In fractures it is caused by displacement of the ends of the fragments ; in dislocations by the presence of the head of the bone in its new situation. In hernia, very strik- ing changes generally attend the figure of the affected parts, especially when the protrusion is old and unusually bulky. Extraordinary consistence of a part is indicative either of excessive indura- tion from inflammatory deposits, particularly semi-organized lymph, or of the presence of a solid tumor, or a displaced bone. When the part is un- usually soft, the alteration of consistence may depend upon the presence of pus, fluid blood, serum, or serum and lymph, and often requires the closest scrutiny for the successful detection of its precise character. Under such circumstances the history of the case frequently affords important diagnostic data, especially the age of the accumulation, and the presence or absence of inflammatory symptoms. If the part fluctuates distinctly, and is, withal, red, tender, or painful, the probability is that the alteration of consistence is due to the existence of pus; if, on the other hand, it be perfectly free from dis- coloration and uneasiness, although the undulation under pressure may be most perfect, the conclusion must be that the disease is either a chronic ab- scess, or else some serous or hematoid cyst. The mobility of a part may be diminished or increased, thus throwing im- portant light upon the nature of the case. As a general rule, it may be stated that it is lessened in dislocations, and augmented in fractures. The value of this symptom is well shown in diseases of the articulations, as well as in inflammation of other parts of the body, which, if at all seriously in- volved, have their mobility always proportionably diminished. In malignant tumors, loss of mobility of the morbid growth generally forms a prominent phenomenon in the advanced stage of the disease, in consequence of the firm adhesions that take place between it and the surrounding structures. A similar effect may be produced by the manner in which such tumors are bound down by the aponeuroses and muscles. In affections of the eye an alteration of the mobility of the iris often affords most important diagnostic information. Abnormal pulsation in a part leads to the suspicion of the existence of aneurism, and this suspicion will almost be converted into certainty, if, in addition to this phenomenon, there is a peculiar thrill, with a vibratory sen- sation, and a decided diminution of the volume of the part upon the applica- tion of pressure to the cardiac side of the artery supplying it with blood. The mere fact of the existence of abnormal pulsation should put the surgeon upon his guard, in order that, by redoubling his efforts at a thorough ex- ploration, he may not commit any errors of diagnosis ; laying open, perhaps, an aneurism, when he supposes that he is dealing only with an abscess or a hygroma. The surgeon occasionally meets with what is denominated crepitation, a rough, grating, or friction sound, of great value as a diagnostic in fractures, emphysema, and inflammation of the sheaths of the tendons. In many cases it may be both felt and heard. In fractures it is produced by rubbing to- gether the ends of the broken bone, and is generally so distinct as to be completely characteristic of the nature of the lesion. In order to elicit it, a good deal of management is often necessary ; but iu general it will be sufii- EXTERNAL CHARACTERS. 457 cient, after the ends of the broken bone have been fairly placed in contact, to grasp one piece firmly, and to hold it so while the other is rotated on its axis; or both fragments may be moved simultaneously in opposite directions. The crepitation of emphysema is a kind of crackling sound, similar to what is produced by the rumpling of dry parchment, or by rubbing together nume- rous little dry, friable balls filled with air. The part, moreover, feels soft and puffy, and the contained air raay be easily pressed frora one spot to another. Bony tumors of the antrum of Highmore and of the lower jaw, attended with great expansion and attenuation of their walls, occasionally emit, when pressed between the fingers, a peculiar crackling noise, similar to that of dry parchment. The sound thus elicited, however, is altogether different from crepitation, properly so termed, and its chief value consists in showing the alteration which the osseous tissue is capable of undergoing when it is sub- jected to long-continued eccentric pressure. The crepitation attendant upon inflammation of the sheaths of the tendons is altogether different frora the two preceding varieties, resembling the sound caused by rubbing dry starch between the fingers. When the disease is chronic it may sometimes be both heard and felt. It evidently depends upon the presence of plastic matter, and is most common about the wrist and ankle. This sound is often closely imitated in affections of the mucous bursae, espe- cially when they are pretty well distended with fluid, intermixed with flakes of lymph and fibrinous concretions. A faint crepitating sound is sometimes produced by breaking up the clots of a sanguineous cyst, and rubbing the fragments between the fingers. The noise, when it does occur, is always most distinct at the base of the tumor, where most of the solid matter is necessarily collected. An alteration of temperature in parts affected with disease is sufficiently common, and occasionally affords valuable diagnostic intimations. With what interest does not the surgeon watch the rise of heat in a limb after the ligation of its principal artery 1 A casual examination is generally sufficient for its detection ; when more than ordinary nicety is required, recourse raay be had to the thermometer. The intensity of the morbid action may some- times be pretty accurately measured by merely observing the increase of its temperature. A sudden diminution of temperature, in a part previously in a high state of inflammation, may generally be regarded as an omen of unfa- vorable import, as it is denotive of the approach of gangrene. An increase of the sensibility of a part is a frequent, if not an almost con- stant, occurrence in disease, especially when it is of an acute character. In ophthalmia, the slightest ray of light is a source of distress to the patient; in otitis, the ear is intolerant of sound ; and in gastritis the stomach is oppressed by the smallest quantity of fluid, however bland, or however cau- tiously used. Parts, such as bones and ligaments, that are perfectly devoid of feeling in health, often become exquisitely sensitive in inflamraation ; and thus it is that the practitioner is not unfrequently enabled to detect the exist- ence of morbid action in structures hidden from view, much better than he can in any other manner. The proper way of ascertaining the existence and amount of raorbid sensibility is to make gentle and methodical compression, or to percuss the affected part, so as to communicate to it the vibrations of the whole hand, or, what is preferable, of one of the fingers. When pain exists, a careful distinction should be drawn between that which arises from inflammation and that produced by spasm and neuralgia. In inflamraation, the pain is steady and persistent, increased by motion and pressure, commencing with the morbid action, keeping regular pace with it, and gradually disappearing as the morbid action declines. In spasmodic affections, or colic, on the contrary, the pain is paroxysmal, or marked by 458 GENERAL DIAGNOSIS. distinct intermissions; abrupt, both in its invasion and departure ; relieved by pressure, and change of posture, and generally attended with flatulence of the stomach and bowels. In neuralgia, the pain occurs in transient and violent paroxysms, darts along the course of the affected nerves with the rapidity of lightning, and is usually accompanied by more or less tenderness of the part, without any distinct tumefaction, discoloration, or augmentation of temperature. Finally, there are certain affections which may sometimes be readily diag- nosticated by a careful examination of the cutaneous surface, and that of the mucous outlets. Thus, if there are copper-colored eruptions upon the skin, and excavated ulcers on the fauces, or tubercles upon the tongue, cheek, or lip, no one could fail to conclude that the system was laboring under a syphilitic taint. Partial or complete destruction of the uvula, tonsils, or arches of the palate, would inevitably lead to a similar inference, especially if, added to this, there is evidence of actual disease. Scars upon the cuta- neous surface, scattered irregularly about, large, deep, white, and permanent, are generally denotive of the former existence of rupia. The character of an ulcer will sometimes lead to the detection of its cause, or to the state of the system which has induced its development. Last autumn a girl, aged fourteen, was brought to my Clinic at the Jefferson Medical Col- lege, on account of a large chronic ulcer seated in front of the leg, directly over the tibia; it had been in progress for the better part of a year, was exces- sively painful, and had resisted a great variety of local and constitutional remedies. Having brought the patient under the influence of chloroform, I scraped away a thick mass of semi-organized substance which formed the bottom of the ulcer, together with the carious and softened portion of the bone; and when she returned to me a week afterwards I was struck with the remarkable improvement that had taken place both in the part and system. Shortly after her visit, however, not less than five or six small unhealthy- looking ulcers, with thick, everted edges, and a foul, nasty surface, broke out around the old one, which by this time had also changed for the worse. Con- vinced that the disease was of a syphilitic nature, I placed the patient, without any further inquiry into the case, upon the use of iodide of potassium and bichloride of mercury, under the influence of which, and a nourishing diet, she rapidly regained her health and strength, with good sound cicatrices. Thus it will be perceived that the diagnosis in this case, founded upon the appearance and obstinacy of the patient's ulcers, was confirmed by the result of the treatment employed for their cure. SECT. V.—INSTRUMENTAL EXPLORATIONS. There are certain affections whose character can be ascertained only by a careful examination with the aid of instruments, full access to them in any other manner being impracticable. The instruments mainly required for this purpose are the probe, bougie, sound, speculum, stethoscope, and exploring needle, each of which will therefore demand some notice. Probe.— The probe, fig. 94, is chiefly employed for the purpose of explor- ing fistulous tracks and sinuses, the course of balls, and the presence of foreign bodies. It may therefore be considered as a highly valuable instrument, one which is daily and hourly brought into requisition by the surgeon in extensive practice. It is generally made so as to be flexible, being composed of silver, or other suitable metal; and varies in length, diameter, and shape according to circumstances. The ordinary pocket probe is about five inches in length, and of the diameter of a crow-quill, one extremity being blunt, the other somewhat pointed, or furnished with an eye. For exploring the lachrymal INSTRUMENTAL EXPLORATIONS. 459 passages a much more delicate instrument is required ; the uterine probe, on the contrary, is very large ; a long and rather stout instrument is generally Fig. 94. employed for ascertaining the existence of a foreign body in the air-passages after having opened the trachea, for tracing the course of a ball, and for exploring certain varieties of fistules and sinuses. The index finger, when sufficiently long, and not too thick, is the best probe of all, as the information furnished by it is generally much more relia- ble than that supplied by a metallic instrument. It is particularly available in the examination of the vagina, uterus, and rectum, whether the object be to detect the presence of disease, malposition, or the existence of an extra- neous body. The rectal touch, performed with the index finger, is constantly practised by the surgeon in sounding patients for stone in the bladder, with a view not only of ascertaining the presence of the foreign substance, but also for the purpose of determining its size and situation. Enlargement of the prostate gland, and the existence of calculi in its substance, can seldom be satisfac- torily diagnosticated in any other manner. Displacements of the uterus, pelvic tumors, and malformations of the internal genital organs, are often promptly detected by the rectal touch ; and there is no practitioner that does not employ the finger in suspected disease of the anus and lower bowel. The rectal touch can readily discriminate between a hemorrhoidal tumor and a carcinomatous growth, a polyp, a prolapsus of the mucous membrane, or a foreign body. The extent of the spasmodic contraction of the anus, which attends fissure of that outlet, is generally readily ascertained by the insertion of the finger. The vaginal touch affords important information in relation to the diseases of the vagina and uterus. It is in this manner that the practitioner ascer- tains the existence of the various kinds of tumors that are liable to form in these organs, whether benign or malignant, and also the different displace- ments to which they are subject. A practised finger will readily detect a carcinomatous ulcer of the uterus, a rent in the vagina, and a calculus in the bladder. Whatever instrument is employed, it should be well oiled and warmed, to facilitate its introduction, and great care should be taken to pass it along in as gentle and easy a manner as possible. If the parts requiring to be ex- plored are inflamed and tender, it may be necessary, before undertaking the examination, to lessen the sensibility by preliminary treatment, consisting of soothing measures, otherwise it may be productive of severe pain and an aggravation of the disease. No general rules can be laid down respecting the position of the part or of the body during the examination, although it must be sufficiently obvious that this is a matter of paramount importance to a satisfactory result. In exploring fistulous tracks it is occasionally neces- sary to enlarge their orifice somewhat, in order to afford a more ready passage to the instrument or finger. Bougie.—For ascertaining the condition of the mucous outlets of the body, as the urethra, oesophagus, and rectum, a bougie, which is but another name for a probe, is generally employed, the principle upon which the examination is conducted being the same as in exploring a part with the probe properly so called; that is, the instrument, which is either straight or curved, and composed of gum elastic or metal, is well oiled and warmed, aud then care- 460 GENERAL DIAGNOSIS. fully introduced as far as the seat of the obstruction, the distance between which and the external orifice is now determined by looking at the graduated scale upon the surface of the bougie, or by making a scratch upon it with the nail. The examination is completed by insinuating the instrument gently into the stricture, so as to measure its extent, and the degree of its resistance. The information thus elicited is generally of the greatest diagnostic and prac- tical value. Sound.—The instrument employed for exploring the bladder is called a sound, although it is in reality nothing but a probe, blunt pointed at the dis- tal extremity, and a good deal curved, so as to adapt it to the course and shape of the urethra. It is composed of steel, being perfectly smooth, and of a round shape. Its object and mode of use will claim special attention in connection with the diagnosis of vesical diseases, which could not be esta- blished satisfactorily in any other way. Speculum.—Of the value of the speculum as a means of diagnosis in affec- tions of the vagina, uterus, anus, nose, and ear, it is unnecessary to say anything of a formal character, as it is fully appreciated by every sensible practitioner. Indeed, it is only surprising when we consider the great aid which we derive from its use that its employment should still be so much restricted, as it seems to be, in certain parts of this and other countries. Invented at an early period of the science, it was completely lost sight of for many ages, until it was re-introduced, about thirty years ago, to the notice of the profession by Recaiuier, who thus conferred an inestimable benefit upon the public. The speculum is composed of polished metal, or of glass, and consists either of a cylinder, or of two, three, or four movable blades, secured by screws, and furnished with an appropriate handle. A wire speculum (fig. 95) is sometimes used. For most purposes to which such an instru- Fig. 95. ment is applicable the cylinder answers exceedingly well, and it possesses the additional recommendation of simplicity of construc- tion, convenience, and cheapness. The valvular speculum, on the contrary, is a complicated contrivance, expensive, and liable to get out of order. Nevertheless, there are certain forms of disease, especially of the uterus, which hardly admit of satisfactory explora- tion by any other means. Whatever form of instrument be selected, it should be well oiled and warmed, and then carefully inserted into the cavity which it is designed to explore, the patient having been previously placed in the most eligible position for undergoing the examination. Unless the case is one of unusual urgency, the exa- mination should always be put off until there is a clear day, as the light of the sun is far better, as well as more convenient, than an artificial one. In exploring the uterus, the touch should precede the introduction of the specu- lum, with a view of ascertaining the existence or non-existence of any dis- placement of that organ. I have never found it necessary to use an oral speculum, an instrument occasionally met with at the cutler's shop. Making the patient take a full inspiration, while he holds his mouth wide open, will generally permit a thorough inspection Of the tongue, cheeks, and fauces; where greater nicety is required the tongue may be depressed with the handle of a spoon, a spatula, or a tongue-holder, and the tonsils and arches of the palate separated by means of a director or a long probe. Exploring needle.—The value of the exploring needle cannot be too highly appreciated by the practical surgeon, as he is obliged to use it in the exami- nation of a great variety of external affections, the diagnosis of which does not admit of accurate determination in any other manner. On the other hand, however, there is reason to believe that there is no instrument, certainly none of its size, that is more frequently misapplied by the uninformed prac- INSTRUMENTAL EXPLORATIONS. 461 titioner, or one which may do a greater amount of harm when used without proper judgment and discrimination. Like everything else that is good, it is liable to abuse; a circumstance which cannot be too strongly impressed upon the mind of the young surgeon. I am sure I have seen immense injury and even loss of life produced by its careless and reckless use. Numerous exploring instruments are in the hands of the profession; some of which, displaying great delicacy and ingenuity, seem to combine all the advantages that such contrivances are capable of affording, while others are extremely clumsy, and, consequently, very imperfectly adapted for the pur- pose they are designed to fulfil. The great fault with most of them is that they are too large, thus inflicting an amount of injury upon the affected part, which* especially in malignant diseases, is often followed by the most disas- trous effects, causing, perhaps, not merely severe pain and hemorrhage, but such a change in the vital relations of the morbid growth as to lead to its rapid development, if not to the speedy destruction of the patient. I recol- lect seeing, some years ago, a tumor upon the hip of a lad, aged sixteen, which, after having been subjected to various examinations by highly re- spectable surgeons, was at length pierced with a large exploring needle. The swelling, which had been supposed to be nothing but a chronic abscess, and which for some time had been almost stationary, now rapidly increased in volume, ulcerated, and fungated, and in less than a fortnight destroyed life. Dissection showed that the morbid growth was one of the encephaloid kind, the activity of which had been greatly augmented by the changes induced in its vital relations by the injury done by the instrument. A large volume might be filled, if one had time, with a rehearsal of the mischief that has been committed by the exploring needle in the hands of careless and unscrupulous practitioners. Exploring needles consist either of a solid cylinder or of a species of trocar and canula, sharp-pointed, fine, and perfectly smooth, so as to facilitate their introduction and easy management. They are made of various lengths and diameters, according to the depth, volume, and nature of the part to be ex- amined. The annexed cut, fig. 96, represents an exploring needle, with a Fig. 96. lateral groove. The best instrument of the kind, according to my experi- ence—one which answers every purpose in superficial affections, and which may always be used with the most perfect safety—is the ordinary cataract needle, spear-shaped, and sufficiently stout to prevent it from breaking. This is inserted into the most prominent portion of the tumor or morbid accumu- lation, with a sort of rotatory motion, the object being to condense, as it were, the edges of the opening to promote the escape of the contents of the swelling, which readily occurs, if they are of a fluid consistence, a drop of the liquid often adhering to the instrument, or resting upon the orifice of the little puncture. When the contents are of a semi-solid nature, or the tumor is very deep-seated, the needle should be larger, or, what is preferable, it should be replaced by a very small trocar, long enough to reach and pene- trate the affected structures. Whatever instrument be used, it must not, on any account, be permitted to come in contact with any important vessels or nerves. When the swelling is of unusual bulk, it may be explored at several points of its extent at the same sitting. The little puncture made in the operation should be immediately closed with adhesive plaster or collodion. When the object is to exclude the entrance of air, the instrument may be 462 GENERAL DIAGNOSIS. carried some distance between the integument and the swelling, so as to make the opening somewhat valve-like. A needle, perforated in its entire length, has lately been recommended, on the ground of its superior efficacy in exploring deeply-seated disease, its great value consisting in the facility of discriminating between different kinds of fluids, or in reaching deeply-seated fluids without the admixture of the superficial. Dr. Addinell Hewson, of this city, has invented an exploring instrument for the purpose of obtaining a small portion of a tumor, or morbid deposit, with a view to a microscopical examination of its structure, the tube which he employs for this object being furnished with a peculiar contrivance at- tached tothe rod which slides in its interior. Such a procedure, it strikes me, is more ingenious than useful, as its disturbing influence upon th? mor- bid mass can hardly fail, at least occasionally, to impart new life and energy to the affected tissues. Ophthalmoscope.—Another instrument has lately been added to our diag- nostic armamentarium ; this is the ophthalmoscope, of which due mention will be made in the proper place. Whether the high expectations anticipated from its use will be fully realized time aloue can determine. Laryngoscope.—This is an instrument of very recent introduction into medical and surgical practice. It is intended, as the name implies, to assist in exploring the larynx, and the only objection to its employment is the diffi- culty of its application, few practitioners being possessed of the requisite de- gree of tact to use it to advantage. Otoscope.—To Mr. Toynbee, of London, belongs the merit of introducing an instrument called the otoscope, which promises to be of great aid in the examination of the ear, with a view of determining its precise condition in cases of supposed disease. It is of very simple construction, as well as of easy ap- plication, and is likely to come into extensive use. Stethoscope.—The use of the stethoscope, as a means of surgical diagnosis, is comparatively limited, and it might be altogether dispensed with by those who have a well practised ear, and are not averse to the employment of im- mediate auscultation, or the direct application of the ear to the affected parts. Lisfranc thought that the stethoscope might be advantageously resorted to for the purpose of detecting crepitus in deep-seated fractures; or, what is the same thing, in fractures covered by a large amount of muscular and other tissues, as, for example, in those of the neck of the thigh-bone in very fleshy subjects. Few occasions, however, can arise in which such a mode of explo- ration can be of any real service, and I am not aware that any of our more experienced practitioners ever employ the instrument with this object. Laennec, long ago, proposed auscultation as a means of detecting the pre- sence of calculi in the bladder. He thought that it would be particularly serviceable in ascertaining the existence of very small concretions, which, when struck with the sound, emit only a very indistinct noise ; and he sug- gested that, under these circumstances, the stethoscope should be applied to the pubic or sacral region while the instrument was being freely moved about in the organ. The recommendation, however, has not met with any particular favor, and there are, I suppose, few surgeons who would feel inclined to cut a patient for stone on such slender evidence of its presence. The chief value of auscultation, then, is restricted to the examination of diseases of the heart, pericardium, lung, and pleura; and to the investigation of certain lesions of the abdomen, uterus, and ovaries, simulating pregnancy, with a view to the detection of the foetal circulation. Dry tapping, as it has been emphatically called, would probably be of much less frequent occur- rence, if the stethoscope were oftener employed in supposed dropsy in young unmarried females. EXAMINATION OF THE DISCHARGES. 463 SECT. VI.—EXAMINATION OF THE DISCHARGES. The discharges, normal and abnormal, frora different parts of the body, often furnish the surgeon important diagnostic information. Thus, an habit- ual flow of tears over the cheek is usually denotive of disease of the lachrymal passages, and necessarily suggests the propriety of a careful examination of them with a view to the detection of obstruction. For a similar reason the surgeon is prompted to inspect the ear in otorrhcea, and the nose when it is the seat of muco-purulent profluvium. The very nature of the discharge in- forms him of the existence of inflammation, but how that inflammation is pro- duced, whether by the presence of a foreign body, a piece of dead bone, or a polyp, is a question which can only be decided by the most careful scrutiny; requiring, perhaps, the employment of the syringe to wash away the secretion, and repeated inspection before the precise nature of the case can be satisfac- torily made out. One of the most important symptoms of inflammation of the maxillary sinus is a flow of pus into the throat; but no surgeon can be certain that it proceeds from that cavity unless he has previously ascertained that there is no disease of the mucous membrane of the nose. The character of the sputa has long been an object of study with practi- tioners on account of the useful information which they afford in regard to the existence of particular diseases. Such information is hardly of less value to the surgeon than to the physician, as it apprises him of the presence of lesions which forbid surgical interference, or place him in possession of useful data respecting the occurrence of pulmonary complications, so comraon after accidents and capital operations. The reddish streaks in the expectoration excite suspicion of the existence of pneumonia ; the rust-colored sputa con- firm that suspicion, and at once invest the case with its proper importance. The fetid putrilaginous matter coughed up in gangrene of the lungs is charac- teristic of that disease from whatever cause proceeding. In phthisis, after the occurrence of caverns, the expectorated matter is ejected in distinct rounded masses, with irregular and indented edges ; it sinks in water, and is of a yel- lowish color, with various shades of ash and even green, and streaked with opaque specks. A discharge of blood by vomiting is denotive of hemoptysis when the fluid is of a scarlet color, and of hematemesis, when it is perfectly black. In affections of the throat, attended with thick mucous or muco- purulent secretion, the sputa are sometimes streaked with blood. The saliva in mercurial stomatitis has a characteristic odor, and the same is true of the discharge which accompanies gangraenopsis. A thick yellowish discharge, more or less abundant, from the vagina, is indicative of inflammation of that canal, of the uterus, or of both, and the addition of blood may usually be regarded as an evidence of concomitant ulceration. In the virtuous woman such a profluvium is generally to be con- sidered as the result of accidental causes ; in the courtesan, on the contrary, it at once awakens a suspicion of the existence of gonorrhoea or chancre. In cancer of the womb, the disease is attended, in its earlier stages, by hemor- rhage, and afterwards, when ulceration has set in, by a foul, purulent, or sero-sanguinolent discharge', more or less copious, and so excessively fetid as to indicate unmistakably the character of the lesion. In the male, a discharge of matter from the urethra generally furnishes useful information respecting the character of the disease under which the individual is laboring. When the discharge is thick, yellowish, and abund- ant, it is denotive of gonorrhoea, or chancre, though in the latter case it is seldom very profuse; when thin, and lactescent, or like the white of an egg, it indicates the existence of gleet, or prostatorrhcea. A large and sudden 464 GENERAL DIAGNOSIS. discharge, especially when no profluvium precedes or follows it, is to be taken as an evidence of spermatorrhoea. The presence of spermatozoa in hydrocele sometimes throws important light upon the source of the water. It has been ascertained that whenever the fluid contains animalcules of this kind, the disease is generally of an encysted nature; for, although they also occur in ordinary hydrocele, yet the circum- stance is so uncommon that it must be regarded as altogether of an excep- tional character. Of the signs afforded by the renal and urinary secretions, as evidences of disease, either of a local or general character, proper mention will be made in the chapter on the affections of the urinary organs. Here I shall only add that a careful examination of these secretions is often a matter of paramount moment to the surgeon, especially when he is obliged to decide respecting the propriety of a severe operation, the result of which might be seriously compromised by the existence of organic lesion either of the kidneys, or of some other important viscera. Hardly any man, however reckless, would enter upon such an enterprise if the urine were loaded with albumen. The existence of disease of the anus and rectum, and even the true nature of such disease, may often be satisfactorily inferred by the discharges furnished by these parts. A flow of pure blood, especially during defecation, is gene- rally denotive of internal hemorrhoids; so also if there be frequent evacua- tions of thick, bloody mucus, either while the person is at the water-closet, or in the intervals of his visits. A narrow, compressed, or flattened state of the feces is indicative of mechanical obstruction, occasioned either by stricture of the rectum, enlargement of the prostate gland, or contraction of the anus. In ulcerated cancer of the lower bowel, the discharges are generally very profuse, of a muco-purulent nature, mixed with blood and mucus, and exces- sively fetid; in fact, characteristic of the nature of that horrible malady. The matter of certain abscesses serves to point out their nature and situa- tion, or their accidental communication with neighboring parts. Thus, in the mammary gland, the fluid may contain milk ; in the liver, bile; in the kidney, as when an opening takes place externally, urine. Abscesses of the wall of the abdomen have been known to contain biliary calculi; of the joints, fragments of cartilage and bone. In acute abscesses, the contents are thick and yellowish ; in chronic, or strumous, thin and slightly greenish, with an intermixture of small, opaque, whitish flakes, resembling grains of boiled rice. The discharges accompanying ulcers generally afford valuable hints respect- ing the kind of action that is going on in them. Healthy granulating ulcers or wounds always yield a thick yellowish pus, possessing all the properties of laudable pus, as described under the head of Suppuration ; when, on the contrary, their action is unhealthy, the discharge is thin and bloody, ichor- ous, or sanguinolent, and more or less irritating. In cancerous ulcers, the discharge is generally profuse, foul, devoid of pus globules, and excessively fetid. In ulcers of the bones, it is ichorous and irritating ; never healthy, so long as there is any diseased osseous tissue. The odor emitted by a part in a state of disease sometimes supplies im- portant data for the diagnosis of a case. Most readers are familiar with the remarkable anecdote related of J. L. Petit. Travelling through Germany, this celebrated surgeon, while stopping at an inn to change horses, was struck with the odor of gangrene, which he distinguished from several others, hardly less offensive. Not understanding the language of the country, he made his wishes known to a female who showed him into an adjoining room, where he found a man apparently moribund from a mortified intestinal hernia. Happy in being able to render him some assistance, he carefully dressed the parts, and meeting, before he set out upon his journey, with a French phy- sician, he instructed him in the future management of the case. Upon his MICROSCOPICAL EXAMINATION. 465 return, five months afterwards, he had the gratification to learn that the man had completely recovered his health without a stercoraceous fistule. The odor attendant upon ozaena is characteristic; no one that has ever perceived it can mistake it. The contents of an abscess at the verge of the anus always emit a fecal smell; a peculiar fetor accompanies the formation of a urinary fistule, and no one can be deceived by the odor of the breath in salivation. In hospital gangrene the stench is so remarkable that, once noticed, it can never be forgotton, although it is so unlike everything else of the kind as to render it impossible to define or describe it. The odor which accompanies gangrene of the mouth of children is unmistakable. The diag- nosis of ulcerated cancer of the uterus can often be established by the sense of smell alone. Large wounds in a state of profuse suppuration not unfre- quently exhale a peculiar nauseous or sickening odor, in some degree charac- teristic of the action attending them. The pus of scrofulous lymphatic ganglion, for a long time pent-up, is sometimes horribly fetid. A smell, similar to that of a macerating tub, often attends abscesses depending upon caries of the spine. In all these cases, as well as in many others that might be adduced in illustration of the subject, it is probable that the peculiarity of the odor is due partly to the admixture of the natural secretions of the struc- tures affected. SECT. VII__MICROSCOPICAL EXAMINATION. The study of surgical affections has been much advanced of late years by the use of the microscope, the improvements in which during the last quarter of a century have been so important as to have actually established a new branch of science. Discoveries and investigations made by means of this instrument must be alluded to in connection with nearly every form of dis- ease, and its aid will often be found essential to the complete study of parti- cular cases occurring in practice. A concise description of the different varieties of microscopes, and their employment, will therefore not be out of place here. The fundamental principle of all appliances for assisting vision is to be found in the refractive power of certain media upon rays of light. Glasses, generally of a lenticular shape, single or combined, are the media chiefly em- ployed ; either natural or artificial light being available for our purpose. The light is very commonly concentrated and intensified by means of lenses or mirrors. The student should bear in mind that it is not the object which is magnified, but merely the image impressed upon the retina. The rationale of this en- largement may be briefly set forth as follows :—Let a single lens, convex on both sides, be used to examine an object so small as to be just perceptible at the ordinary distance of distinct vision, say nine or ten inches from the eye. The eye, the lens, and the object being in their proper relations to each other, the rays of light coming from the object will so converge in passing through the lens as to form a distinct image upon the retina; in other words, the object will be seen by the eye as if it were an object of much greater size, placed at the point of ordinary distinct vision. When this occurs, the object is said to be in focus. The space thus presented to the eye is called the field. In a single lens the rays of light towards the circumference of the field are always prisraatically colored to a greater or less degree, this being very marked in what is known as the Stanhope lens; and portions of the image will also be indistinct, from the fact that by such a lens all the rays are not brought to foci equally distant from the eye. These two phenomena are called, re- Vol. I.—30 466 GENERAL DIAGNOSIS. spectively, chromatic and spherical aberration; they are to a great degree obviated in the Coddington lens, which is composed of a sphere of glass, having at its equatorial line a deep groove, filled with opaque matter, by which means the central aperture is limited. Now, as was before stated, all our means for obtaining magnified views of objects are based essentially on the same optical principle, namely, the re- fraction of light. The microscopes ordinarily used are of the kind called double, which means that the image of an object, magnified by a lens or set of lenses, is again magnified before it reaches the eye. Here let it be dis- tinctly understood that a single microscope may consist of any convenient number of lenses, provided they form but one set. The lens or set of lenses forming the first magnified image constitute the object-glass, and are so arranged as to obviate the chromatic aberration before alluded to. The eye- piece consists of a lens or eye-glass, by which the image transmitted by the object-glass is again magnified, and of another lens at some distance below the eye-glass, in order so to change the direction of the rays as to allow more of the object to be seen at once—in other words, to enlarge the field— whence it receives the name of ^e/cf-glass; between these two glasses is placed a stop or diaphragm, with a central aperture, for the purpose of arrest- ing the circumferential rays, and thus correcting both the spherical and the chromatic aberration. The eye-glass, diaphragm, and field-glass, fastened in their proper relative positions in a tube, thus constitute the eye-piece, which fits accurately into another tube ; Fig. 97. Smith and Beck's large compound microscope. at the lower end of which tube is secured the one holding the object-glass, and these three por- tions, the eye-piece, the object- glass, and the tube into which they both fit, constitute the compound body. In the manufacture of mi- croscopes, the proper relation of all the parts is ascertained upon optical principles, that is, the in- strument is said to be corrected; sometimes, in order to compensate for certain conditions, it needs over- correction, and sometimes, again, it needs under-corxection. The compound body, thus constituted, itself fits into a tube connected with the stage of the microscope; this latter tube and the stage being either fixed vertically, or ca- pable of oblique inclination by means of a cradle-joint. The stage just mentioned is a plate upon which the specimen to be examined is laid, as will be presently stated. The stand of the microscope is that portion which supports the stage and compound body; it must be somewhat heavy, so as to give firmness to the instrument. The annexed cut, fig. 97, represents an excellent pattern for a microscope; it is known as the " Smith aud MICROSCOPICAL EXAMINATION. 467 Beck," and combines great strength and steadiness with facility of manipula- tion. Objects are studied by transmitted or reflected light; in the former case a mirror is placed below the stage, which is of course per- Fig. 98. forated, and the mirror is mov- able around one or both of its horizontal diameters, so as to catch light from any required quarter, and throw it up through the aperture in the stage, and through the object, as in fig. 98. If reflected light is to be used, the open- ing in the stage is closed up, and a double convex lens, or " bull's eye," is employed to concentrate the light upon the object. It is necessary in examining objects by transmitted light, tO be able to limit the amount Arrangement o^nicroscope for transparent Ejects. of light coming from the mir- ror ; every microscope should therefore be provided with a diaphragm-plate below the stage. This is a metallic plate, perforated with holes of different sizes, so arranged as to pass in succession under the opening in the stage, when the plate is rotated. The alteration or adjustment of the focus is variously performed in differ- ent microscopes. In some the compound body is acted on by two milled heads, one large, with a rack and pinion movement, named the coarse ad- juster; the other smaller, with a screw movement, called the fine adjuster. In others the compound body is worked up or down merely with the hands, and the stage is made movable by means of a screw with a milled head. Various methods are also adopted for moving the object so as to bring different portions of it into the field. Sometimes the fingers alone are used ; sometimes a lever and universal joint, or a set of screws, acting upon the stage so as to carry it in any desired direction. Although very convenient, these appliances, as well as those for the adjustment of the focus, are not absolutely necessary, the fingers acquiring a great degree of dexterity by practice. Nothing has as yet been said of the preparation of the specimen. The methods of doing this may be divided into two, according as the object is mounted dry or wet; the latter being the one almost exclusively adopted in our ordinary examinations, which are, moreover, almost always conducted by means of transmitted light. Generally a very small portion of the sub- stance is placed on a glass slide, moistened with a drop of water, and co- vered with a strip of extremely thin glass. Some microscopists prefer to use, instead of water, a solution of gum, sugar, or phosphate of soda, of a specific gravity of about 1030; this is intended to prevent endosmotic changes in the tissue. When a liquid, such as blood, chyle, milk, or urine, or a mass composed of separate cells, is examined, it suffices to put on the fine glass cover, perhaps with a slight degree of pressure, to obtain a suit- ably thin layer for study. Fibrous textures require tearing apart with needles, and so also do the cells of certain growths, such as the epitheliomata. Bony and cartilaginous tumors, and also some glandular ones, are displayed to better advantage in thin sections. Great importance should be attached, in all these researches, to the perfect 468 GENERAL DIAGNOSIS. cleanliness of the glass slides and covers, to the purity of the water or other liquid used, and to the freedom of the object from any foreign matters. Cu- rious mistakes have sometimes been made from want of care in these respects; and, with a view of still further guarding against error, it is well for the ob- server to become acquainted with the shape and appearance of such impuri- ties as are liable to be met with. Hairs, animal and vegetable, animalcules, air-bubbles, and portions of articles taken as food, are perhaps the most common of these. Less fatigue is caused to the eye by the use of a microscope which can be inclined somewhat, than by one which is fixed in the vertical position ; and it is important, for the same reason, that the habit should be acquired of so concentrating the attention upon the field of the instrument that the unem- ployed eye need not be closed; in this way much straining of both organs is avoided. Any one who uses the instrument frequently, will find it to his ad- vantage also to employ the same powers as much as possible; thus enabling himself to estimate more accurately the comparative sizes of the elements brought under his notice, without the trouble of a calculation except where great exactitude seems called for. The best powers for habitual use may be chosen between 300 and 450 diameters; higher ones than these are very sel- dom necessary. Certain chemical reagents are often applied to objects under the micro- scope, their effects in many cases affording valuable information as to struc- ture and composition. Iodine, dissolved in water by means of iodide of potassium, turns starch blue. Nitric acid gives a marked yellow color to animal textures generally ; either this or hydrochloric acid diluted, or a com- bination of the two, will remove the calcareous portion of bone or tooth. Alcohol renders nerve-fibres and other animal tissues more opaque, and there- fore more evident. Ether removes fatty matters, except when they are en- veloped in an albuminous covering. Potassa and soda, in solution, have each of them a solvent effect on certain animal textures. But the reagent perhaps oftenest employed is acetic acid, which brings out, in a remarkable manner, the nuclei so commonly possessed by organic cells, by rendering the cell wall transparent. When a specimen of any kind cannot be at once subjected to microscopical examination, it should be kept in pure water, slightly alcoholized and fre- quently renewed; in this way its characters will not be changed, as they would be either by the action of strong alcohol or by decomposition. Let us now inquire in what branches of surgical science the investigation by the microscope of morbid changes, deposits, and processes can be made practically useful. We may, in the first place, exclude prognosis and treat- ment, which can only be indirectly influenced by this mode of study. Etio- logy is likewise to be thrown out, for reasons which can be readily illustrated by an instance. Thus, the itch insect cannot be assumed to be the cause of the disease, in cases in which it is found, for we cannot prove that its presence is not a mere epiphenomenon. Pathology and diagnosis are the departments most indebted to the microscope for their advancement. They are of course very closely related to one another, and of great practical importance; and as we are at present especially concerned with them in this combined aspect, we have nothing to say in regard to inflammation, nor to the repair of inju- ries, however deserving of attention these subjects may be in their appropriate place. The use of the microscope affords much light in regard to material patho- logy ; it shows us the changes in texture, and the adventitious deposits, which accompany or constitute disease. Hence it is at once evident that, great as its value may be, as an auxiliary, it cannot possibly set aside other modes of observation; the results of clinical experience must in every case MICROSCOPICAL EXAMINATION. 469 be as carefully weighed as if we had nothing else to depend upon ; otherwise we shall not only fall into grave errors, but depreciate the scope and dignity of surgical science. Nor can it be denied that there are some questions which are entirely beyond the range even of the assisted eye; let any one, for instance, examine under the microscope portions of pus from a chancre, from a urethra affected either with gonorrhoea or with simple inflammation, and from a common boil; that there exist certain essential peculiarities in each of these no one will deny, but to detect those peculiarities by this means no one need attempt. The great question in microscopy discussed at present by all pathologists is, whether there is any distinctive and characteristic element in the so-called malignant deposits, by which they may be at once recognized. At one time the caudate cell was thought to constitute evidence of malignancy; at another, the large nucleus; at another, the double or the vesicular nucleolus; again, the multiplicity of cell forms ; and finally, the existence of malignant tumors, as a class possessing distinct form-elements, has been practically, if not ex- pressly, denied. An attempt is even now being made, by certain German pathologists, to show that cancer and tubercle—the latter of which is, in fact, as properly malignant as any other growth—are merely abortive attempts at cells of a healthy character; tubercle cells being considered as nuclei merely. Any discussion of this view would be out of place here, and mention is made of it simply in order to show that opinions are still at variance in regard to the true theory of morbid growths. It is certain that many tumors recur again and again after removal, which do not present the microscopical appearances of cancer as described by most authors. It is no less certain that some tumors which do present such appearances have been successfully excised; at least the subjects of them have died without any fresh evidence of malignant disease. Nevertheless, it is by no means certain that there is not a distinct and specific cancer cell; but this cell must present different forms in different cases, or even in the same case. Caudate cells do not signify a malignant character in the growth containing them. All tissues of new formation are apt to have them in greater or less proportion ; some tumors are composed of them entirely. Connective or areolar tissue, and old cicatrices, always contain them. Nor can any form of nucleus or nucleolus, nor any number of nuclei or nucleoli, be assigned as indicative of malignancy. Pus cells generally pos- sess two or three nuclei; fibro-plastic or fibre-forming cells often show two or more nucleoli. On the other hand, there are assuredly circumstances under which the testimony afforded by microscopic examination is by no means unimportant, and is confirmed by subsequent events. For instance, an isolated tumor, apparently composed of areolar tissue, involved the submaxillary gland of a patient; upon its removal it was examined beneath the microscope, and found to contain cells of various shapes and sizes, some very much elongated, and all with large nucleolated nuclei ; it was pronounced malignant, and reappeared within three weeks. Again, a case occurred in which the diag- nosis was somewhat doubtful between cancer and menorrhagia; the former idea was shown to be correct, by the discovery in the discharge, under the microscope, of cells of extremely various sizes, caudate, elongated, and round, with large single or double nuclei; some of the cells contained also young cells. Such elements, observed in the discharge from a diseased bladder or rectum, would constitute evidence of malignant deposit in the organ. There are cases, moreover, in which a knowledge of the microscopic struc- ture of a tumor may enable us to allay the most painful apprehensions on 470 GENERAL DIAGNOSIS. the part of the patient; thus, a growth occurring in the female breast may be shown to consist simply of a hypertrophied portion of the gland, and therefore to be destitute of any malignant character. In order to draw any positive inference from microscopic observations, the growths or tissues examined should be carefully scrutinized, and in many instances several different portions of them subjected to separate study. Thus, a hypertrophied lobe of the mammary gland may perhaps contain a deposit of a decidedly malignant character, and this fact may entirely escape notice in a partial or hasty examination ; so also bony and cartilaginous deposits are apt, when found in connection with the soft tissues—such, for instance, as the testicle—to be associated with less innocent formations. Another no less important precaution, for the credit of microscopy, should not be forgotten. We may assert of a particular tumor that it presents no sign of malignancy; but we cannot therefore declare that the individual from whom it has been removed is exempt from cancer. He may be already the subject of a carcinomatous diathesis, which will reveal itself at some future time, perhaps at the very same point rendered more vulnerable by the sub- stitution of cicatricial for normal tissue. Coincidences of this kind have undoubtedly been adduced as proof of the insufficiency of the information afforded by the microscope. The best guide, in the present state of our knowledge upon this subject, is experience ; the beginner will often find himself entirely at a loss, and unable to make up his own mind in regard to particular cases. No argument is necessary to set forth the imprudence of a rash decision under such circum- stances ; both diagnosis and prognosis should be withheld until further obser- vations can be made. It is by no means uncommon for the surgeon to be in doubt as to the character of discharges taking place from some of the outlets of the body; and in clearing up these points the microscope may render essential service. The saliva will often be found to contain altered epithelial scales, and various parasitic sporules and filaments, indicating derangement of the mucous membrane of the mouth. The sputa may be examined with benefit in some cases of doubtful pulmo- nary disease ; the presence of the peculiar corpuscles of tubercle, or of fibres from the parenchyma of the lung, indicates phthisis, while that of cancer cells would denote cancer of the lung. Care is necessary in these cases to avoid mistaking the free nuclei of cancer for tubercle corpuscles; an error which may have been committed by those who have asserted the coexistence of the two forms of disease in the same subject. Parasitic plants are some- times found in the sputa, especially in cases of tuberculous disease ; they are probably accidental only. Occasionally an opening is formed in the dia- phragm, through which parasitic animal growths find their way from the liver into the air-passages ; thus, the hooklets of the echinococcus have been expelled by coughing. Fibrinous casts of the smaller bronchial tubes are often met with in pneumonial sputa. All these substances must be distin- guished, not only from one another, but also from particles of foreign matter, such as food adhering to the teeth, which may seriously mislead the observer. Vomited matters present some interest. They consist usually of undigested food, with portions of epithelium, but in some diseases they contain also special ingredients. Blood, pus, cancer cells, and sarciuae are the chief of these. The examination of the urine microscopically is elsewhere discussed; that of fecal matter has some importance in cases of supposed cancerous disease of the rectum, in cholera, melaena, and some other morbid states. This sub- ject has received too little attention, especially when its physiological bearing is taken into account. Here, also, care is requisite, lest particles of undi- MICROSCOPICAL EXAMINATION. 471 gested food, parasitic growths, or other substances, should give rise to serious errors in theory or in diagnosis. Uterine and vaginal discharges have been before alluded to ; their micro- scopic study is chiefly important in the diagnosis of cancer, tubercle, and other morbid deposits. Milk is sometimes to be judged of by its microscopic characters; its colos- tral characters—the compound granular bodies and the variability in the size of its oily particles—should disappear by the fifth or sixth day after parturi- tion. In order to compare specimens of milk, it is evident that the drops examined should be of the same bulk, and the thin glass cover made to press equally, in each case. Blood, examined under the microscope, is sometimes found to contain an abnormally large proportion of white corpuscles; a condition known under the name of leucocythemia. It must be acknowledged that we have as yet by no means appreciated the importance of the changes undergone by the blood iu disease. It is occasionally of great practical moment to determine whether certain fluids or secretions, as mucus, urine, milk, or semen, furnished by an organ laboring under disease, contain pus, inasmuch as the presence or absence of this fluid may not only throw great light upon the diagnosis of the case, but lead to important therapeutic indications, perhaps the avoidance of a serious operation, as, for example, the amputation of a limb in the case of granular degeneration of the kidney. The most satisfactory test, undoubtedly, of all is the globular character of the pus, as revealed by the microscope, perfectly healthy mucus having no such bodies. It is only when mucus is derived from an irritated or inflamed surface that it presents corpuscles, which may then consist either of undeveloped epithelial cells, lymph corpuscles, or pus globules. Pus and pus liquor are highly albuminous, and therefore readily coagulable by heat, alcohol, and acids ; healthy mucus, on the contrary, contains no pus liquor, and is therefore not coagulable. If the sus- pected secretion be agitated with a solution of potassa, it will, if purulent, be converted into a dense, gelatinous mass, but not if it consist of mucus. Mucus, treated with acetic acid, coagulates into a thin, membranous pellicle; pus does not. Subjected to the contact of ether, mucus yields no traces of fat, whereas this substance may always be extracted in considerable quantity from pus, especially if at all pure. Finally, mucus floats in water; pus, on the contrary, sinks in it. Further observations on the distinction between pus and other fluids will appear in the chapter on the urinary organs, so as to render, for the present, any other remarks here unnecessary. The surgeon is not unfrequently called upon for medico-legal information ; and here the microscope may be of essential service, as, for instance, in the detection of blood-stains, or of spermatozoids in and about the vagina in cases of alleged rape. Facts of great importance have in this manner been established. All microscopic examinations should be recorded, and drawings made of any notable appearances observed ; in this way alone can permanent addi- tions be made to the fund of knowledge possessed by the individual or by the profession at large. 472 MINOR SURGERY. CHAPTER XIII. MINOR SURGERY. Minor surgery comprises an account of some of the more common instru- ments used in surgery, of the mode of making incisions, or of performing the elementary operations, the establishment of issues, the introduction of the seton, the application of the actual cautery, bleeding, and the art of bandag- ing and of dressing. As some of these topics have already been incidentally discussed, especially in the chapter on inflammation, I shall here confine my- self to the consideration of those that have not yet been touched upon in previous parts of the work. SECT. I.—INSTRUMENTS. Instruments are as necessary to the surgeon in the execution of his opera- tions as they are to the mechanic in the performance of his daily labor. But as the best workman employs the fewest tools, so the best operator employs the fewest instruments ; and to the man of science and taste nothing is more disgusting than an ostentatious display of such material. A few articles, well selected, and kept in proper order, ready to do their work at the shortest notice, are all that any surgeon really requires for the successful performance of nearly every operation that he may be called upon to undertake. The simplicity of his armamentary often affords a better idea of his skill aud science than the most daring feat upon the operating table. The elementary and really important instruments are very few in number; they are the scalpel, needle, saw, forceps, probe, and director, which are the parents of nearly all the numerous and diversified surgical contrivances found in the shops of the modern cutler. With a little modification the scalpel is converted into the bistoury, the lancet, and the amputating knife, and may be thus made to answer all the purposes required of a cutting instrument. The same needle with which a suture is made may, with a little difference of size and shape, be readily used for couching and lacerating a cataract, or insert- ing a seton. The saw may be modified without limit, and the same is true of the forceps, whether intended for dissection, dressing, or the division of bone. The probe, which, from its great usefulness, raay almost be regarded as another finger, varies in size and shape, from the little delicate, almost thread-like instrument devised by Anel for examining the lachrymal canal, to the sound employed by the lithotomist for exploring the condition of the bladder. The grooved director, which serves to guide the knife in the divi- sion of the soft parts, as in operations for hernia, impermeable stricture, and stone in the bladder, is, in fact, nothing but a modification of the ordinary probe. The knives generally in use among surgeons for the more ordinary daily operations are the scalpel and bistoury, of various sizes and shapes, so as to INSTRUMENTS. 473 adapt them to the exigencies of each particular case. All such instruments should have a tolerably large handle, and I decidedly prefer one that is somewhat rough, as being less likely to slip from the fingers when it becomes wet with blood. The blade should be rather long and slender, gradually tapering to a point, which should be quite sharp, or, at any rate, not at all rounded. In some operations, a double-edged, spear-shaped knife is found serviceable, as in the extirpation of tumors, and the extraction of the cata- ract. Finally, it is sometimes advantageous to have a knife whose handle terminates in a semi-sharp steel edge. Such an addition is occasionally of great service in the extirpation of tumors. The annexed figures afford a good idea of the more common forms of scalpels. Fig. 99. Fig. 100. Fig. 101. Fig. 102. Fig. 103. Fig. 104. The bistoury differs from an ordinary scalpel chiefly in being longer and more slender; it may be straight or curved, with a sharp or blunt extremity. It is often made so as to open and shut like a penknife, as in fig. 105 ; but the best instrument of the kind is one with a fixed handle. The term bis- Fig. 105. toury has been supposed to be derived from Pistori, the name of a town where it was at one time extensively manufactured. Particular forms of this instrument, invented for particular operations, will be alluded to in different parts of the work. The adjoining sketches afford good illustrations of the ordinary forms of 474 MINOR SURGERY. the bistoury; fig. 106 represents the sharp-pointed instrument, and fig. 107 the probe-pointed. Fig. 106. Fig. 107. There are hardly any operations in which it is not necessary for the surgeon to avail himself of the use of forceps. The instrument usually employed is the common dissecting-forceps, represented in fig. 108. In some cases, as Fig. 108. when the object is to pinch up a delicate structure, as the conjunctiva, or a very thin layer of fascia, a pair of forceps provided with a small side-prong, pointing inwards, as represented in fig. 109, will be found very convenient. Fig. 109. Scissors are nothing but two knives united by a screw, and furnished each with a ring-handle; if thin, and properly sharpened, they divide the tissues Fig. 110. Fig. 111. with little or no contusion, and may be employed for a great variety of pur- poses. They are particularly valuable in many of the more delicate opera- INSTRUMENTS. 475 tions upon the eye. They may be straight or curved on the edge or on the flat, pointed or blunt at the extremity, or one blade may be sharp and the other blunt. The annexed drawings exhibit the two principal forms of scissors used by the surgeon. For holding the flaps out of the way in performing certain operations, especially such as involve the removal of morbid growths, among the more deep-seated structures, or the exposure of arteries, instruments, called retract- ors, are often of great service, and should find a place in every well arranged operating case. For holding and pulling out morbid growths, such as deep-seated tumors of the neck or thigh, and for drawing down the cervix of the uterus in operating for vesico-vaginal fistule, as well as for other purposes, a Museux's forceps, shown in fig. 112, or a common volsella, is often of great use. The teeth Fig. 112. being plunged into the morbid mass, the instrument is either held by the sur- geon himself, or the requisite traction is exerted by an assistant. Fig. 113 Fig. 113. represents another contrivance, which may be used for a similar purpose, its prongs being firmly screwed into the substance of the morbid growth. The forceps shown in fig. 114 is very serviceable in the extirpation of large polyps of the uterus. Fig. 114. Fig. 115. The grooved director, sketched in fig. 115, is of great service in laying open sinuses and fistules, in exposing arteries, and in dividing the coverings of hernia?, and of deep-seated tumors. It is generally blunt at the extremity, but in some cases it is found more convenient to have it somewhat sharp, so as to effect more easy penetration of the tissues. 476 MINOR SURGERY. The trocar, represented in fig. 116, and so called from the circumstance of having a three-edged extremity, consists of a cylindrical rod, passed through a silver canula. It is employed for drawing off various kinds of fluids, as serum and pus. Its use, at the present day, is chiefly 118. confined to the removal of water from the chest, abdo- men, and vaginal tunic of the testicle. There is an in- strument of this kind with a flat, spear-shaped extremity, but it is not much employed, its canula being more liable to obstruction than that of the round trocar. There are few instruments which the surgeon has oc- casion to use more frequently than needles; they may be straight or curved, round or flat, and should be of various sizes, as in Fig. 117. In some instances, as Fig. 117. when we are obliged to take a deep stitch, sew up a fissure of the palate, penetrate an unusually hard struc- ture, or encircle a deep-seated artery, it is convenient to secure it to a handle, as in fig. 118. SECT. II.—INCISIONS. Suture needle; with im- proved point, a. b. Needle in fixed handle; useful in tying erectile and other tumors. It is not my intention to enter into any minute de- tails respecting the manner of holding the knife, in operating upon the living subject, as this is a kind of information which should be acquired in the dissecting- room, in connection with the study of surgical anatomy. A few rules, concisely and plainly stated, will be quite sufficient for the pur- pose, and will enable any man of sense to execute, with facility, neatness, and dispatch, any operation he may be called upon to undertake. Anything like a flourish for the sake of display or the hope of attracting the applause of the vulgar, is as repugnant to good taste as it is out of place upon such an occasion. INCISIONS. 477 There are four principal positions in which the knife may be held for ope- rative purposes, and with these every surgeon should make himself familiar. The annexed sketches will serve to convey a better idea Fig. 119. of their character than any description however elabo- rate. They are generally distinguished by the prefix of first, second, third, and fourth. In the first position, fig. 119, the knife is held like a writing-pen, between the thumb and the first two fingers, which grasp the instrument gently yet firmly at the junction of the handle with the blade, the edge being inclined down- wards or upwards accord- Fig. 120. ing to the intentions of the surgeon. This position is a very common one, as it is employed in a great variety of operations, as lithotomy, the extirpation of tumors, herniotomy, and the extrac- tion of the cataract. In the second position, fig. 120, the handle of the instrument lies in the palm, the thumb and middle finger holding it at its anterior ex- tremity, while the index finger is slightly extended along the back of the blade, the ring and little fingers assisting in supporting and steadying the handle. The edge of the blade is inclined downwards or up- wards, according to circumstances. Iu the third position, fig. 121, the knife is held like the bow of a violin; that is, the instrument, turned away from the palm, is lightly balanced in the hand, the four fingers being applied against one side, and the thumb against the other. In the dissection, the blade is usually held somewhat sidewise, and the operation is performed chiefly by alternately flexing and extending the wrist. Fig. 121. In the fourth position, fig. 122, the knife is held like an ordinary carving-knife, the handle, which inclines towards the ulnar margin of the wrist, being firmly grasped by, and almost Fig. 122. 478 MINOR SURGERY. completely concealed in, the hand, the tips of the last three fingers nearly touching the hypothenar eminence. This position is chiefly used in the am- putation of the larger limbs, and, occasionally, in the extirpation of huge superficial tumors, when the surgeon wishes to produce a rapid and brilliant effect. The incisions employed in operative surgery may be conveniently reduced to three principal ones, namely, the straight, curvilinear, and angular, which are the parents of all the rest. In executing these incisions certain rules should be observed, of which the most important are the following:— 1st. The knife, whether it be a bistoury or scalpel, should be in as com- plete a condition as possible, being perfectly sharp and clean, and as light as may be consistent with the necessary strength ; its size should also be care- fully adapted to the occasion. 2d. Before commencing the incisions, care should be taken to stretch, ex- tend, or tighten the skin, which is done either by the operator alone, or partly by him and partly by his assistants. Attention to this rule is of great im- portance in numerous operations, as it not only expedites the movements of the knife and imparts precision to the incisions, but, what is often a matter of the greatest consequence, enables us to save integument, as, for instance, in case of amputation. 3d. The incisions, whatever be their shape, should be sufficiently large to answer the purpose for which they are designed, being made so, if possible, before the dissection is begun, as this generally greatly facilitates the removal of the parts, or their separation from each other. The principal exception to this rule is where the operation involves the division of large vessels, which, if they were all wounded at once, might be productive of serious hemorrhage. 4th. The superficial incisions should be of equal depth throughout, the knife being entered perpendicularly at one extremity, and brought out simi- larly at the other, the object being to avoid the formation of what is called a tail, or a partial division of the integuments at each end, as will inevitably happen when the point of the instrument is introduced obliquely. A gentle but steady sawing motion of the knife should be employed rather than firm pressure. 5th. In dividing the common integuments, the knife should always, if pos- sible, be carried parallel to the axis of the part to be exposed or removed, in order that there may be no interference with any important vessels or nerves, which usually run in that direction. Another great point to be gained, in observing this precaution, is that we prevent the flaps from bagging, and so serving as receptacles for the lodgment of blood and inflammatory deposits. 6th. The incisions should be made as rapidly as possible, seeing that the division of the common integuments is generally the most painful part of an operation. Moreover, while they should be sufficiently extensive for the object in view, care should be taken not to make them larger than is neces- sary. 7th. All cutaneous incisions should be made with special reference to the prevention of unseemly scars. To do this successfully is not always either easy or even practicable. As a general rule, the object is best attained by carry- ing the knife in the direction of the muscular fibres of the part, or in the line of its wrinkles. Thus, in operating on the forehead, the surgeon will best attain his wishes if he makes his incision horizontal, not oblique, much less perpendicular. In operating upon the lower jaw, or in extirpating tumors from this region, the incisions should be so directed as to run along the base of the bone which will thus offer the best chance of concealing the resulting cicatrice. 8th. The operator, in the exercise of his functions, must be careful not to wound himself, his assistants, or his patient; an occurrence as awkward as INCISIONS. 479 improper, and one that will seldom happen if everything is properly arranged beforehand. The straight incision may be made either from without inwards, or from within outwards. The former method is usually adopted in the ordinary operations, as in the extirpation of tumors, in opening abscesses, and in the ligation of arteries. Where great caution, however, is required, as in operat- ing for strangulated hernia, or in the removal of morbid growths in front of the neck, the incision must be made from within outwards. For this purpose a fold of integument, being pinched up, is held by the surgeon and his assist- ant, while its base is transfixed by the knife, and divided by making the in- strument cut its way out. The dissection is afterwards to be conducted upon a grooved director. Occasionally, as in operating about the neck, especially when the object is the removal of a large tumor at the angle of the jaw, the inci- sion may advantageously be made in a curvilinear direction, Fig. 123. either like an Italian/, or in the form of a semi-ellipsis, as in fig. 123. The chief reason for this procedure is that, while it affords the operator more room, it leaves a more seemly cica- trice. The elliptical incision consists of two curvilinear cuts, meeting at their ex- tremities, as in fig. 124. It is chiefly employed in the extirpation of tumors, where the object is to remove along with the diseased mass a portion of redundant or unhealthy integument. Fig. 124. The incisions are made rapidly, in the usual manner, one after the other, the skin being properly stretched, and care taken not to cut away more than is absolutely neces- sary, since it will otherwise be difficult, if not impossible, to bring the edges of the wound together, after the operation is over, so as to obtain a good and rapid union. Not a little judgment is frequently re- quired to determine, in a given case, how much integument may conveniently be preserved or removed ; the surgeon, remembering how contractile the skin is, will generally be cautious how he sacrifices it. Even if the flap be un- seemly immediately after the operation, a few days will generally suffice to reduce it to a proper shape and size. Two semi-eliiptical, crescentic, or serai-lunar incisions, as in fig. 125, may sometimes be advantageously made, also with the object of removing a portion of integument, as, for instance, in extir- Fig. 125. pating a diseased mammary gland. The incisions may be directed vertically, obliquely, or hori- zontally, as may seem most suitable. The angular incision maybe used for various purposes, as in the extirpation of tumors, herniotomy, excision of joints, the exposure of diseased bone, and in the transplantation of flaps for the restoration of lost or mutilated parts. It may be made in different ways, but commonly so as to represent the shape of some letter, as in the subjoined figures, according to the exigencies of the particular case. Fig. 126. Fig. 127. Fig. 128. Fig. 129. Fig. 130. Fig. 131. In dissecting up the flaps, made by these different incisions, the instrument should, as a general rule, be kept in close contact with the parts to be re- moved ; the knife should be swept along as rapidly as maybe consistent with 480 MINOR SURGERY. safety; good use may generally be made of the fingers, which will in most cases be found altogether preferable to the forceps. Special regard should always be had to the prevention of hemorrhage. If well-trained, intelligent assistants be at hand, there will, in general, be no necessity for tying even- little artery as soon as it is divided ; the instant it springs, a finger is clapped upon it, and thus the operation proceeds to its completion, when, satisfactory clearance being effected, the ligation is at once promptly entered upon, and continued until every bleeding vessel is properly secured. When the dissection involves the exposure of an important structure, as a large artery, a strangulated hernia, or an encysted tumor, which it is desirable not to pierce, the tissues must be divided layer by layer upon a grooved director gently and cautiously insinuated beneath them ; or they may be pinched up with a pair of forceps, although this is both less elegant and less safe than the other method. In performing this part of the operation, the successive divisions must be effected in the line of the external incisions, the best knife for the purpose being a narrow, probe-pointed bistoury. SECT. III.—AVULSION, ENUCLEATION, LIGATION, AND CRUSHING. 1. Avulsion.—Instead of cutting away morbid growths with the knife or bistoury, recourse is sometimes had to avulsion, or to twisting and tearing. It is in this way that the surgeon usually removes polyps from the nose and uterus, the instrument which is employed for the purpose being a suitable pair of forceps, with which the tumor is seized and broken off, by rotating the instrument gently yet firmly upon its axis. All active or sudden and forcible pulling is avoided, as tending to inflict serious mischief upon the parts around by lacerating and injuring them to an undue extent; or, as in the case of the nose, perhaps dragging away the turbinated bone, or, as in that of the uterus, inverting that organ, or pulling it down beyond the vulva. Moreover, by avoiding this procedure there will always, as a general rule, be much less risk of copious hemorrhage, severe pain, and shock to the nervous system. Avulsion is soraetimes advantageously practised in the extirpation of tumors developed in and among the tissues, especially when they are deeply situated, or when they lie in the immediate vicinity of large vessels, which it would be hazardous to approach with the edge or extremity of the knife. Under such circumstances, the finger may occasionally advantageously take the place of the cutting instrument, the connecting structures being forcibly lacerated, and the mass twisted and lifted out of its bed. This mode of pro- cedure is often resorted to in the removal of tumors from the neck and paro- tid region dipping deeply down behind the base and angle of the jaw, in close proximity with the pharynx and the large cervical vessels and nerves, where a false movement with the scalpel might be instantly fatal. It is aston- ishing what little bleeding frequently follows operations thus performed, and how well the parts generally heal after such rude manipulations. One reason why there is usually so little hemorrhage is that the vessels are torn instead of being evenly divided, as they are in the ordinary procedure. 2. Enucleation.—Enucleation is another species of avulsion, and is often advantageously employed in the extirpation of fatty, fibrous, and fibro-plastic tumors. The integuments having been thoroughly divided over the morbid growth, along with its capsule, if there be any, the diseased structures are rapidly peeled out either with the finger, or with the handle of the scalpel. In certain cystic tumors the bag with its contents may often be peeled off bodily, or, its cavity being laid freely open, and its contents evacuated, the walls of the cyst may be pulled away with the forceps. AVULSION, ENUCLEATION, LIGATION, AND CRUSHING. 481 3. Ligation.—There are certain operations in which the removal of the diseased parts is effected chiefly through the agency of the ligature. Of this mode of procedure familiar examples are afforded in the removal of hemor- rhoidal tumors, polypous growths of the nose, vagina, uterus, and anus, and in nervous formations about the face, forehead, and other regions of the body. The ligature may be applied either directly to the part by the fingers, or by means of a needle, and should be drawn with sufficient firmness to strangu- late the included structures, as the object is to cut off the supply of blood, and cause an eschar. Occasionally the ligature is used subcutaneously, as in the case of nevous growths, involving often very interesting and complicated operations. Instead of the ligature, a silver wire is sometimes used, either by itself, or by means of a double canula, as in fig. 132. Fig. 132. Double canula. 4. Crushing.—Parts, again, may occasionally be removed by a process of crushing, as proposed a few years ago by Mons. Chassaignac, of Paris, the instrument which he has devised for that purpose being what he calls the ecraseur, or crusher; the inventor hoping thus to meet certain contingencies in operative surgery which he, in common with others, had frequently encountered in practice, and which he supposed could not be overcome in any other man- ner. His chief object was to supply a substitute for the ligature in the removal of certain tumors, as hemorrhoids, and polyps of the vagina and uterus. The idea seems to have been to contrive an instrument that should combine the security of the ligature with the rapidity of the knife, thus preventing hemor- rhage and pain, and promptly ridding the part of abnormal structure. The ecraseur, as might be supposed, was originally rude and clumsy, but, by the ingenuity of surgeons and cutlers, has been rendered very graceful and con- venient, if not absolutely perfect. The annexed sketch, fig. 133, affords an Fig. 133. excellent representation of the shape and construction of the instrument, as manufactured by Gemrig, Kolbe, and others of this city. It will be per- ceived that it essentially consists of two pieces, a sheath, barrel, or tube, either flattened or cylindrical, and of an articulated chain, attached to a steel rod, lying within the sheath, and moved by a handle. The chain is con- structed upon the same principles as in the ordinary chain saw, but the links are stronger, and perfectly obtuse, except when it is desired to combine division with crushing, in which event their edges are somewhat beveled. The instrument is made of various sizes and shapes, so as to adapt it the more readily to the various cases presented in practice. The chain, unless constructed with great care, is very liable to break, especially if used for the removal of dense, indurated structures, the division of which requires a good deal of force. The application of the ecraseur has recently been very much extended, and VOL. i.—31 482 MINOR SURGERY. it is quite impossible to foresee where, in the hands of its admirers, it raay ultimately cease. During the last twelve months the journals have been filled with accounts of all kinds of wonderful achievements of this instrument, even including amputation of the arm and thigh by its inventor; while its more moderate and less enthusiastic partisans are content with restricting its use to the removal of various kinds of tumors, especially hemorrhoidal, ne- vous, and ovarian, and the tongue, penis, prepuce, and neck of the uterus. The advantages claimed for it are, first, the rapidity of the operation, which is greater than that with the ligature, although less than with the knife, the instrument acting more powerfully upon the tissues embraced in its loop ; secondly, the prevention of. shock, the chain doing its work gradually and almost imperceptibly, so as hardly to afford the system an opportunity of taking cognizance of what is going on ; thirdly, the protection of the part against hemorrhage, the vessels being placed in a condition similar to those in a lacerated and contused wound ; and, lastly, the making of a smaller and less exposed wound than either the ligature or knife, and, consequently, less inflammation and a more rapid cicatrization. The principal rules to be observed in the application of the ecraseur are the following : In the first place, if the tumor has a broad base, it should, if possible, be pediculated, by drawing it away from its points of attachment, and casting a ligature around it, its base having been previously transfixed by one or two stout needles. When the coverings of the morbid growth are unusually hard, or insensibly lost in the surrounding parts, a gutter may be formed in them with the knife, preliminary to the application of the chain. Secondly, the division of the tissues is to be effected slowly and gradually, not rapidly or by fits and starts, and for this purpose the handle of the ecraseur should be turned only about once every ten, twenty, twenty-five or thirty seconds. The time occupied by the entire operation must of course vary according to circumstances, from five minutes, as the average minimum, to twenty minutes, as the average maximum. The great objection to a rapid operation is the danger of hemorrhage. Thirdly and lastly, the patient, during the whole procedure, should be under the influence of an anaesthetic, otherwise the pain will be extreme, especially in the earlier stages. The subsequent treatment is very simple. If pain arise when the patient wakes from the effects of the anaesthetic, a full anodyne is given, the part is kept at rest in an elevated position, under the influence of water-dressing, and any constitutional symptoms that may show themselves are met as they occur, just as after any other operation. The wound generally heals in a very short time, with very little appearance of inflammation. I am not aware that the application of the ecraseur has ever been followed, in cases at all adapted to its use, by pyemia, or any grave constitutional effects, and this is certainly one of the strongest arguments that can be urged in favor of its employment. The ecraseur is one of those novelties whose use is always, at first, followed by great abuses, which time alone can rectify. The indiscriminate employ- ment which characterizes it at the present moment is only calculated to bring it into disgrace, by arraying against it the prejudices of the more calm and enlightened members of the profession. When it shall assume its legitimate rank, which it must do before long, it will cease to be applied to the am- putation of the limbs and of the mammary gland, if not also of the penis and testicle, aud will be restricted, in great measure, if not entirely, to the removal of the tongue, the neck of the uterus, and hemorrhoidal, erectile, and polypous tumors of the vagina and uterus; but even in these affections it will not always supersede the use of the ligature. In internal piles, for instance, I should certainly myself prefer the ligature, and in polypous growths the most eligible operation will generally be avulsion. ABSTRACTION OF BLOOD. 483 SECT. IV.—ABSTRACTION OF BLOOD. Abstraction of blood may be effected by scarification, puncture, incision, leeching, and cupping. The fluid is sometimes taken from a vein or an artery; the operation, in the former case, constituting venesection, and, in the latter, arteriotomy. 1. Scarification.—Scarification is performed with the lancet, scalpel, or bistoury, passed lightly and rapidly over the inflamed surface, so as to divide the engorged vessels, and afford them an opportunity of freeing themselves of their contents. It is employed chiefly in conjunctivitis, tonsillitis, erysi- pelas, and irritable ulcers, and may be repeated once a day, or once every other day, according to the exigencies of the case, the bleeding being pro- moted by the liberal use of warm water. In irritable ulcers of the extremi- ties as well as in other parts of the body, scarification is an exceedingly useful practice, which I have pursued, for many years, with great advantage. The proper mode of proceeding is to immerse the limb, previously constricted just below the knee, in a vessel of warm water, and then to make from four to eight vertical incisions over'the sore, extending merely through the super- ficial portion of the true skin. In this manner I have repeatedly bled my patient to syncope, making thus a most salutary impression both upon the part and system. In granular conjunctivitis, the eyelids, especially the upper, may often be scarified with the happiest effect; and in ophthalmia, attended with chemosis, deep incisions are generally practised to relieve engorgement and prevent strangulation of the vessels of the cornea. In tonsillitis, scari- fication nearly always greatly mitigates the symptoms, and in erysipelas, especially the phlegmonous variety of that disease, it forms a most important element of the local treatment, nothing else being so well calculated to re- move tension and prevent gangrene. 2. Puncturing.—Puncturing is performed pretty much with the same in- tention as scarification. It is particularly valuable in erysipelas, active oedema, boils, carbuncles, hemorrhoids, and affections of the tonsils, uvula, lymphatic glands, scrotum, prepuce, uterus, labia, and nymphae, its beneficial effects depending upon the amount of drainage which follows the operation. The best instrument for performing the operation is a very narrow, sharp- pointed bistoury, thrust rapidly into the inflamed surface, to a depth varying from a line to half an inch, according to the degree of swelling of the affected parts, care being taken to avoid injuring important vessels and nerves. In phlegmonous erysipelas, as many as fifty, seventy-five, or even a hundred punctures may sometimes be made with advantage. 3. Leeching.—Leeching is applicable to a great variety of affections, and is perhaps more frequently employed than any other mode of topical bleed- ing. The operation, however, is not without pain, and, unless properly per- formed, may even be followed by danger. Thus, in epidemic erysipelas, I have known it to give rise to an attack of this disease, which speedily de- stroyed the patient. Sometimes, again, leech-bites degenerate into bad sores, and produce a great deal of constitutional irritation. Ill effects will be most likely to arise when the leeches are sickly, and when they are applied to persons of a nervous, irritable temperament. Hence, great caution should always be exercised in their selection, as well as in the manner of using them. The best leeches are the Swiss, German, French, and Spanish, which generally take hold with great avidity, and draw each from half an ounce to six drachms of blood, including what flows after the animal drops off. The American leech, although much larger than the European, bites reluctantly, and sucks sluggishly, on which account it is now rarely used. Moreover, the 484 MINOR SURGERY. wound made by the foreign leech emits four times as much blood as that made by the native; a fact not to be lost sight of in ordering this kind of bleeding. Whatever species be employed, the rule is to divest the part of hair and dirt, otherwise the animal will either not take hold at all, or only after much coaxing, its tastes and habits being extremely fastidious. li', notwithstanding these precautions, it is not inclined to bite, the best plan will be to smear a little blood upon the surface, drawn from the operator's finger, previously constricted with a tight fillet, or to wet it with a little sweetened milk. Immersion of the leech for a few minutes in small beer will sometimes induce it to take hold when hardly anything else will. When the number to be applied is considerable, they should be put in a tumbler, which is then inverted upon the part from which the blood is to be drawn, by which means they will be prevented from crawling about. It is a good plan, gene- rally speaking, not to group them too closely together, but to let them fasten themselves at some little distance from each other. Another rule is not to pull them off, but to let them detach themselves, as they will lie sure to do as soon as they have " taken their fill." Their forcible separation is not only a source of pain, but it sometimes leaves a portion of the jaw in the little tri- angular wound made by its bite, which is sure to become inflamed and irrit- able in consequence. As soon as they have all dropped off, the bleeding is encouraged by sponging the surface well with warm water, and then covering it with a thickly-folded flannel cloth, wrung out of hot water, and frequently renewed, for a period varying from thirty minutes to two hours, or even longer, according to the desired effect. The blood having ceased to flow, the part is sprinkled with a little powdered starch, and covered with a dry cloth. If there be any disposition to bleed more, or longer, than is deemed proper, the bites are covered with a piece of dry tinder, which, especially if a little pressure be conjoined with it, generally soon puts a stop to the effusion. The number of leeches to be applied varies from a single one to several dozens, according to the intensity of the morbid action, and the age and strength of the patient. In the adult a good average number is from fifteen to twenty; in children, under five years of age, from three to six. In infants a single leech has sometimes been followed by fatal depression. The extra- ordinary delicacy of the skin, and, consequently, the great depth of the animal's bite, are reasons why leeching should be practised with more than common caution at this tender age. There are certain localities where leeches should not be applied. Thus, in the first place, the face, neck, and other parts habitually exposed are, if possible, avoided, because the bites of these animals are liable to be followed by disfiguring scars, particularly objectionable in the female. Secondly, they must not be applied to the eyelids, scrotum, prepuce, labia and nymph®, structures abounding in loose cellular tissue, and therefore readily admitting of great infiltration of blood, as well as extensive discoloration. Thirdly, they must not be placed along the course of a superficial artery or large vein, or over any of the nervous trunks; lest, in the first case, they should occa- sion serious hemorrhage, and, in the second, severe pain. Fourthly, care is taken to avoid the centre or focus of an inflamed surface, as they might seri- ously aggravate the morbid action, if not induce gangrene. Lastly, surgeons make it a rule not to apply these animals in the vicinity of specific ulcers, as chancres and buboes, for fear of inoculating their bites, and thus propagating the specific disease. A discharge of blood by leeches for a number of successive hours is some- times very desirable, as soon as one set drops off another supplying their place. In violent ophthalmia, croup, peritonitis, dysentery, erysipelas, and buboes, there is no mode of depletion so beneficial, or so well adapted to put a prompt and permanent stop to the disease, as this. ABSTRACTION OF BLOOD. 485 In leeching the uterus, vagina, ano-rectal outlet, the nose, and inside of the cheek, the animals must be confined in a glass or wire speculum, the opening in the instrument being held upon the part from which the blood is desired to be taken. Serious, and indeed, frightful, hemorrhage sometimes follows a leech-bite. The occurrence is especially to be dreaded in children, in whom it occasionally produces fatal exhaustion. The best remedies are dried tinder, bound firmly upon the part, compresses wet with saturated alum water or a solution of the persulphate of iron, and cauterization with the solid nitrate of silver, cut to a delicate point, and inserted into the little wound, previously well cleansed and dried. If these means prove abortive, the edges of the wound are trans- fixed with a cambric needle, and approximated by ligature; a procedure which I have never known to fail. 4. Cupping.—Cupping is by no means so eligible a mode of bleeding as leeching, being more painful, less elegant, and not so generally applicable. It is, nevertheless, when properly executed, a valuable operation, particularly in the early and declining stages of inflammation. An incipient pleurisy, pneumonia, or articular inflammation, is often promptly relieved by the appli- cation of half a dozen cups ; but it is chiefly in the latter stages of acute dis- ease, after the morbid action has been weakened by other remedies, and in chronic affections, that cupping asserts its true rank as an antiphlogistic agent. It is seldom, if ever, permissible in gastritis, peritonitis and enteritis, on account of the great pain produced by the application of the scarificator. The operation, to be really serviceable, should be performed as near to the seat of the disease as practicable, care being taken not to open any large vessel, to prick any nervous trunk, or to wound any tendons. The surface selected for the application of the cups must be free from bony prominences, and, without being very soft, must have a pretty good stratum of subcutaneous cellular substance, otherwise it will be impossible for the cups to maintain their hold, and extract a sufficient amount of blood. If the part be thickly covered with hair, it must be previously shaved. Fig. 134. Fig. 135. Scarificator. Cupping apparatus. The scarificator, fig. 134, usually employed for dividing the skin, is pro- vided with eight, twelve, or sixteen little blades, moved by a common spring, 486 MINOR SURGERY. and so arranged as to make a corresponding number of incisions, none of them being deep enough to extend entirely through the cutaneous tissues, lest the fatty matter, projecting into them, should fill up the little orifices, thereby impeding the flow of blood. The cup is capable of holding from one to two ounces; it is bell-shaped, and is composed of glass, having a large mouth, with a stop-cock at the other end, to adapt it to a syringe for exhaust- ing the air, as in fig. 135. When such an apparatus is not at hand, the ordinary cupping-glass may be used, or any still more simple contrivance, the air being rarefied by inverting the vessel over the flame of a lamp, or by means of a little pellet of cotton, wet with alcohol, and set on fire in the glass. In a few moments the skin will rise up and form a red conical swell- ing, which is now scarified, the cup being immediately Fig. 136. replaced, and allowed to remain until the coagulum which fills its interior prevents the flow of blood, when it is care- fully removed, to be again replaced as soon as the incisions have been freed from obstruction. Should the bleeding cease before the requisite supply has been obtained, the surface may now be cross cut, and the operation be pro- ceeded with as previously. As much blood having been drawn as may be considered proper, the glasses are re- moved, and the parts are covered with a soft cloth moist- ened with oil. The number of cups to be applied varies from one to a dozen, according to the effect it is designed to produce. The most elegant and convenient cup, by far, is one recently invented in this country, consisting of the body Cupping-giass with °f the ordinary glass cup, surmounted by a cone of vul- vuicanized india-mb- canized India-rubber, as seen in fig. 136. In order to ber top. apply it, all that is necessary is to indent the top with the finger, the removal of which permits the part instantly to regain its former position, thus exhausting the air within, which it does with great force and efficiency. 5. Venesection.—Venesection is commonly regarded as so trivial, simple, and easy an operation, that it has rarely received the consideration and atten- tion to which its intrinsic importance really entitles it. Everybody, no matter whether he has any knowledge of the anatomy of the parts involved in the operation, or the slightest skill in the use of instruments, is supposed to be capable of performing it, and hence it is often done in the most bung- ling and disreputable manner, entailing much suffering, if not loss of limb and life, upon the patient, aud great discredit, if not ruin, upon the practitioner, When we consider the frequency of the operation, and the character of the men who usually perform it, our only surprise is that these disasters are not more common. During a practice of upwards of a quarter of a century, in which I have often had occasion to open different veins, I have had the good fortune never to do any harm in this way, and it would afford me great pleasure if I could make a similar statement concerning the practice of some of my professional brethren. Candor, however, compels me to assert that I have repeatedly witnessed in their hands the most serious effects from this source. In two cases I have seen the patients perish from phlebitis; in three, I have been called upon to tie the brachial artery at the bend of the arm, on account of injury sustained from the lancet; in several, I have known vast and protracted suffering to succeed the puncture of a nerve; and in three instances I have seen the arm endangered by erysipelatous inflammation, followed by immense abscesses, and great impairment in the function of the elbow-joint, wrist, and fingers. In one of the cases here adverted to, the operator, a young man, was sued for mal-practice, and, after much trouble ABSTRACTION OF BLOOD. 487 and vexation, mulcted in the sum of several hundred dollars, which he was little able to pay. I need hardly add that he never recovered from the effects of his misfortune, which pursued him during the remainder of his life. It is related of Mons. Marechal, who flourished in the reign of Louis XIV., and who was styled, by one of the poets of his day, the prince of surgeons, that he greatly suffered in his reputation, for several years, on account of a fatal accident which followed the operation of bleeding which he performed upon a foreign nobleman. These circumstances should be sufficient to put practi- tioners upon their guard, and should induce them to study this operation in all its bearings and relations, so that they may be able to perform it with credit to themselves and advantage to their patients. A vein may be opened with a spring lancet, a thumb lancet, or a bistoury, according to the whim, fancy, or habit of the operator. I have been so long accustomed to the use of the former of these instruments that I rarely em- ploy any other. My experience has taught me that the operation, when done with the spring lancet, generally answers every purpose, as it respects the size and shape of the orifice, the safety of the parts, and the facility of mani- pulation, while it is incomparably less painful than when it is performed with the thumb lancet, or bistoury. These are, I think, important desiderata, which no unprejudiced practitioner can overlook. No one who has himself been bled with these different instruments can hesitate about his future choice. I have often heard persons, who had been previously bled only with the thumb lancet, declare, after having been bled with the spring lancet, that nothing could ever induce them again to submit to the use of the former in- strument, such wras the difference in regard to the pain in the two operations. I know that the thumb lancet is generally considered as a more scientific instrument than the spring lancet; it is certainly more simple, and, perhaps, also more easily kept in order ; but these advantages do not, in my judgment, outweigh the disadvantages. Both these instruments are so well known that any description of them here would be superfluous. If a bistoury be used, one of very small size should be selected, somewhat like that used in opening abscesses, described at page 147. It should be quite narrow in the blade, slightly pear-shaped at the extremity, and not more than half an inch long in the cutting part. Such an instrument, confined iu a light handle, is more elegant than the ordinary thumb lancet, as well as more easily managed, and is, I think, decidedly more surgical and scientific; a circumstance so much insisted upon by some practitioners. Whatever instrument be employed, care should be taken that it is perfectly sharp and clean, that is, free from rust and other adventitious matter. It should always be washed and thoroughly wiped both before and after the ope- ration, for it is only by observing these precautions that the instrument can be kept in proper order, and that the surgeon can hope to avoid undue irri- tation and other mischief in the wounded structures. In bleeding at the bend of the arm I am always in the habit of selecting the largest and most superficial vein, having previously ascertained that the brachial artery is not in danger of being wounded, as it may be when it lies just behind the vessel, or close along its side. When the artery separates high up, one of its branches generally lies immediately below the skin, and might thus be easily opened by an incautious operator. As it respects the superficial nerves, it is seldom possible altogether to avoid them, whatever vein may be selected; nor is this a matter of much moment, provided they are completely divided, and not merely pricked. The veins of the bend of the arm, with the accompanying nerves, are well seen in fig. 137. In order to distend the veins, a fillet, a yard long by an inch in width, and consisting of a piece of muslin, is tied firmly round the arm, about two inches and a half above the bend, the ends being secured with a slip knot. 488 MINOR SURGERY. Care is taken not to draw it so tightly as to interrupt the circulation in the brachial artery. The patient, extending his arm at a right angle with the trunk, in a state midway between pronation and supination, grasps a common cane, a yardstick, or any other suitable object, holding Fig. 137. the limb in an easy, gentle position. The surgeon then, standing behind the limb, pierces the vein, mak- ing the opening obliquely, and of sufficient size to fur- nish a free stream. The adjoining sketch affords a better idea of the manner of holding the lancet thau Fig. 138. the most elaborate description could. The surgeon uses whichever hand may be most convenient; the vein is thoroughly steadied with the finger previously to making the incision, and care is taken that the orifices in the skin and vessel do not afterwards lose their parallelism, lest the flow of blood should thereby be seriously embarrassed, or the fluid escape exten- sively into the subcutaneous cellular tissue. Should the latter accident occur, the fillet must immediately be removed, and the requisite abstraction effected from another vein. Sometimes the blood flows sluggishly, although the open- ing may be quite capacious and unobstructed. When this is the case, the patient should be requested alternately to flex and extend his fingers, so as to cause energetic contraction of the muscles of the forearm, which often power- fully promotes the bleeding; or, instead of this, or along with it, the operator applies friction to the limb frora below upwards with his hand, although such a procedure is seldom attended with much advantage. Sometimes the flow of blood is interrupted by the protrusion of a pellet of fat into the orifice of the vein, or in consequence of the timidity of the patient, or the occurrence of partial syncope. When the spring lancet is used, the instrument is held between the thumb and the first two fingers, the heel being raised a little from the surface, while the fleam is gently pressed upon the distended vein. The opening is effected in the same oblique manner as in bleeding with the thumb lancet. The blood should always be received into a large basin held by an assistant, and special pains should be taken not to soil the patient's body or bedclothes. When the object is to make a strong and permanent impression, the blood is taken from a large orifice, the patient being, the while, in the semi-erect pos- ture. If he is very plethoric, and the object is to abstract a very large quan- tity of blood, without occasioning syncope, the recumbent posture is selected. When the requisite amount of fluid has been discharged, the fillet is untied, and the arm is nicely wiped with a napkin wet at one end; the edges of the orifice are then carefully approximated and covered with a small, thick com- press, supported by a narrow roller passed around the elbow in the form of the figure 8. The arm should then be put in a sling and kept at rest for the ABSTRACTION OF BLOOD. 489 next forty-eight hours, as premature motion is calculated to favor the deve- lopment of suppuration and erysipelas. When blood cannot be obtained from the arm, it may sometimes, in case of urgency, be drawn from a vein on the back of the hand, from the cephalic vein as it runs along the groove between the deltoid and pectoral muscles, or from the external jugular vein. In the latter case, the requisite distension is produced by pressure with the thumb, applied just above the collar bone, or by means of a thick, narrow compress, firmly secured by a roller carried round the neck and shoulder. The requisite incision is made with a bistoury, car- ried from below upwards and outwards, in a direction contrary to that "of the fibres of the platysma myoid muscle. Before removing the compression, care is taken to close the orifice of the vein, lest air should get into it, and thus occasion serious, if not fatal mischief. The accidents which are liable to attend and follow this operation are, in- filtration of blood into the subcutaneous cellular tissue, inflammation of the edges of the wound and of the surrounding parts, phlebitis, angeioleucitis, puncture of the nerves, and wound of the brachial artery. a. An extravasation of blood beneath the skin is one of the most common effects of this operation, and may be caused by various circumstances, as the smallness of the incision, the want of parallelism between the outer and inner openings, the great laxity of the areolar tissue, transfixion of the vein, and the accidental occlusion of the wound by the interposition of adipose sub- stance. The extravasation may be diffused, or circumscribed, forming in the one case an ecchymosis, in the other a thrombus. In the former variety, the blood sometimes extends along the anterior part of the limb, nearly as high up, on the one hand, as the axilla, and, on the other, as far down as the in- ferior third of the forearm ; imparting, at first, a dark, purplish hue, and afterwards, as the fluid becomes absorbed, a mottled, greenish, yellowish, or sallow appearance to the skin. A thrombus is a collection of blood imme- diately around the wound, from the volume of a marble to that of a pullet's egg, irregularly rounded at the base, and usually somewhat pointed at the top. Both these accidents are most liable to occur in thin, emaciated sub- jects, in bleeding at the basilic vein, and they should always be promptly remedied by attention to the exciting cause ; or, where this is impracticable, the bandage should immediately be removed, and the requisite quantity of blood taken from another vessel. The latter procedure is particularly indi- cated when the infiltration is dependent upon transfixion of the vein, the pre- sence of a pellet of fat, or unusual laxity of the areolar tissue. Defective parallelism may sometimes be corrected by changing the position of the limb; and a small orifice may be enlarged by the re-introduction of the instrument. Under no circumstances, whatever may be the nature of the difficulty, should the operator attempt to promote the flow of blood by the use of the probe, inasmuch as this would inevitably be followed by mischief. When the extravasation is slight, it will usually disappear spontaneously in a very few days; when considerable, recourse must be had to refrigerant and sorbefacient applications, particularly a strong solution of the hydro- chlorate of ammonia, alcohol and water, and, in the latter stages, camphorated lotions, soap liniment, and stimulating unguents. If matter form, or if the parts become angry and inflamed, leeches, blisters, and cataplasms raay be necessary, with incisions to evacuate the effused blood and other fluids. b. The edges of the little wound, made in this operation, soraetimes inflame and suppurate; or, instead of this, a small abscess, conical, circumscribed, and very painful, forms immediately around it. Occasionally, especially in feeble, sickly, and intemperate persons, the morbid action assumes an erysipe- latous type. The most common causes of these mishaps are a dull, rusty, or foul lancet, imperfect apposition of the lips of the wound, improper tightness 490 MINOR SURGERY. of the dressings, premature use of the parts, and, above all, the contact of the fingers, after the removal of the fillet, for the purpose of preventing the further"escape of blood. The latter circumstance has not received sufficient attention. The fingers of the operator, without his being aware of the fact, are often covered with perspiration and other matter, which, when brought in contact with the edges of the incision, are almost certain to irritate and inflame them. My invariable practice is never to touch the wound for any purpose, but, after the fillet is removed, to approximate its lips with a clean compress, made of old muslin, and confined by an appropriate bandage. If, despite proper precautions, inflammation and suppuration arise, the usual antiphlogistic means must at once be employed. c Phlebitis, to a slight extent, is probably of much more frequent occur- rence after this operation than is generally imagined, while the severer forms of the disease are comparatively rare. It may be induced by various circum- stances, of which the employment of a foul lancet is perhaps the most common. In one instance I knew it to be caused by probing the wound, under the supposition that it contained a piece of the fleam of a spring lancet, broken off in the operation, which was performed by a young and inexperienced practitioner. The patient, a man, about thirty-six years of age, was laboring under bilious fever, from which, but for this unfortunate event, he would probably have recovered; phlebitis, however, set in, and he lost his life in less than a week. In another instance, more recently under my observation, the vein was opened with a thumb lancet, and the disastrous effect seemed to have arisen without any evident cause, the patient, a stout negress, having labored at the time under inflammation of the wrist joint. Death ensued in less than ten days after the operation. In some instances, if, indeed, not frequently, the inflamraation takes place without any obvious cause, and that too, perhaps, when the operation has been performed in the most unexcep- tionable manner. The symptoms of this form of phlebitis do not require special notice, inas- much as they do not differ from those of phlebitis in general. The attack is commonly ushered in by pain, stiffness and swelling of the affected part, and by rigors, alternating with flushes of heat, and followed by copious perspira- tion. The inflamed vein is gradually converted into a hard, rigid cord, and the morbid action steadily pursues its course towards the heart, its progress being indicated by a reddish blush of the skin. In some instances, metastatic abscesses form in different parts of the body, particularly in the subcutaneous cellular tissue round the larger joints, if not also in the joints themselves. Meanwhile, the symptoms assume a typhoid character, the mind wanders, great soreness is felt in the muscles and articulations, the patient complains of excessive prostration, and death generally follows in from six to eight days from the commencement of the invasion. The treatment consists in the application of leeches, blisters, and iodine along the course of the vein, and the exhibition of calomel and opium, with the twofold object of bringing the system promptly under the influence of mercury, and allaying pain and promoting sleep. Abstraction of blood frora the arm is rarely indicated, and is, in general, prejudicial. Active purgation and the free use of antimony must also be avoided. If abscesses form, they must be thoroughly and promptly opened. Should recovery take place, sor- befacients will be required to promote the removal of effused fluids in and around the diseased vein, which, however, despite our treatment, usually remains impervious. d. Angeioleucitis is usually produced by the same causes as phlebitis, which it also resembles in its nature, progress, and symptoms. The morbid action, still more than in the latter disease, has a tendency to extend up the limb, the course of the affected lymphatics being indicated by reddish lines, very ABSTRACTION OF BLOOD. 491 narrow, and exquisitely tender on pressure. The malady, which is quite in- frequent, and which rarely does much harm, requires the same treatment as phlebitis, with which it is occasionally associated. e. Puncture of a nerve, whether a considerable-sized trunk, or a mere thread-like filament, raay prove to be a very serious accident. The nature of the injury is always indicated by a peculiar stinging, burning, or pricking pain, and a sense of numbness, creeping, or formication in the distal portion of the limb. When very severe, the local distress may be attended with a certain degree of shock and a tendency to syncope, which, however, geuerally pass off in a very few minutes. Very unpleasant secondary symptoms some- times succeed this accident, at a period varying from several weeks to several months. One of the most common and distressing of these is neuralgia, which is often attended with regular paroxysms, precisely as neuralgia is when it occurs from ordinary causes in other situations. The disease is then apt to be exceedingly severe and obstinate, often resisting for months, and even years, the best directed efforts at relief. In the cases which have fallen under my observation, it has usually been accompanied, especially in its earlier stages, with considerable swelling, numbness, and stiffness in the distal por- tion of the limb, together with exquisite tenderness on pressure along the course of the affected nerve. I have never known tetanus to follow this accident, but such an occurrence I should think quite possible, particularly in a person of a nervous, irritable temperament, laboring, at the time of the injury, under disorder of the digestive organs. The milder effects of this injury will usually pass off in a very short time without any remedial measures, simply by attention to rest and elevation of the limb. This failing, recourse is had to anodyne and astringent fomenta- tions, the application of iodine and even blisters, purgatives, light diet, and other antiphlogistic means. The bandage will often be of great service, especially when there is considerable swelling. If the pain is of a neuralgic character, quinine, strychnine, and arsenious acid will be indicated, and, if given persistently, and in suitable quantities, will be of immense benefit. Where the suffering is extremely violent and intractable, the best remedy is division of the affected nerve, as near as possible to the seat of the injury, by the subcutaneous method; or, where this is impracticable, by exposing the nerve first, and then severing it. Occasionally it becomes necessary to re- move a small portion of the affected nerve, especially if, as now and then happens, it is expanded into a little nodule, or is exquisitely tender and sensitive on pressure. /. A wound of the brachial artery is always a very serious accident, and is probably much more frequent than is generally supposed. The injury may be very slight, amounting to a mere puncture, or it may be several lines, half an inch, or even an inch in extent, as in a case under my observation, some years ago. The direction of the wound may be oblique, longitudinal, or transverse, according to the manner in which the instrument is held at the time of the operation. Occasionally the artery, instead of being pierced or stabbed, as it ordinarily is, is transfixed; a circumstance which always seri- ously complicates the case. The immediate effect of this accident, which is always denoted by the im- petuous, saltatory nature of the stream, and by its scarlet complexion, is to send the blood into the connecting cellular tissue, forming a soft, dark-colored, and circumscribed tumor, or a diffused swelling, which may involve the greater portion of the anterior surface of the limb from the middle of the forearm to within a short distance of the axilla. Such an occurrence is always formidable in its character, alarming to the patient, embarrassing to the sur- geon, and liable to be followed by the worst consequences. The treatment of this accident is by systematic compression, when the 492 MINOR SURGERY. Fig. 139. opening is small, and by ligation of each extremity of the artery, when it is large. 6. Arteriotomy.—This operation is occasion- ally necessary in urgent affections of the brain and eye, and is usually performed upon the an- terior branch of the temporal artery, a vessel which possesses the twofold advantage of being very superficial, and at the same time resting upon a resisting bone. Feeling for the artery, in front of the temple, the surgeon applies firm pressure upon it with the finger, so as to steady it properly, while he makes the requisite inci- sion with a small bistoury, carried obliquely across the vessel, care being taken to cut the parts in such a manner as to admit of a full and rapid stream. A sufficient amount of blood having flowed, the artery is completely divided, in order that its extremities may retract, and thus prevent the formation of an aneurism. A small thick compress is then placed upon the wound, and firmly secured by a bandage, carried round the head in the manner represented in fig. 139. Compress applied to the temporal artery, after arteriotomy. SEC. V.—TRANSFUSION OF BLOOD. Transfusion of blood from the veins of one person to those of another is imperatively demanded when a patient is rapidly sinking from hemorrhage, whether the result of disease, accident, or operation. It has hitherto been more particularly employed in profuse and exhausting flooding, and there are about twenty cases upon record where it was thus instrumental in preserving life. In such an event it is the last resource of the obstetrician, and no one should hesitate to perform it, even although the woman should literally be in the act of dying, or when, to borrow the language of an eminent writer, "the vital spirit is fluttering with tremulous delay upon the lip." Instead of blood, saline fluid is sometimes transfused, as in attacks of Asiatic cholera, attended with excessive prostration, consequent upon the copious rice-watery discharges from the bowels effectually draining the vessels of their serous contents. The operation in question requires great care and skill for its successful execution. The chief danger to be guarded against is the entrance of air into the vein, the smallest quantity of which might prove destructive. As ordinarily performed, it is necessary to have at hand, besides a lancet, a tumbler and a glass syringe, the latter being in complete working order. The person from whom the blood is taken must be in good health, and free from all con- stitutional taint. The arm being tied up, and the vein opened, the blood is allowed to fall into the tumbler as it stands in a basin of water, at a tem- perature of about 100°, lest the fluid should coagulate, and thus become unfit for use. As soon as about two ounces have been drawn, it is sucked up into the syringe, the nozzle of which is then inserted into the patient's vein, the median basilic, for example, previously exposed by an incision at least an inch in length, and raised upon a probe. In this manner one portion after an- other is cautiously thrown in until from twelve to sixteen ounces have been transfused, a quantity which it will seldom be judicious to exceed. Should the pulse flag during the operation, or convulsive tremors arise, the proceed- ing must immediately be suspended, as it is an evidence that injury instead of benefit is accruing. TRANSFUSION OF BLOOD—VACCINATION. 493 A great number of contrivances have been devised for imparting to this operation a more scientific character than when it is performed with the ordi- nary syringe. The method, however, here described will generally be fouud to answer any purpose, combining, as it does, simplicity with convenience and safety. When greater nicety is aimed at, the apparatus represented in fig. 140, and constructed, at my suggestion, by Mr. Gemrig, may be used. It consists, as Fig. 140. Author's transfusing apparatus. will be perceived, of a small cupping glass and syringe, with a gum-elastic tube, about eighteen inches long, having a stop-cock at its distal extremity, which is surmounted with a nozzle cut off obliquely, like the barrel of a pen. The patient's vein having been exposed by an incision and freely opened, the nozzle is inserted into it and securely held by an assistant. A vein is then punctured in a healthy person's arm, but the blood is restrained from flowing by the pressure of the finger applied some distance below, until the cup has been placed over the orifice and exhausted of air by means of the syringe. As soon as this has been done, the stop-cock is turned, so as to permit the fluid to pass readily from one vessel into the other. SECT. VI.—VACCINATION, The surgery of vaccination is very simple. It may be performed either with lymph, removed between the sixth and ninth day, or, what answers nearly equally well, with the dried scab rubbed upon a plate of glass, with tepid water, until it is of a thin consistence, and of a very pale milky hue. The matter is taken up with the point of a sharp, narrow lancet, a tenotomy knife, or a common needle, and inserted into the skin on the outer surface of the arm, just below the deltoid muscle, or on the outer and upper part of the leg at a suitable distance from the knee, at two spots, each about the diameter of a three cent piece, and sufficiently apart to prevent them from running together during the height of the resulting inflammation. The impregnation may be effected by a number of little punctures, by three or four superficial incisions, or, simply, by a slight abrasion of the epidermis. Whatever method be adopted, no blood should be drawn, as it might wash away the vaccine matter. When the operation is performed with lymph taken up ou bits of ivory, a procedure which some practitioners prefer to any other, the points should be held for a few seconds in the steam of hot water, and then rubbed upon the raw surface. The progress of a successful vaccination is as follows :—The wound, on the third day after the operation, is found to be slightly inflamed and elevated; and, on the fifth day, a characteristic vesicle appears, of a beautiful pearl-colored 494 MINOR SURGERY. aspect, circular or oval in shape, and occupied by a drop of thin, limpid fluid. On the eighth day the vesicle is in its greatest perfection ; it is now some- what of a yellowish hue, distinctly cellulated in structure, very prominent, slightly umbilicated at the centre, and surrounded by a circular areola, the skin around being inflamed, tense, and painful. Occasionally considerable swelling of the glands of the axilla exists. The constitution is thoroughly implicated, and, as a consequence, the patient is feverish and restless. On the eleventh day, the areola begins to fade, and the vesicle, which usually spontaneously bursts, gradually dries up into a hard, brownish, circular scab, which, dropping off from the eighteenth to the twenty-first day, leaves behind it a small, rounded, pitted and indelible cicatrice, attesting the success of the operation. Vaccination may be performed as early as the sixth week after birth, and at all periods of life subsequently. If the child is sickly, the general health should previously be amended, particularly so if there be any eruptive disease. Some persons evince the most remarkable insusceptibility to the influence of the vaccine poison. I have seen a number of cases in which the operation was performed upwards of twenty times before it finally succeeded. Healthy children afford the best lymph, and the matter of primary vaccina- tions is more energetic than that of secondary vaccinations. The bad effects of the operation are, 1st, too much local action, the inflam- mation sometimes assuming a real erysipelatous character; 2dly, severe inflammation of the axillary glands; 3dly, ulceration, or even gangrene, at the seat of the vesicle, leaving a sore which is occasionally very tedious in healing; 4thly, a lichenous or roseolar eruption, attended with distressing itching, and often considerable swelling; and 5thly, an appearance of vesicles upon the general surface, resembling those of varicella, or even those of genuine cowpox. It is proper to add that the regular development of vac- cinia is sometimes retarded by the pre-occupation of the system by other affections, as measles and scarlatina. The effects of vaccination are soraetimes completely lost, in the proportion, probably, of about forty persons in one thousand. It is for this reason that the operation should occasionally be repeated. SECT. VII.—COUNTER-IRRITATION. Counter-irritation may, as stated elsewhere, be established in various ways, as by rubefacients, vesicants, and dry cupping ; but when the object is to make a deep and protracted impression, the means usually selected are the permanent blister, the seton, and issue. Sometimes the moxa and acupnnc- turation are employed. 1. Rubefacients.—& rubefacient effect, or temporary irritation of the skin, may readily be produced by a great variety of articles, as ammouiated lini- ments or unguents, spirits of turpentine, hot water, mustard, and the hot iron. The latter, in the form of the objective cautery, as the French term it, con- sists in passing a piece of iron, heated perfectly white, rapidly over the sur- face at a distance of from three to five inches. The skin becomes almost instantly red, and if the application be continued for a few minutes vesication will follow. A very useful and speedy rubefacient action raay also be produced by means of Dr. Corrigan's button cautery, fig. 141, heated in the flame of a brass spirit lamp until the forefinger, resting upon the shank of the instrument near the disk, begins to feel uncomfortably hot, the period usually required not ex- ceeding a quarter of a minute. As soon as it is ready, it is applied as quickly as possible, the skin being tipped successively, at intervals of half an COUNTER-IRRITATION. 495 Fig. 141. inch, over the whole of the affected part, which soon assumes a bright red appearance, and becomes the seat of a glowing sensation. The disk of the instrument is half an inch in diameter by three lines in thickness, with a flat surface, and a thick iron wire shank, two inches in length, and inserted in a small wooden handle. 2. Dry Cupping.—Dry cupping is occasionally employed, especially in chronic affections, in which it is often of great value. The air being exhausted, as in the more common operation, the cup is allowed to remain on the part for a period varying frora thirty to forty-five minutes. At the end of this time it will generally be found that there is not only a marked afflux of blood, but likewise more or less vesi- cation of the skin, objects which the practitioner should always endeavor to attain whenever he advises such an ope- ration ; for, unless it be performed efficiently, it might as well not be performed at all. Dry cupping is particularly serviceable in chronic disease of the brain and spinal cord, the thoracic and abdominal viscera, and the larger joints. The number of cups em- ployed, and the repetition of the operation, must of course be regulated by the exigencies of the particular cases. 3. Permanent Blisters.—A permanent blister is made by letting the fly remain on the skin an unusual length of time, and then divesting the part of epidermis. It is capa- ble of furnishing a free discharge of pus, which may often be maintained for a long time, either by the occasional re-application of the fly, or by means of some irritating ointment, as the savin or mezereon, or, what I pre- fer, an ointment composed of an ounce of lard and three to eight drops of nitric acid. Whatever article be used, the surface should be constantly pro- tected with an emollient poultice or the warm water-dressing, otherwise the sore will become excessively irritable, and cease to furnish the desired dis- charge. Whenever the secretion begins to slacken, a little of any of the unguents here mentioned may be applied to the sore to renew the morbid action. I have occasionally used the dilute fly ointment for this purpose, but having several times produced strangury with it, I have latterly abandoned it. 4. Seton.—A seton is a subcutaneous wound, holding a foreign body. It may be made with a bistoury, and a piece of gum-elastic tape, or, in the ab- sence of this, a narrow strip of muslin, conveyed beneath the skin by means of an eyed probe or the seton needle, represented in fig. 142. The integu- Corrigan's button cautery. Fig. 142. ments being pinched up, the instrument is pushed on through the cellular tissue, care being taken not to interfere with any muscular fibres, tendon, nerve, or vessel. The ends of the seton are tied long, and held out of the 496 MINOR SURGERY. way by a strip of adhesive plaster. The mode of introducing a seton with the knife and probe is shown in fig. 143. Fig. 143. An emollient cataplasm is the most suitable dressing, both immediately after the operation and subsequently, during the sojourn of the foreign body. At the end of the second day, the tape is drawn gently across the wound, a fresh portion taking its place, and this process is afterwards repeated as often as cleanliness and other circumstances may render it necessary. If the dis- charge becomes deficient, recourse is had to some stimulating ointment; if offensive, to the chlorides. When the tape becomes soiled and unfit for use, it is replaced by a new one. Sometimes fungous granulations spring up at the orifices of the subcutaneous wound, causing much pain and inconvenience. The best remedy is excision, followed by the nitrate of silver. The insertion of a seton is usually attended with little bleeding ; but I recollect the case of an elderly gentleman, a patient of a late eminent practitioner, who nearly lost his life from this cause, the operation having been performed upon the nape of the neck. The blood seemed to have proceeded from a small artery among the cervical muscles, the instrument having penetrated too deeply. A seton is, on the whole, a filthy, painful, and imperfect form of counter- irritation, which it might, perhaps, be well to exclude altogether from prac- tice, as its place may always be easily supplied by the issue. 5. Issue.—An issue is an artificial ulcer, intended to furnish a discharge of pus. It is adapted to the same class of cases as the seton, but is more cleanly, less painful, and more convenient. Moreover, such a sore affords a good surface for the local application of morphia and other remedies, which may often be advantageously used, in this way, for relieving pain, as well as for other purposes. Issues may be made in various ways, as with the knife, the Vienna paste, and the actual cautery. The first of these methods is not sufficiently efficient to justify its general employment; it is better adapted to the scalp than to any other region of the body, and may be advantageously used in diseases of the pericranium, and of the brain and its meninges. An incision being made through the skin and cellular tissue, from half an inch to an inch in length, its cavity is filled with some foreign body, as a pea, grain of corn, small peb- ble, or piece of orris root, which soon produces a pyogenic action, that may afterwards be increased, if necessary, by the use of some stimulating ointment, in the same manner as in the case of the seton. The substance is confined with a strip of adhesive plaster and a bandage, and is occasionally replaced by a fresh one, cleanliness being maintained in the usual way. A better plan is to make the issue with the Vienna paste, composed of equal parts of quicklime and caustic potassa, thoroughly triturated together, and preserved in a closely corked vial until required for use. The requisite quantity is then put upon a piece of glass, or upon the bottom of a saucer, and converted into a thick paste with alcohol. A layer about two lines in COUNTER-IRRITATION. 497 thickness, and of the desired diameter, is put on the skin, and allowed to remain for eight, ten, or fifteen minutes, according as we wish to make a slight or deep impression. The surface, which will be found to be of a pale drab color, is washed with vinegar and water, to neutralize the alkali, and covered with an emollient cataplasm, to promote the detachment of the slough, which usually happens in frora five to eight days. Sorae pain attends the operation, but this is soon over, and bears no comparison with the hor- rible distress produced by the application of caustic potassa alone ; besides, the Vienna paste does not diffuse itself over the adjacent parts, and thus unnecessarily destroy the skin. The extent of the issue is regulated by the extent of the layer; one of the diameter of a twenty-five cent piece affording, when the sloughing is completed, a sore from three to five times that size. The best permanent dressing is a poultice ; the best promoter of discharge, a stimulating ointment, or the occasional use, for a few hours, of a small blister. The most eligible issue of all, however, is that made with the actual cautery; it affords not only an abundant and protracted discharge, far beyond what follows the more ordinary issue, but, what is often a matter of no little con- sequence, it makes an impression both upon the part and system, which no other mode of counter-irritation is capable of producing. On these accounts, this kind of issue should have a decided preference over every other in all protracted and obstinate cases of disease where the employment of revulsives is indicated, as in caries of the hip-joint, Pott's disease of the spine, and similar affections, in which its powers, as a topical remedy, are unequalled. The actual cautery, when used for this purpose, is of course attended with pain, and for this reason it will generally be well to administer some anaes- thetic, although the suffering is much less than is usually imagined. For- merly, before the discovery of this class of agents, I was constantly in the habit of making this kind of issue, and often had occasion to notice the little pain it produced, even in very young children and nervous persons. The manner of proceeding is to heat the cautery perfectly white in a chafing-dish of charcoal, and then to hold it, with some degree of firmness, upon the proper spot, until the skin is converted into a dark eschar, care being taken not to penetrate beyond the subcutaneous cellular substance. A cloth, wrung out of cold water, is immediately laid upon the part, and frequently renewed, for ten or twelve hours, when it is replaced by a poultice or the warm water-dressing. The slough usually drops off in from five to ten days, leaving a sore, which, while it is easily kept clean, furnishes a free discharge, and may be maintained open, with but little care, for an almost indefinite period. A cautery the size of a half eagle will make an issue, after the separation of the eschar, of the dia- meter of a silver dollar. The instrument should be fully half an inch thick, otherwise it will not retain its heat sufficiently long. Fig. 144. 6. Moxa.—The moxa is a soft combustible substance held upon ^^ the skin, and suffered to burn down slowly, so as to produce a tem- porary irritant effect. It may be prepared frora various articles, as agaric, hemp, cotton, rotten wood, the pith of the common sunflower, and the down of the artemisia chinensis ; but the one which I usually prefer is soft patent lint, soaked in a strong solu- tion of nitrate of potassa. When thoroughly dried, this is rolled up into tolerably firm cylindrical cones, an inch and a half long by one inch in diameter. In applying them they should be ignited at the top, and held upon the part intended to be cauterized with a pair of dressing-forceps, a long hair-pin, or a porte-moxa, fig. 144; care being taken to protect the surrounding surface with a piece of wet linen perforated at its centre. When it is desired ||i to hasten the combustion a blowpipe raay be employed, but in § general this is unnecessary. Whatever substance be used, the Porte-moxa. vol. I.—32 498 MINOR SURGERY. heat can be so graduated as to produce any amount of irritation, from the slightest rubefaction to a superficial eschar. When the latter effect is desired, the moxa should remain on until it is wholly consumed ; otherwise it may be removed as soon as the pain becomes somewhat severe, or, instead of placing the burning material in contact with the skin, it may be held at a little dis- tance from it. The eschar is of a yellowish, gray, or dark color, and usually drops off in six or eight days. The pain produced by the operation may be promptly relieved by the application of liquid ammonia, cold water, or pounded ice. The moxa seems to act on the same principle as the objective cauterization, and the ammoniated counter-irritants, already spoken of, and is a valuable agent in many chronic cases, when it is intended to produce a sudden impres- sion upon the nerves of the affected part: it should always be applied as near as possible to the seat of the malady, and the effect should be sustained for weeks, or even months, by the repeated application of the agent. The diseases in which it seems to be most efficacious are amaurosis, neuralgia, nervous deafness, partial paralysis, coxalgia, and spinal irritation. 7. Acupuncturation.—Counter-irritation raay be effected also by acupunc- turation. This consists in the insertion of very slender, well polished, sharp- pointed steel needles, figs. 145, 146, 147, from two to four inches in length, furnished with a metallic head, or a head of sealing wax. Figs. 145, 146, 147. To prevent them from breaking, they should be rather soft and flexible. They are introduced into the affected part, which is previously stretched, by a gentle rotatory motion, aided by slight pressure, and are suffered to remain from one to six hours, according to the effect they produce, or the object they are intended to fulfil. In some instances a period often minutes is sufficient; in others, they may be kept in for one or two days. They may be carried to a depth of several inches, but care must be taken not to transfix any important viscera, vessels or nerves, though this has been often done with- out ceremony, and without any injurious results. The number of needles to be used varies from one to a dozen, according to the extent of the affected part and the sensibility of the patient. The operation rarely causes much pain, and is scarcely ever followed by any un- pleasant symptoms. In most cases a slight blush, which subsides in a few hours, is observed around each punc- ture. In withdrawing the needles, which is sometimes Acupuncture needles. effected with difficulty, owing to their having become oxidized, a movement of rotation should be given to them, at the same time that pressure is made upon the adjacent surface with the thumb and forefinger. Acupuncturation has been employed in a great variety of affections, as neuralgia, rheumatism, gout, sciatica, paralysis, cephalalgia, and epilepsy; recently it has been recommended in the treatment of aneurism, hydrocele, varicocele, and anasarca. Its advantages have been much overrated, and the practice, which has been borrowed from the Chinese and Japanese, has fallen into disrepute. 8. Electro-puncturation—Needles are sometimes introduced into the tissues for the purpose of transmitting to the affected part a current of electricity or galvanism. The operation, denominated, in the one case, electro-punctura- tion, and, in the other, galvano-puncturation, is performed in the same manner and with the same instruments as in the ordinary process, except that the latter have a small ring at the top for receiving the conducting wires of the ESCHAROTICS. 499 poles of the battery. Only two needles are used at first, but the number is gradually increased as the patient becomes able to endure the action of the current. When it is intended to produce a shock, a Leyden jar may be employed, but for maintaining a steady effect a small horizontal galvanic pile is the most appropriate apparatus. This mode of counter-irritation is almost entirely restricted to the treatment of chronic affections, attended with deep-seated and inveterate pains, as gout, rheumatism, neuralgia, and sciatica. 9. Galvano-cauterization.—A very ingenious and useful instrument for applying heat by means of galvanism was invented in 1850, by Mr. Marshall, of London, and is depicted in the annexed sketch, fig. 148. It is called the Fig. 148. Marshall's galvanic cautery. galvanic cautery, and is particularly serviceable as a stimulant in the treat- ment of old rebellious sinuses and fistules. The apparatus consists of a pair of forceps with projecting iron handles, and long, narrow blades, ter- minating at an acute curve, and arranged so as to hold a platinum wire. The diseased passages being well cleaned and dried, the wire is intro- duced cold, and then heated by the galvanic current red hot or otherwise, according to the wished-for effect. When it is designed to destroy the tissues, as in the operation for anal fistule, the wire must be drawn to and fro with a sawing movement to facilitate their division. The battery should have from six to nine cells, filled with a mixture of one part of sulphuric acid to ten of water. The rods are isolated by an intermediate strip of ivory. SECT. VIII.—ESCHAROTICS. There is a class of operations which consist in destroying the affected tissues with caustics, consisting of the hot iron and of various escharotic substances. These procedures, however, once so much in vogue among sur- geons, have become almost obsolete, although they are perhaps still too much practised in certain quarters, especially in France. At the present day they are restricted, in great measure, to affections of the neck and orifice of the uterus, and of the mammary gland, hemorrhoidal tumors, varicose veins of the extremities, specific ulcers, as chancres and malignant pustules, and the bites of snakes and rabid animals. When the hot iron is used for the purposes in question, it should be heated to a white heat, and retained in contact with the diseased parts sufficiently long to effect their destruction, their surface being previously thoroughly dried. In performing the operation, the surrounding structures should be carefully protected from injury, and in order to obtain the desired result it is frequently necessary to have two, three, or even four cauteries in readiness, so that, as one becomes cold, another may take its place. The eschar gene- rally drops off at a period varying from four to ten days. The best appa- ratus for heating the iron is a little furnace, charged with charcoal, the combustion being promoted with a pair of bellows. The annexed sketch, 500 MINOR SURGERY. Different forms of cauteries. fig. 149, conveys a good idea of the principal forms of iron in use at the present day. The conical-shaped instrument is well adapted for cauterizing narrow and deep-seated ca- Fig. 149. vities; the cylindrical one may also be used for this and similar purposes. The hatchet-shaped iron is well adapted for making a linear eschar, and the large round one for establishing a deep, permanent issue. Caustic potassa, the Vi- enna paste, chloride of zinc, bichloride of mercury, arse- nic, ammonia, and certain acids, as the nitric, hydro- chloric, and sulphuric, are powerful caustics, producing their peculiar effects more or less promptly, according to the length of time during which they are retained, and the strength in which they are used. As their application is generally attended with severe pain, it is proper that the patient be previously put under the full influence of an anaesthetic. Moreover, as so'me of the articles here specified have a tendency to diffuse themselves over the surrounding healthy surface, care should be taken to prevent this by placing a wall of simple cerate or collodion around the part to be cauterized. Caustic potassa is a powerful escharotic, but as it is extremely painful and very tardy in its action, it is now seldom employed. The Vienna paste, com- posed, as already stated, of equal parts of quicklime and caustic potassa, although also productive of severe suffering, does its work much more rapidly —generally in frora ten to fifteen minutes—and is therefore usually preferred. The chloride of zinc is usually mixed with farina, forming thus what is called the phagedenic paste of Canquoin, of which there are three strengths, known as number one, two, and three; the first consisting of one drachm of the metal to double that quantity of farina, the proportions of the second being as one to three, and of the third as one to four, the latter being of course much the weaker. The preparations act with great efficiency, but are productive of excessive pain. Bichloride of mercury, in the proportion of three parts to one of powdered opium, with the addition of a sufficient quantity of sulphuric acid to convert it into a paste of the consistence of tar, makes a powerful escharotic; but, owing to the excessive pain which it causes, and the risk of its inducing salivation, it is now rarely used. A similar objection is applicable to the caustic mixture, formed of equal parts of white arsenic and sulphur, formerly so much in vogue. A decisive escharotic effect may speedily be produced by the use of equal parts of ammonia and lard. A very destructive escharotic, admirably adapted for the removal of epi- thelial growths, may be prepared with fifteen grains of white arsenic, seventy- five of cinnabar, and thirty-five of burnt sponge, made into a thick paste with a few drops of water. This constitutes what is called Manec's paste, and is applied in the form of a thin layer to the surface of the affected part, previously well cleansed in order to promote its effects. The great objection to this remedy is the excessive pain it produces and its liability to cause vomiting, depending, doubtless, upon the absorption of some of the arsenic. Generally also its application is followed by deep discoloration and severe swelling. For these various reasons it should be employed with great caution. DRESSING. 501 The stronger acids, as the nitric, hydrochloric, and sulphuric, produce an instantaneous escharotic effect when applied to a denuded surface; hence tbey are often used for cauterizing inoculated wounds and destroying the edges of ulcers. Of all the acid preparations, however, the best and most reliable is the acid nitrate of mercury, of which frequent mention will be made hereafter. The formula which I employ is that usually known in this country as Bennett's. It is prepared by dissolving, with the aid of heat, 100 parts of mercury in 200 parts of nitric acid, and evaporating the solution to 225 parts. The application produces a white eschar, which is detached, piecemeal, in from the third to the tenth day. Whatever article be employed, the utmost care must be taken to prevent its diffusion over the surrounding healthy tissues, otherwise the effects may be most unfortunate. Chromic acid also deserves favorable mention ; its application, which causes but little pain, is particularly valuable in cases of warty excrescences and of recent chancres. SECT. IX.—DRESSING. The art of dressing, humble though it be, must not be despised by the surgeon; since, in many situations, both in private and hospital practice, it must necessarily form a part of his daily routine duties. There is, indeed, great reason to believe that this matter is too much neglected by prac- titioners, and that it is too frequently delegated to ignorant, careless, and unscrupulous nurses, and to the so-called dressers, who are often not a whit more enlightened, or more conscientious. The most important appliances used in dressing are forceps, scissors, and syringes, sponges, lint, pledgets, tents, adhesive plaster, bandages, cataplasms, and unguents. The dressing forceps, fig. 150, differ from the ordinary dissecting forceps in having ring handles, and cross blades, terminating each in a rounded, spoon-shaped extremity, supplied internally with serrated edges, to adapt it the better for seizing and holding such sub- «-. stances as may require ^ removal. They are light and slender, and from four and a half to five inches in length. When Dressing forceps. not at hand, the ordinary dissecting forceps may advantageously be used as a substitute. The best scissors, for dressing purposes, are the ordinary straight pocket case instrument, which may be used either for cutting adhesive strips and bandages, or, if necessary, for paring the edges of ulcers, or for removing redundant granulations. Scissors curved on the edge or flat are sometimes very convenient. The sponges used in dressing should be very soft and clean, and the same articles should never be employed upon different persons, especially when they are affected with open ulcers, as the discharges might thus be made the vehicle of propagating disease, as, for instance, in chancre, gonorrhoea, erysi- pelas, malignant pustule, and hospital gangrene. In all such cases they should be destroyed as soon as the dressing is completed, or thoroughly washed in water, and then soaked in a solution of chlorinated soda. As a general rule, no sore should be wiped ; but the water should be pressed upon it from a sponge held some distance from its surface, which 502 MINOR SURGERY. will generally effectually wash away any secretions that may be in contact with it. Adherent lymph, charpie, or unguent may be picked away with the forceps. The surface around, however, may be gently sponged, if soiled ; otherwise it may be wiped with a soft dry cloth. The water may be tepid, cool, or cold, according to circumstances, and arrangements should always be made to receive it into a suitable basin, placed beneath the affected parts. The old dressings should be put into a separate vessel, and promptly removed from the patient's apartment. Fetor is allayed by the free use of the chlorides, sprinkled both upon the body and bedclothes, as well as about the room. Lint is a soft, fleecy substance, consisting either of prepared cotton, or scraped linen, or, what is preferable, the ravellings of linen, as those of an old napkin, sheet, or pillow-case, each thread being picked out separately. The article generally employed in this country is patent lint, which is kept in rolls in the shops, and makes an excellent dressing, although not equal to linen ravellings, or the charpie of the French surgeons; one surface is glazed, the other smooth. The objection to it is that it is not sufficiently porous to admit of the free escape of the secretions of the parts to which it is applied, and, consequently, also, that it keeps them too warm. A very excellent, cheap, and convenient article for dressing wounds and ulcers may be prepared by folding a piece of old muslin until it forms a body from a quarter of an inch to half an inch iu thickness, and then punching numerous holes into it, giving it thus a sievelike appearance. It is very light and airy, and while it absorbs moisture, it also admits of ready drainage. It forms a good substitute for patent lint, and may be used in cases where the other is not applicable. It may be called the perforated muslin. Dr. Levis, who has thoroughly tested its efficacy in the surgical wards of the Philadel- phia Hospital, speaks of it in high terms of commendation. Spongio-piline is now much employed as a dressing. It is a soft, porous fabric, looking very much like a piece of sponge ; it is made in sheets from half an inch to an inch in thickness, and being covered with a glazing of India rubber, is well calculated to retain water and prevent evaporation, at the same time that its weight is not so great as to cause oppression. Sometimes the lint is arranged in the form of a compress, pledget, ball, roll, tampon, tent, or pellet, thus adapting it the more conveniently to par- ticular purposes. Thus, a compress consisting of a strip of folded muslin or linen may be employed for pressing together the sides of a deep abscess, or a number of pieces may be piled upon each other, so as to form a graduated compress, which is often advantageously used for compressing a bleeding vessel, as the brachial artery where it runs along the inner edge of the flexor muscle. The pledget is a strip of patent lint, usually spread with cerate, for protecting the surface of a granulating ulcer; balls, rolls, and tampons are simply masses of soft substance, as charpie, lint, or cotton, arranged so as to adapt them to particular cavities, as the uterus, the nose, or a deep wound, either with a view of arresting hemorrhage, or for absorbing pus and other fluids. The lent consists of a piece of linen, muslin, or patent lint, twisted on its axis, slender, and usually several inches in length, its object being to prevent the reunion of the sides of the incisions made in puncturing abscesses, and in laying open sinuses, as in the operation for anal fistule. Tents are sometimes prepared with wax, in which case they are generally of a conical shape, and employed as dilators. Finally, the pellet is a ball, roll, or mass, of soft tissue, inclosed in a strip of soft cloth, firmly tied; it may be used for the same purposes as the tampon, of which, in fact, it is merely a variety. When intended for the nose, uterus, or rectum, a stout thread or piece of twine may be tied to it in order to facilitate its removal. Within the last two years a good deal has been written respecting the use BANDAGING. 503 of drainage-tubes, a means of treatment suggested by Mons. Chassaignac, for favoring the discharge of matter from abscesses and sinuses, especially when large and deep-seated. These tubes, which are from one to two lines in diameter, and perforated by numerous oval foramina, are made of India rubber, and are, consequently, highly elastic and flexible ; their shape is cylindrical, and their length varies, on an average, from three to six inches, according to the exigencies of each particular case. The great objection to these tubes is their liability to become clogged, and their tendency to cause undue irritation in the parts into which they are introduced. For these reasons it is questionable whether they will ever come into general use. Poultices form an important element in a great variety of dressings, but as these have already received sufficient attention, it would be out of place to say anything further respecting them here. I shall only add that, when they are selected for this purpose, they should be used with special reference to the comfort of the parts, care being taken that they do not oppress by their weight, or irritate by their long retention and the stimulating character of their ingredients. The mode of employing water-dressings has also been sufficiently considered in another part of the work to render any further remarks regarding them here unnecessary. Unguents, ointments, or salves of various kinds are employed as dressings in ulcers and other open surfaces; much has been said and written upon the subject, especially of late years, and attempts have been made to discard these substances altogether from practice. Still, notwithstanding all this, unguents hold a prominent place in the affection of many practitioners, as well as in that of the common people, and it would be difficult, I am sure, always to dispense with their use. I imagine that prejudice has had much to do in pro- scribing this class of remedies; when such a man as Listen raises his voice against any point of practice, it is usually very hard for the lesser lights of surgery to resist its influence, and the cry therefore at once becomes general, whether there be any just reason for it or not. It cannot be denied that ran- cid ointments act as irritants; this, however, is not the fault of the article, but simply of him who uses it. Prepared and employed for the occasion, experience teaches me that the application of unguents is often attended with the most salutary effects, admirably protecting granulating surfaces, and rapidly promoting cicatrization. As a general rule, I have found that all the officinal medicated ointments are much too strong, requiring to be diluted from one-half to seven-eighths. Whatever dressings be employed, they should be carefully confined by means of a bandage, evenly and lightly applied, so as to afford the requisite support, and no more. In most situations, this may be readily done with the common roller; but in certain regions, as in the groin, perineum, anus, and head, particular contrivances may be necessary, as the spica, the T bandage, and the four-tailed bandage. For retaining dressings upon the testicle and mammary gland the suspensory bandage will be found most con- venient. SECT. X__BANDAGING. Bandages are substances employed for retaining dressings in cases of wounds, ulcers, abscesses, fractures, dislocations, and other affections, as well as with a view to their direct curative effects, which, as will be shown by and by, are probably much greater than they are generally supposed to be. They vary much in shape and size, and also in regard to the materials of which they are composed, and the object which they are designed to fulfil. A vast number of bandages have been described in certain modern works, especially 504 MINOR SURGERY. those on minor surgery, much ingenuity, and, according to my belief, much time, having been wasted, in trying to adapt them to every part and region of the body, and to every circumstance, however insignificant, to which such contrivances can possibly be applied. By running into these extremes, the art of bandaging has been greatly complicated, and much injury inflicted upon a department of surgery, which, if properly administered, is capable of conferring immense benefit in almost every form of accident and disease affecting the external parts of the body. The ancient surgeons racked their brains to invent names for designating bandages, and the claims of not a few of them to distinction were based almost exclusively upon such absurd and puerile pursuits. If a man was so fortunate as to devise an apparatus for expelling peccant humors, for retaining a cataplasm upon the scalp, or for supporting a diseased breast, the height of his ambition was generally amply gratified. It is to be feared that these employments have had too many imitators in modern times. The more simple a bandage is the more likely will it be, if judiciously used, to answer the purpose for which it is intended; all complicated con- trivances of this kind are objectionable on account of the difficulty of applying them, the ease with which they become deranged, and the trouble and vexa- tion of changing them, the attempts to do so being frequently attended with serious inconvenience and pain to the patient, and perhaps great detriment to the parts affected. In general, the single-headed roller is all that can be required in almost any case ; occasionally the strip-bandage, commonly known as the bandage of Scultetus, represented in fig. 151, may advantageously be employed, especially in compound fractures and dislocations. The many- tailed bandage ought, on the contrary, Fig. 151. to be discarded from practice, as in- convenient and useless. It consists, fas the name indicates, of a number of transverse slips, of the same width but unequal length, stitched to a longitu- dinal portion, and wras formerly much employed in cases of fracture of the ] Bandages are composed of various materials; generally of muslin, bleach- _ ed or unbleached, of calico, or of linen, the only objection to the latter being _______^ its expense. Occasionally they are made of flannel, especially when it is desirable to protect the parts from cold, as in oedema of the extremities, and in the swelling attendant upon a gouty or rheumatic state of a joint, in persons of an unhealthy, broken con- stitution, who are commonly so ex- tremely susceptible of atmospheric vi- cissitudes. In general, muslin will be found to answer every purpose, being both cheap and easily procured; it should be soft yet firm, smooth, strong, and not too yielding, divested of selv- Bandage of Scultetus. age and seara, and washed before it is applied. Calico is not a good mate- rial for bandages, as it is usually too light and flimsy; I never employ it. In some cases, particularly in affections of the veins of the leg requiring BANDAGING. 505 steady and equable compression, gum-elastic cloth may advantageously be used. The length and width of a bandage are of course subject to much diversity, depending upon the shape and size of the part to which it is intended to be applied. Hence, while in one case it need hardly be half an inch in width, and not more than a foot in length, in another it may require a width of two, three, or even six inches, as in injuries of the chest, and a length of many yards. Muslin is usually torn into the requisite sized strip, whereas linen, being much stronger, is best shaped with the scissors. The ravellings being picked away, each piece is rolled into a firm cylinder, and put away for use, so that it may be ready for any emergency that raay arise. The winding raay be effected either by hand, the cloth being held upon the front of the thigh, or by appropriate machinery, such as is to be found in the office of every practitioner, and of which illustrations may be seen in most of the works on minor surgery. However effected, it should be done with great care, since no one can possibly apply a bandage well that has been wound in a loose and slovenly manner. When intended to be used upon an extremity, the rule is always to begin at the distal portion of the limb, and to proceed from thence upwards some distance beyond the seat of the disease or injury. The end of the bandage being slightly unfolded is held firmly upon the part with one hand, while the Fig. 152. Fig. 153. Mode of applying the roller by circular and Appearance of the bandage after it has been reversed turns. applied. cylinder is carried round the limb with the other, and thus the application is continued by circular and reversed turns, as they are named, until the object has been completed, the fingers being pressed upon each reverse to flatten and equalize it, as in fig. 152. If the bandage were put on spirally, it could not 506 MINOR SURGERY. Fig. 154. maintain itself upon the limb for any length of time; but what is worse, the compression would be so unequal as to cause severe suffering, and perhaps even mortification. The application, then, must be made circularly, and care taken that each turn of the roller be reversed, so that the inner surface shall be the outer, and the upper edge the lower, the pressure being uniform throughout, or not greater at one point than at another, as in fig. 153. The evil effects of unequal compression by the bandage are well illustrated in fig. 154, copied from John Bell's works; it also shows how important it is always to begin the application of the bandage at the distal extremity of a limb, aud not above the wrist or ankle, as hap- pened in the case so graphically described by the celebrated Scotch surgeon. In all cases of severe injury or disease, with a ten- dency to swelling and to the extension of the morbid action, due allowance must be made for the inflammatory effusions that will necessarily occur. Hence, too much care cannot be taken both in applying the bandage and in watching its effects after- wards. For want of this precaution many a limb has been destroyed, and the reputa- tion of not a few practitioners irretrievably ruined. Some surgeons are fond of employing the double-headed roller ; but I have never had occasion to resort to it, and am satisfied that there are few cases, if any, in which it may not be advantageously replaced by the single- headed, whose application has just been de- scribed. The double-headed bandage is con- sidered as being particularly serviceable in the treatment of wounds penetrating deep among the muscles, where it is of paramount importance to effect accurate apposition of the deep as well as of the superficial sides of the solution of continuity; but even here no indication is presented that cannot be readily fulfilled with the compress and single- headed roller. In my own practice I have certainly never been at a loss in this respect. The bandage of Scultetus, represented in fig. 151, consists of a number of strips, gene- rally from ten to twenty, or of pieces of an ordinary roller, of equal or unequal length and breadth, according to the intentions of the surgeon. They are arranged in such a manner as that, when applied, each succeed- ing one shall overlap from one-third to one- half of the preceding one, the compression being made in the same gentle, uniform manner as in the employment of the ordinary roller. This form of bandage is peculiarly useful in the treatment of compound fractures and dislocations, in connection with which it will frequently be mentioned. Bandages are sometimes applied wet; but in doing this much vigilance must be exercised, lest shrinking too much as they dry, they produce a Gangrene from strangulation of an in- jured limb by absurd bandaging BANDAGING. 507 greater degree of compression than may be compatible with the comfort and safety of the parts. What is called the starched bandage, an excellent modern device, will receive particular attention in connection with the treat- ment of fractures of the extremities, to which it is more especially adapted. When it becomes dry, it forms a stiff, firm, immovable case, well calculated to maintain the ends of the broken bone in contact with each other. Ami- don, gum-shellac, plaster of Paris, and other kindred articles may be used for the same purpose, the bandage being wet with them, and immediately applied to the affected limb. The bandage, viewed as a therapeutic agent, has been much neglected by modern practitioners. No one who has properly used it, or who is capable of properly applying it, can, for a moment, doubt its great utility ; my ex- perience with it for the last twenty-five years amply attests this fact; still, it is necessary that we should temper our enthusiasm, and that we should not allow ourselves to be betrayed into a species of hobbyism, calculated to mislead the judgment, and to bring surgery into discredit. Employed indis- criminately, it cannot fail, in many cases, to cause serious mischief, and to be followed by chagrin and disappointment. When the hand of a master is not present to direct and guide our practice, the result may frequently be most disastrous both to the patient and the surgeon. The evil effects of bandages, in their aggregate capacity, are hardly less serious than those of mercury, the lancet, and other potent remedies; if they are, it is only be- cause this agent is less frequently employed in practice. Numerous instances have come to my knowledge, where limbs, and even life, have been the forfeit of its injudicious use. It is not difficult to perceive how the bandage acts in producing its salu- tary effects. In fractures and dislocations, as well as in large wounds, it powerfully controls muscular contraction, and at the same time prevents tumefaction, by giving tone and support to the capillary and other vessels. Its influence as a sorbefacient is evinced in the rapid abatement of the swell- ing which so often follows compression by the bandage in erysipelas, oedema, and various kinds of injuries ; or, more strikingly still, in orchitis, when, after the subsidence of the more active disease, the testicle is strapped with adhe- sive plaster, which is but another form of bandage. Here in a short time, ordinarily in less than twenty-four hours, the swelling usually so far disap- pears as to allow the organ to slip out of its artificial case, or, at all events, to such an extent as to require renewal of the dressing. The general effect of the bandage would thus seem to be somewhat similar to that of mercury, controlling capillary action, and promoting the absorption of effused fluids: but it has the additional advantage, and no trifling one it is, that it supports the muscles and prevents spasm, as is so remarkably evinced in fractures and in the stump after amputation. Of the extent to which bandaging may be carried, a good idea may be formed from the frequent allusion that will be made to it in different parts of this work ; it will suffice here to observe that it is applicable, as a general rule, to the treatment of all classes of wounds, from the most simple to the most severe, to fractures and dislocations, ulcers, abscesses, erysipelas, whit- low, orchitis, chronic inflammation of the superficial veins, and to nearly all affections of the limbs in which there is an effusion of serum, or serum and plastic matter. 508 OPERATIVE SURGERY. CHAPTER XIV. OPERATIVE SURGERY. Operative surgery has too often been regarded as an opprobrium of the healing art. This opinion, as foolish as it is unfounded, is not peculiar to the public, who, in matters of this kind, are generally but poor judges, but has frequently been advanced even by medical men. That this department of surgery is often abused cannot be doubted ; but does it thence follow that it is a disgrace to the profession and an injury to the community ? Such a view would be absurd, because it would be utterly irreconcilable with the dictates of common sense and the results of daily experience. As long as the human body is liable to accidents, and as long as nature is incapable of arresting, by her own efforts, the various morbid processes which she herself institutes, so long will practitioners be compelled to invoke the aid, and, I may add, the blessings, of operative surgery. Is it a disgrace to amputate a leg for a mortification of the foot, to extirpate a testicle that has been destroyed by cystic disease, to divide the stricture in strangulation of the bowel, to extract a stone from the bladder, to depress a cataract, or to tre- phine the skull in a punctured fracture ? Surely, no one will doubt that in these, and a hundred other instances, our object can be attained only by an operation. Medicine, under such circumstances, however judiciously admin- istered, is not only utterly futile, but is always ready to avail itself of the aid of surgery. Its empire is temporarily suspended, and it only resumes its legitimate functions after the use of the knife. It is true beyond doubt, and it is fortunate that it is so, that, in the hands of judicious and enlight- ened practitioners, a resort to instruments is much less frequent now than it was even ten years ago; many limbs which would formerly have been sub- jected to amputation are now easily saved, and many diseases which were once regarded as utterly hopeless now readily yield under the influence of our therapeutic efforts. Operative surgery is progressive ; it has done a vast deal, but a vast deal remains yet to be accomplished. If it has emerged out of chaos into order, and out of darkness into light; if it has laid aside its farrago of instruments, and its fondness for blood ; if, in a word, it has assumed the fair and stately proportions of a science, it owes it to itself to perfect itself in the greatest possible degree, as well as in the shortest possible time, in order that it may be still more entitled to the respect and admiration of the profession, and the gratitude of the public. It is only a disgrace when it is practised for base and selfish ends; not when it interposes its resources for the purpose of removing disease and averting death. Qualifications of a Surgeon.—The performance of operations presupposes the possession of certain qualities on the part of the surgeon. It is not every man that can become an operator, even presuming that he has the requisite kuowledge of anatomy and of the use of instruments. Courage, which is so indispensable, is possessed by comparatively few ; the sight of blood, and the idea of inflicting pain were so disagreeable to Ilaller, that, although he taught surgery with great success for seventeen years, he never, it seems, QUALIFICATIONS OF A SURGEON. 509 during all that time, performed a solitary operation upon the living subject, Courage, like poetry, has often been said to be a gift of nature, and nothing is, perhaps, more true; but it is equally certain that a timid man may, by attention to his education, and by constant practice, become, in the end, a good operator. Habit does a vast deal for us in such cases, for it literally becomes a second nature. I recollect a man, who in his youth nearly fainted at the sight of blood as it flowed from a vein of the arm into the basin, which it devolved upon him to hold during the operation of venesection, and yet who, by a course of self-training and a complete knowledge of anatomy, has made himself a thorough master of the knife. Celsus, long ago, happily defined the qualities which constitute a good operator. He should possess, says the illustrious Roman, a firm and steady hand, a keen eye, and the most unflinching courage, which can disregard alike the sight of blood and the cries of the patient. But the above are not the only qualities, important though they be, which should be possessed by an operator. If he is not honest in his purposes, or scrupulously determined, in every case, to act only with an eye single to the benefit of his patient, and the glory of his profession, he is not worthy of the name which he bears, or tit for the discharge of the solemn duties which he assumes. In a word, such an operator is not to be trusted, for he will be certain, whenever opportunity offers, to employ the knife rather for the tem- porary eclat which may follow its use, than for the good of the individual whom he unnecessarily tortures. He will not hesitate to amputate a limb, although the patient should die the moment he is removed from the table, or to tie the carotid arteries for a malignant disease of the eye, although he knows full well that such a procedure never has, in any instance, been of the slightest benefit. Such men, of whom there are, even yet, unfortunately, too many in our profession, deserve the name of knivesman and knaves rather than of surgeons and honest men. No operation should ever be undertaken without due deliberation, and without a careful consideration of the various consequences involved in the result. Everything that is done should be done with reference exclusively to the patient; self should not have the slightest weight in the matter. The question, in every case, should be, is an operation necessary to save life, or to place the individual in a condition calculated to promote and insure his recovery ? If this can be answered affirmatively, the operation should by all means be proceeded with ; but if it be ascertained, clearly and satisfactorily, that it presents no such prospect, both humanity and common sense dictate the propriety of declining it. It is a sad and humiliating spectacle to see a surgeon cut off a limb, or remove a cancerous tumor, merely for the sake of having it said that he performed an operation. I am daily shocked by the reports of cases of the extirpation of malignant growths in the hospital as well as in the private practice of this and other countries. The question may well be asked, when will such silly and un- meaning, or, to use the proper expression, criminal procedures cease to dis- grace our profession and to shock our sensibilities? Every surgeon who wishes to make himself a skilful operator shouid have a most thorough knowledge of anatomy. His acquaintance with the healthy structures and their relations with each other should be so clear and distinct that he should be able to see them as it were in a mirror, or with his eyes shut. He should carefully study their color and consistence, that, seeing and feeling them, he may readily distinguish them from each other, and not be obliged to ask his assistants whether this is an artery, that a nerve, or this a tendon, a muscle, or a ligament. Nor should he limit himself merely to the study of healthy and relative anatomy. He should also have an intimate and comprehensive knowledge of morbid anatomy, or of the changes which are impressed upon the organs and tissues by disease and accident, and also 510 OPERATIVE SURGERY. of the various growths, formations, and deposits. The information thus de- rived will be of the greatest aid in facilitating the different steps of the operation, and enabling the surgeon to determine what to remove and what to spare. No man can become an accomplished operator unless he practises con- stantly on the dead subject. Dexterity, grace, and elegance are to be acquired only by long and patient exercise. From what I have seen of our students, they are lamentably deficient in the use of the knife. Many of them, indeed, engage in the active duties of their profession without ever having performed a solitary operation on the cadaver, and hence it is not surprising that failure and disgrace should so often attend their early trials on the living subject. There should be, as I publicly declared more than twenty years ago, in every medical school a demonstrator of the operations of surgery, whose duty it should be to perform, in the presence of his pupils, all the operations on the dead body which it is ever necessary to perform on the living. Such exercises could not be too frequently repeated by the teacher, or too often performed by the student. In all operations involving unusual anatomical complexity, a good plan is to make a thorough dissec- tion of the parts immediately beforehand. Langenbeck and Lisfranc always adopted this method, and I have often profited by it in my own practice. Preparation of the Patient.—No operation, unless it be of the most trivial nature, should ever be attempted without due preparation of the patient's system. The only exception to this rule is in case of emergency, where, in order to save life, we are obliged to act on the instant, without any precaution of this kind, and sometimes even without the necessary assistants. The cha- racter and amount of the preliminary treatment must, of course, vary in different cases and under different circumstances, and do not, therefore, admit of precise specification. It may be stated, in general terms, that, if the patient be unusually plethoric and in the vigor of life, he should be bled at the arm, until he begins plainly to feel the effects of the loss, when the flow should be arrested. In opposite states of the system, however, such a pro- cedure will not only be unnecessary, but might even be prejudicial. In all instances it is well to take into the account the probable loss of blood that will take place during the operation. If this is likely to be considerable, all preliminary abstraction must be carefully refrained from, even in healthy, robust subjects ; for there can be no doubt whatever that a copious, or even a considerable, loss of blood before, during, or immediately after an operation, has a marked tendency, in many cases, to retard recovery, and to dispose to the occurrence of erysipelas, pyemia, tetanus, and other ill effects. Indeed, so thoroughly am I convinced of the truth of this remark, that I feel as if it could not be urged too frequently, or too forcibly, upon the mind of the practitioner. It was formerly thought that a certain amount of hemorrhage, under such circumstances, would not only do no harm, but that it would positively be beneficial, by rendering the system less liable to inflammation. /Modern experience, however, has shown that such an opinion is utterly untenable. It would be difficult to conceive of any case, about to be subjected to the knife, in which purgatives are not indicated, or in wdiich, if they are not posi- tively indicated, their exhibition would not be eminently beneficial. These remedies not only clear out the bowels, but they often exert a most salutary influence in modifying and restoring the secretions of the liver and mucous follicles, and it is just as much of a rule with me to prescribe them before my operations as it is to attend to the patient's diet. The best articles for this purpose are blue mass and colocynth, or calomel and rhubarb, either alone, or in union with a small quantity of ipecacuanha or tartar emetic. The PREPARATION OF THE PATIENT. 511 latter substances are especially valuable when there is much disorder of the secretions, with headache and loss of appetite. Occasionally nothing answers better than, or hardly as well as, a dose of castor oil, Epsom salts, or citrate of magnesia. Independently of their direct cathartic effect, purgatives are often extremely useful in clearing out the bowels, where, as for example in lithotomy and in anal fistule, it is desirable to prevent any action upon them for several days after the operation. A proper regulation of the diet is generally regarded, and very justly so, as of paramount importance. The extent to which this should be carried must, of course, depend upon the circumstances of each particular case ; but, as a general rule, it should not, on the one hand, be too rigid or protracted, and, on the other, not too abundant. Much of the success of an operation is often directly traceable to the attention which is bestowed upon this sub- ject. In most instances it will be advisable to enjoin entire abstinence from meat and the coarser kinds of vegetables, coffee and strong tea, hot biscuit, pastry, condiments, and, in short, all articles of an indigestible and heating nature. The quantity of food taken in the twenty-four hours should also be less than ordinary, for nearly, if not quite, as much harm may result from an undue amount of mild and unstimulant food as from the moderate use of the more solid and substantial articles. Instead of dieting and purging the patient, it may be necessary to feed and stimulate him before it is safe to use the knife. He may be exhausted, deficient in nerve-power, or pale and anemic, requiring a rich, concentrated animal or animo-vegetable diet, milk, brandy, ale or porter, and, perhaps, quinine and iron, especially the tincture of the chloride. Finally, attention should be paid to the state of the body and mind. For some days or even weeks, the most perfect quietude should be observed, especially if the operation is at all likely to be of a serious character. If, for example, the object is to extract a foreign substance from the knee-joint, or to perform an operation for the radical cure of varicose enlargement of the veins of the leg, it is hardly possible to use too much caution in this respect. In such cases the patient should not only refrain from exercise, but he should remain recumbent for several weeks, with the limb in an elevated position. In general, however, the restraint need not be carried to such an extent, a few- days' confinement to the house being quite sufficient for the purpose. The patient's mind should always be in as tranquil a state as possible. AH business cares should be laid aside, and no outward troubles of any kind should be permitted to obtrude themselves during this probationary period. He should indulge in no unpleasant forebodings concerning the result of the operation, or, if this be inevitable, the surgeon should exert himself to the utmost to assuage and mitigate them by proper explanations. In a word, it is his duty, in all cases, to encourage the timid and console the desponding by every means in his power. A surgeon who neglects his duty in this re- spect is unfit to be intrusted with the lives of his fellow-beings. Many of our patients are from abroad, away from home and friends, and therefore pecu- v liarly in need of sympathy. I have never put off an operation on account of the particular season of the year. When it is recollected that the gravest accidents, requiring ampu- tation, occur every hour of the day, and every day of the year, such a pre- caution would seem to be entirely at variance with common sense, if not wholly useless. I should certainly, however, not advise the undertaking of any serious operation in extremely hot weather, if it were possible to post- pone it without detriment to my patient. The same objection, however, does not'lie against very cold weather, inasmuch as a good fire and a properly regulated temperature of the apartment can generally be obtained, without much trouble, even in midwinter and in the most rigorous climate. 512 OPERATIVE SURGERY. No operation, even of the most trivial nature, should be performed during the prevalence of an epidemic. This remark is particularly applicable to erysipelas, which, under such circumstances, is almost sure to ingraft itself upon the wound, much to the detriment both of the part and system. Dur- ing an epidemic of this kind in Kentucky in 1845, '46, and '47, the slightest abrasion of the skin, a leech-bite, and the application of a blister, were often followed by an obstinate, and sometimes even a fatal, attack of the disease; and the consequence was that I was compelled, for many months, to decline the use of the knife nearly altogether. Age is, as a general rule, no barrier to an operation. Even infants at the breast have occasionally undergone the operation of lithotomy, and in certain congenital affections, as occlusion of the anus and urethra, the knife is obliged to be used almost immediately after birth. I am, however, as will be stated in its proper place, no advocate for very early interference in harelip ; and I should say that it was best, as a general rule, to put off all severe operations in infants as long as possible, for it cannot be denied that they bear the shock and loss of blood, consequent upon such undertakings, much worse than per- sons of riper years and more developed constitutions. Very old people often bear operations remarkably well, and recover from their effects with surpris- ing facility. Pregnancy should always be considered as a bar to the use of the knife, except in those cases in which it is imperatively demanded to save life. Even the extraction of a tooth is occasionally followed by abor- tion or miscarriage, from the perturbating influence which it exerts upon the system. The habits of our patients should not be disregarded in considering the question as to the propriety or impropriety of operative interference, for there can be no doubt that they frequently materially influence the result. Intemperance of every description, especially if long continued, always modi- fies the constitution, and renders it less able, as a general rule, to bear the shock and subsequent effects of the operation than in ordinary cases. In habitual drunkards mania a potu, erysipelas, and unhealthy suppuration are of frequent occurrence after the use of the knife. Huge feeders, or persona who are fond of the pleasures of the table, and who take little exercise in the open air, are scarcely less exempt from these affections. Inordinate sexual indulgence, the habitual loss of blood, and debility from previous suffering, often place the life of the patient in danger after a severe operation. Fat persons, and individuals of a doughy, inelastic constitution, do not bear the knife so well as the fleshy and more robust. The same is true, and in a still greater degree, of strumous people. Nervous, hysterical females are bad subjects for some operations. Hospital patients, especially in the larger cities, do not, as a general rule, possess the same tolerance of the knife as private patients. Should females be subjected to operations during the menstrual period, or just before its occurrence ? Of the impropriety of such a course there can, as a general rule, be no doubt, yet there may be exceptions even here. Cer- tainly no sensible surgeon would extract a cataract at such a time, or remove a diseased mamma, or, in short, perform any serious operation, if it could possibly be postponed. But, on the other hand, daily observation teaches us that women who are badly hurt during the menstrual period often make most excellent recoveries. Hence, I should deem it perfectly proper to perform at least any of the minor operations at this time, and, in fact, almost any other where delay might prove prejudicial. There are certain diseases, even some which are not of a malignant cha- racter, in which surgical interference is wholly inadmissible, either for the time being, or altogether. I allude to those cases in which the malady demanding operation is complicated with other affections. Thus, in anal PREPARATION OF THE PATIENT — ASSISTANTS. 513 fistule, associated with tubercular phthisis, no surgeon, who has any consi- deration for his patient, or any respect for the art and science which he pro- fesses, would think of using the knife. The anal disease, in such a case, may be regarded as nature's issue, the drying up of which would only be surely followed by an aggravation of the pulmonary symptoms. In stone of the bladder no one operates when there is serious organic disease of the kidneys, or even of the bladder itself. Amputation of a limb is never performed, ex- cept in case of accident, when there is an aneurism of the heart; nor is the femoral artery ever tied for popliteal aneurism when a similar affection exists in the arch of the aorta. In all malignant maladies, except the epithelial forms, a resort to the knife is of questionable propriety, even in their earlier stages, and before there is the slightest evidence of the carcinomatous ca- chexia. Indiscriminate operations cannot be too much condemned, as they are in- jurious alike to the patient, the reputation of the surgeon, and the true interests of science. Like a prudent general, the surgeon should know when to retreat as well as when to advance. It is difficult to conceive of anything more laudable than a bold undertaking in a case which must prove fatal with- out speedy relief. At the same time, it would certainly indicate a degree of weakness, if not of absolute wickedness, to attempt an operation when there is not the slightest prospect of benefit. There is a class of operations to which the French writers have applied the term complaisance, that is, operations of expediency, not of necessity. An individual, for example, has an infirmity, as a distorted foot, or a con- tracted finger, which is a source rather of annoyance than of suffering or even positive inconvenience; his pride is piqued, and, as a consequence, his mind is incessantly disturbed by it, so much so, perhaps, as to be wholly disquali- fied for business and social enjoyment. Such persons often importune the surgeon's aid, and it therefore becomes a nice question how he should govern himself in regard to them. Shall he advise an operation, and run the risk of killing his patient, or shall he refrain, and persuade him to bear his cross, for such it actually is? There can, I think, in general, be very little difficulty in arriving at a proper conclusion in such a state of things. For myself, I can see no difference between the physical suffering that is induced by a diseased bone and the mental distress that results from a deformed foot; as far as their effect upon the comfort and happiness of the individual is con- cerned they are precisely on the same level, and hence, if it be right and law- ful to amputate in the one case, why should it not be in the other ? If a young man has a varicocele, even of moderate size, and it completely de- stroys his happiness and usefulness, not by its physical but by its mental effects, is it not our solemn duty to attempt relief by an operation, although the attempt should jeopard his life ? I must confess, I should not hesitate as to the line of conduct to be pursued under the circumstances; at the same time, however, I should not omit to warn my patient of the risk he would be likely to run, and if, after a thorough explanation of the whole matter, he should still persist in his desire to be operated on, I should use every pos- sible precaution, by a course of diet, purgatives, and rest, to put his system in the best possible condition for sustaining the shock of the approaching ordeal. Operations involving the same principle, though not the same risk, are of daily occurrence, and few surgeons hesitate to perform them ; I allude to the division of tendons in club-foot and strabismus, the extraction of the crystalline lens in cataract of one eye, when the other eye is sound, and other analogous affections. Assistants.—There are but few operations which a surgeon can perform alone; in general, he is obliged to have assistants, and the number of these vol. i.—33 514 OPERATIVE SURGERY. must necessarily vary in different cases and under different circumstances. Sometimes only one is required; at other times two, three, four, or even half a dozen will hardly suffice. The more simple an operation the less aid will commonly be necessary. In lithotomy an assistant holds the staff, two others support each a leg, one administers chloroform, another takes charge of the patient's hands, and a sixth presents the surgeon his instruments. In de- pressing a cataract, the operator usually requires only one assistant, to sup- port the head and upper eyelid. Operations on children, especially when we are not permitted to employ anaesthetics, are often peculiarly embarrass- ing, and demand an unusual amount of aid for their successful execution. The beauty, elegance, and rapidity, nay, even the success of an operation, are often marred by the awkwardness of the assistants. To act well their part, they should be thoroughly acquainted with the different steps of the operation which is about to be performed, as well as with the nature and relations of the structures involved in it, so as to be able to anticipate every thought and wish of the principal. It is not necessary that they should be compelled, like so many Thespians, to rehearse the part which they are ex- pected to play in the approaching task ; but we should see that they are properly instructed in their business, and that they all perfectly understand their duty, which should always be carefully explained and assigned before- hand. Nothing can be more awkward for a surgeon than to stop in the midst of an operation to ask for a knife, sponge, or ligature; once begun, everything should proceed with the utmost regularity, and without the slightest interruption from any cause. Good, well-trained assistants are, unfortunately, not always to be obtained; the older members of the profes- sion are too much occupied, or too jealous of each other, to afford their ser- vices, and the younger are too often ignorant of the duties required of them. Duty of the Surgeon.—When the surgeon has a perfect control of his time, as he almost always has, except in cases of emergency, he generally selects a particular hour for performing the operation. The best period of the day, at least in this country, is from 11 to 2 o'clock, as he will then have a good light, and also be in a better trim for the discharge of his duty. An opera- tion, especially an important one, should never be performed late in the after- noon, or in cloudy weather; for, should hemorrhage arise, he might be sadly puzzled in his attempts to arrest it, on account of the want of a good light, which is so indispensable on such occasions. At the hour specified for the operation everything should be in its place; the assistants should attend with military punctuality ; the table should be properly prepared; the chloroform, ammonia, and brandy, instruments, liga- tures, sponges, water, and napkins, should all be at the precise spot where they are required ; in short, nothing should be wanting, but everything be at hand, and arranged in the most perfect order. I have heard of a surgeon, engaged in an amputation, make his flaps, and ask for his saw, which had been left in an adjoining room ! On one occasion a lithotomist performed the lateral section, and was about to introduce the forceps to extract the stone, when, lo and behold, the instrument had not been put on the tray! Such blunders might create a smile, if they did not sometimes involve serious consequences. It need hardly be added that all these preparations should be made in an adjoining room, away from the patient; it is enough for him to know that he is about to suffer, without seeing the instruments of his tor- ture deliberately spread out, one after another, before his eyes. Of the precise time, as to the day and hour, of the operation, the patient should usually be kept in ignorance, as the information, if made, could hardly fail to exert a perturbating, and, consequently, a prejudicial influence upon the mind, and, through it, upon the general system. It is only in the milder cases that this intelligence should be communicated. There is, however POSITION OF PATIENT AND SURGEON—OPERATION. 515 much difference in this respect in different individuals, for, while some would shrink frora the disclosure, and be, perhaps, seriously affected by it, others will not only be indifferent to, but absolutely court it. Position of the Patient and Surgeon.—The position of the patient, the surgeon, and the assistants must vary, of course, in different cases, and can be discussed here only in a general manner. When chloroform is to be given, absolute recumbency is required, to guard not only against delay, but also against the occurrence of serious mishaps. But, apart frora this considera- tion, the horizontal posture should always be preferred whenever the opera- tion is likely to be protracted, or attended with much shock and loss of blood. In other cases, again, as in lithotomy, the operation cannot be performed in any other position than in the recumbent. In amputating the thigh and leg, as well, indeed, as the arm and forearm, the patient always lies down, not only on account of apprehended weakness, but because it is always easier, when he is thus placed, to hold the limb and control hemorrhage. In lace- rating a cataract, the patient generally sits in a chair, with his head supported upon the breast of an assistant; in operating on harelip, the child usually sits upon an assistant's lap, the head being firmly held by another assistant, standing behind or by the side of the first. In lithotomy, the patient lies on his back with the breech reaching over the edge of the table, two assistants support the legs, another holds the staff, a fourth takes charge of the sponges, and a fifth administers chloroform, while the surgeon sits on a low stool in front of the perineum, or, as I usually prefer, rests on one of his knees. Now that anaesthetic agents are so much in vogue, it is seldom that we are obliged to tie our patients, or to roll them up in sheets or aprons, as was the custom prior to the discovery of these most useful remedies. Operation.—Everything being thus prepared—the assistants being at their posts, the instruments arranged upon a tray in the order in which they are likely to be required, the parts divested of hair and dressings, and the patient fully under the influence of chloroform—the operation is proceeded with, slowly, deliberately, and in the most orderly, quiet, and dignified man- ner. All display, as such, is studiously avoided ; ever remembering, in the language of Desault, that the simplicity of an operation is the measure of its perfection. No talking or whispering should be permitted on the part of the assistants, and as to laughter, nothing could be in worse taste, or more de- serving of rebuke. Every important operation should be looked upon as a solemn undertaking, which may be followed in an instant by the death of a human being, whose life, on such an occasion, is often literally suspended by a thread, which the most trivial accident may serve to snap asunder. The time occupied in performing an operation is a matter of some moment, but not as much, perhaps, as is commonly supposed. When a patient is un- conscious, whether from cerebral oppression, or from the use of an anaesthetic agent, it is of very little consequence, other things being equal, whether the operation lasts five minutes or ten minutes, provided it is well executed, which it certainly cannot always be when we aim at great speed. Le Cat, it is said, lithotomized half a dozen patients in nearly twice as many minutes, and the result was that he lost nearly every one. Prior to the application of chloroform to the relief of suffering, rapidity was most commendable, inas- much as it served to prevent shock and pain, though I firmly believe that it was often secured at the expense of much subsequent mischief, if not imme- diate detriment. The maxim of the schools has always been cito, tuto et jucunde; but, as it respects the first of these injunctions, it may be added, in the language of Cato, sat cito si sat bene. Accidents during Operation.—The next topics to be considered are the accidents which are liable to take place during the operation, and the best 516 operative surgery. methods of avoiding or meeting them. These are, first, hemorrhage, and secondly shock. The amount of blood lost during an operation may be very small when measured by ounces, but very large in relation to its effects upon the system. Much will depend, in every case, upon the state of the constitution, and the temperament, habits, and health of the patient. A hemorrhage which may affect one individual very slightly, if, indeed, at all, may affect another most seriously and even fatally. A good deal, again, will depend upon mere idio- syncrasy, and upon the presence or absence of epidemic disease, which, as has already been intimated, generally impresses itself, to a greater or less ex- tent, upon every individual in the community in which such disease prevails. Anything like a copious loss of blood is, as before stated, a great evil, and should, therefore, always, if possible, be prevented. I cannot agree with those who think that the loss of twelve, sixteen, or twenty ounces will be likely to be beneficial, even when there is unusual vigor of constitution. If there be any undue vascular repletion, it can always be relieved, if the neces- sity for it arises, after the operation is over. In all cases, therefore, I deem it to be our duty to guard against hemorrhage as much as possible. It is not necessary, nor even proper, to tie every vessel as fast as it is divided. A well-trained assistant will generally obviate this necessity by compressing the bleeding orifice the moment the knife has swept beyond it, and by the proper exercise of this dexterity a large tumor may often be re- moved before a single ligature is applied. Should the bleeding, however, not be controllable by this means, measures must be adopted to arrest it with- out delay by ligating the principal vessels from which it proceeds. It is seldom, at the present day, that a patient sustains anything like a serious shock from an operation, even if it be comparatively severe and pro- tracted. The use of anaesthetics, if it do not always effectually prevent, gene- rally restricts it within the limits of tolerance, and thus saves the surgeon a vast amount of trouble and anxiety. It is not, however, to be forgotten that the very means which are employed to prevent pain and shock may themselves induce severe, if not fatal, prostration. Hence, as will be seen by and by, too much caution cannot be used in their administration ; the effects of the remedy should be most carefully watched throughout, so that.any symptom denotive of danger may be instantly recognized and counteracted. By keep- ing the patient perfectly recumbent, and providing for the free admission of air into the lungs, all mischief may, in general, be happily avoided. The syncope, caused by the loss of blood, is met by a depressed position of the head, by means of the fan, by dashing cold water upon the face and chest, by holding smelling-bottles near, not to the nose, and, in severe and alarming cases, by sinapisms to the extremities, spine, and prsecordial region, aided, if necessary, by the use of stimulating injections, as brandy, turpentine, am- monia, or mustard. Dressings and After-treatment.—The operation being over, the next thing to be done is to adjust the dressings; these should always be as light as pos- sible, and applied in such a manner as to insure the greatest chance for union by the first intention. The question has been much agitated, of late years, whether the dressings should be applied at once, the moment the knife has accomplished its object, or whether the parts should be permitted to remain free for several hours, to afford them an opportunity of contracting and be- coming glazed with plastic matter. Much might be said in favor of both methods. The proper rule of practice, I think, is to steer a middle course, adopting neither plan exclusively. In large wounds, as those, for example, left in amputation of the thigh, leg, or arm, and in the extirpation of large tumors, the best plan always is to keep the parts open for three, four, or five hours, or until all oozing has ceased, and the raw surface has become in- DRESSINGS AND AFTER-TREATMENT. 517 crusted with plastic matter, a light and porous napkin, properly folded and frequently wrung out of cold water, being kept constantly applied to pro mote these occurrences. If, under such circumstances, approximation be effected immediately after the operation, the surgeon will often be compelled, a short time afterwards, even when he has taken the greatest possible care to secure the vessels, to remove his dressings, in order to arrest the flow of blood; a procedure which is generally not less painful and alarming to the patient than disagreeable and vexatious to the attendant. If, on the other hand, the wound be small, the best plan, I conceive, is to bring the edges together at once, as this saves both time and anxiety. The dressing being applied, the patient is carried into his bed, previously prepared for his accommodation, and placed in such a position as will best promote his comfort and the reunion of the divided parts. Feathers and heavy quilts are to be carefully avoided ; and, in general, it will be well, espe- cially if there is a probability of there being much discharge, whether of blood, secretion, or excretion, to protect the bedding with a piece of thin, soft oil-cloth, spread beneath a folded, movable sheet. The affected parts are placed in an elevated and relaxed position, and maintained, throughout, in a cool, comfortable state. The diet must be light and unirritant, the drink cooling and palatable, and the temperature of the apartment from sixty-five to seventy-five degrees of Fahrenheit. All unnecessary conversation should be avoided; and no persons, except the nurse and the immediate friends of the patient, should be permitted to enter the room during the first twenty- four hours after the operation, or, in cases of great danger and severity, not until a much longer time. When the operation is at all severe, my invariable rule is to administer a full dose of morphia immediately after it is over, or even sometimes an hour or two before it is commenced. The object is not only to allay pain, which is always a great desideratum, but to induce sleep and tranquillity of the system; in other words, to put the part, body and mind, all in a state of absolute repose for at least the first twenty-four hours after the use of the knife. By a full dose of morphia, I mean not less than one grain ; a smaller quantity than this would only serve to fret and worry the patient, instead of composing him. In cases of unusual severity, I do not hesitate to give twice that quantity, never forgetting that excessive suffering always establishes a certain amount of tolerance to the use of anodynes. Too much attention cannot be bestowed upon the patient's diet. If the operation has been at all severe, or attended with unusual shock and loss of blood, he must be fed, not starved, in order to enable the system to reinstate itself as promptly as possible into its former condition, by the manufacture of blood and nervous fluid, both, perhaps, frightfully expended during the previous contest, and now in danger of being still further exhausted by the traumatic fever and the tumultuous action of the heart. The vessels must be replenished; the brain and spinal cord supported. The most suitable articles for this purpose are milk and stale bread, with the free use of brandy, followed, in a day or two, by animal broths, beef essence, rich soups, and the lighter kinds of meats. Sub-acid fruits will also generally prove both grate- ful and nourishing. The drinks should consist of ice water, either pure or acidulated, as may be most agreeable to the patient. A cup of tea is often exceedingly soothing and refreshing soon after a severe operation. Starva- tion after severe shock and loss of blood is often followed by the worst con- sequences, from the tendency which the system has to run into erysipelas, pyemia, and hectic fever, to say nothing of its incompatibility with the ad- hesive process. But patients must not be fed indiscriminately after operations; when the individual is young and robust, perfectly temperate in his habits, and, above 518 OPERATIVE SURGERY. all, when he has not suffered severely from shock or loss of blood, his diet should be restricted and be of the blandest character for a number of days, or, in fact, until the wound left by the knife is in great measure healed. Im- proper indulgence, under such circumstances, cannot fail to light up a fire which hardly anything afterwards may be able to extinguish. Attention to the temperature of the patient's apartment is often a matter of great moment; in general, it will be best to regulate it by the thermo- meter, especially in operations on the respiratory organs, and after the extir- pation of ovarian tumors. Everything like a direct draught must be carefully avoided, and in wet weather it will be a good plan to shut the windows. Some of the above precepts may seem trivial; but I am sure that they are of the greatest importance, and that the want of their observance is often followed by the worst consequences. It is a much easier matter to talk a patient to death, or to retard his recovery, after he has undergone a severe operation, or sustained a violent injury, than most people imagine. Should symptomatic fever arise, or should the parts exhibit evidence of over-action, prompt recourse must be had to the usual antiphlogistic remedies, employed in a decided yet cautious manner, lest they produce harm instead of good. The after-treatment should always, if possible, be superintended by the surgeon himself; his duty is not over with the operation; it ceases only with the cure or death of his patient. " The practice," remarks an eminent authority, " of performing a serious operation, and leaving the after-treatment to others, has, in my knowledge, repeatedly proved disastrous. The medical treatment, a duty not less responsible than the operative, belongs to the sur- geon ; and, indeed, to be employed merely as a handicraftsman, conveys an imputation at which the dignity of a scientific mind revolts." Sources of Danger after Operations.—The great sources of danger, after a severe operation, are, first, excessive depression of the system from shock and loss of blood; secondly, traumatic fever; thirdly, undue inflamraation of the parts ; fourthly, secondary hemorrhage; fifthly, erysipelas; sixthly, pyemia; seventhly, tetanus; and, lastly, constitutional irritation. a. The prostration, consequent upon an operation, is usually denoted by great pallor of the countenance, feebleness of the pulse and respiration, cold- ness of the extremities, yawning and sighing, partial blindness, dizziness, noises in the ears, restlessness, thirst, nausea, and even vomiting. To meet these symptoms, all that is necessary, in general, is to place the patient re- cumbent, to use heat, friction, and sinapisms, to allow a free access of air, and to administer stimulants, as brandy, or brandy and ammonia, by the mouth, if the power of deglutition still remains, or, if not, by the rectum, in the form of enemata. A full anodyne will usually form a most valuable adjunct to these remedies, and should seldom, if ever, be omitted. Great care, how- ever, must be observed in the management of these cases, lest violent reaction follow the depression, and hurry the patient on to a fatal termination. It is only in instances of extreme prostration that stimulants should be given boldly and freely, and without any regard to future consequences in respect to the parts involved in the operation. b. More or less fever must almost necessarily follow every severe operation, offering thus an additional source of suffering and danger to the patient, and of anxiety to the surgeon. To this disease the terra traumatic is usually applied ; the older writers called it bed or wound fever, and Dr. Simpson has recently given a most excellent account of it under the name of surgical fever. It generally begins within the first six or eight hours after the operation, and is characterized by a flushed appearance of the face, a frequent, quick and irritable state of the pulse, dryness of the skin, restlessness, and thirst, which is often excessive, especially after profuse losses of blood. In some TRAUMATIC FEVER. 519 cases there is extreme jactitation, with nausea, if not actual vomiting, and a tendency to delirium, or a confused and bewildered condition of the intellect. The breathing is generally somewhat hurried, and slight mucous rales are often present. The appetite is impaired or entirely wanting, the bowels are constipated, and the urine is scanty, high-colored, and often offensive, being surcharged with saline matters and occasionally even slightly albuminous. Now and then the disease is ushered in by distinct rigors. After the fever has continued for some time a tendency to remit appears; the heat, thirst, and restlessness diminish, the pulse descends, the gastric distress vanishes, and the skin becomes covered with a gentle moisture, which often increases to profuse perspiration. The duration of traumatic fever varies from a few hours to a number of days. In the milder cases, it is generally very evanescent, while in the more severe it is often quite protracted, and is then usually attended with regular vesperal, if not also matinal, exacerbations. Not unfrequently the disease disappears entirely for a few days, and then recurs, with more or less violence, the attack being provoked either by some dietetic or other indiscretion on the part of the patient, or by some change of the system, as the arrest of an important secretion, or the commencement of blood-poisoning. The causes of surgical fever are sufficiently obvious. Every operation of the slightest severity acts as a disturbing agent, depressing the vital powers, and deranging, as a direct and inevitable consequence, all the secretions. We have familiar illustrations of these occurrences in daily practice, in the lancing of boils, the extraction of teeth, and in the operation of bleeding. The least shock, however induced, is sure to be followed by more or less general disorder, and it is hardly necessary to state that the amount of this disorder is always materially augmented when, in addition to the nervous lesion, there has been considerable loss of blood. Nothing so rapidly, or so powerfully, irritates and frets the vascular and nervous systems as these two circumstances. The heart evinces its suffering first, by the feebleness and irregularity, and, after the occurrence of reaction, by the frequency and rapidity of its contractions. The nausea and vomiting, the excessive pros- tration, the yawning, and confusion of intellect, not to mention other symp- toms, are unmistakable signs of the shock, or loss of power, sustained by the great nervous centres. The use of anaesthetics, doubtless, often contributes to the production of traumatic fever, by the disturbance which it occasions in the general system. Now, if we take all these circumstances into view, and the fact that thou- sands of patients are subjected to operations without due preparation of the system, or, indeed, any preparation at all, as in cases of primary amputations, trephining, and the ligation of the larger arteries for the arrest of hemorrhage in gunshot and other wounds, it is certainly not necessary to invoke the agency of blood-poisoning, as is of late so frequently done, to account for the occurrence of traumatic fever. These causes are all sufficient to create the most violent disturbance; or, in other words, to set the whole system in a perfect state of ferment, overturning all its functions, and thus occasioning an amount of reaction capable of destroying life in a few hours, or, at all events, in a few days. While this perturbation is progressing, other and still more serious consequences may ensue, as erysipelas, pyemia, and effusions into the splanchnic cavities, the result of disordered secretion, and of the retention of hurtful matter, eventuating in a diseased state of the blood, and in a predisposition to local inflammation in parts more or less remote from the seat of the original injury. The constitutional derangement will, of course, be materially increased if, in addition to these disturbing agencies, there is an absorption or ingress of foul pus into the system, constituting toxaemia, or blood-poisoning. 520 OPERATIVE SURGERY. The danger in traumatic fever is often very great, and it is, therefore, im- possible to watch the patient too attentively. The risk will be particularly imminent if the disease is very violent, or the system was much prostrated prior to the operation. The danger will then be twofold ; first, from consti- tutional irritation and fatigue of the heart, leading to paralysis of its fibres; and, secondly, from internal congestion and local inflammation. The proper remedies are cooling drinks, taken in moderation, or ice, if there be nausea, or gastric oppression; sponging the surface with cool or tepid water ; mild laxatives; and the neutral mixture, or camphor water, with a minute quantity of antimony and morphia, to promote diaphoresis. If the symptoms are disposed to continue, more active measures may be required, especially purgatives, assisted, perhaps, by a few grains of calomel, particularly when there is marked disorder of the secretions. The lancet is seldom, if ever, to be brought into requisition in any case. Leeching, cup- ping, and blistering may be necessary when there is congestion, or threatened inflammation of important internal organs. Local remedies must, of course, not be neglected. If the fever be obstinate, quinine will be indicated, com- bined, if there be profuse sweat with a tendency to hectic, with iron and elixir of vitriol. Great attention is paid to cleanliness and ventilation. This febrile commotion of the system is sometimes very deceptive, exhibit- ing an appearance of great violence, when in reality it is most slight, promptly yielding to the most simple remedies, or subsiding of its own accord. It resembles a sudden and violent storm, quite alarming, but altogether tran- sient and harmless. c. The resulting inflammation will rarely exceed the adhesive limits, if proper care has been taken to prepare the patient for the operation, and the parts have not been too roughly handled during its performance. But pre- vention is not always possible, and hence the wound should be diligently watched, lest it be assailed, and even overwhelmed before the patient and his attendant are aware of the fact; for it should be remembered that the morbid action is not always characterized, under such circumstances, by the usual symptoms; there may even be an entire absence of pain and tension, perhaps even of discharge. Great vigilance, therefore, is often necessary to detect the earliest inroads of the disease, and to counteract its progress. Of course, all officious interference is avoided, and nature is carefully protected in the maintenance of her rights and privileges. The moment over-action is per- ceived, the dressings are either removed, or, at all events, slackened, and suitable means substituted. Of these the most important consist of leeches, water-dressings, and cataplasms, either simple or medicated, according to the exigencies of the case. If matter form, free vent is afforded, either by a change of position of the parts, or by puncture and incision. Constitutional treatment, of course, receives due attention. d. Secondary hemorrhage may come on within a few hours after the ad- justment of the parts, or it may be postponed to a later period, even to a few days or weeks. It may be arterial or venous, slight or profuse, transient or persistent, just as in the primary form of the accident. The most common causes are, imperfect ligation of the vessels, defective dressing, sloughing, and premature detachment of the ligatures. Whatever they raay be, they should be carefully sought out, and at once counteracted by appropriate measures. The occurrence is always to be deprecated, because it has a tend- ency, not only to alarm the patient and his friends, but to impede and even prevent the adhesive process, requiring, as it not unfrequently does, the re- opening of the wound for its successful management. Fortunately, however, it is, in general, easily avoided, especially if proper attention be paid to the dressings and after-treatment. PYEMIA—TETANUS — CONSTITUTIONAL IRRITATION. 521 e. Erysipelas is most apt to occur in persons of intemperate habits, or of a broken-down constitution, and usually makes its appearance within the first three days after the operation, generally at the site of the wound, or in the parts immediately around. Its presence is always denotive of disorder of the digestive apparatus, and hence one of the first things to be done is to admi- nister medicines calculated to clear out the bowels and to restore the secre- tions of the liver, the mucous follicles, and the salivary glands. For this purpose the best articles are calomel and compound extract of colocynth, or blue mass and rhubarb, followed, if necessary, by the saline and antimonial mixture, with anodynes to allay pain and procure sleep. The local treatment must consist, mainly, of the dilute tincture of iodine, and solutions of the acetate of lead, with punctures and incisions to relieve tension and afford vent to effused fluids. /. Pyemia may set in almost at any time after an operation, but the most common period is from the third to the eighth day. It is usually ushered in by bold and well-marked symptoms, such as violent rigors alternating with flushes of heat, severe cephalalgia, aching pains in different parts of the body, excessive restlessness, great thirst, a quick and frequent pulse, and inordinate dryness of the cutaneous surface. Delirium and extreme prostration soon ensue, and thus the case progresses from bad to worse, until, frequently in less than a week from the commencement of the attack, the patient expires in a state of utter exhaustion. Little is to be done for a system thus assailed. In nine cases out of ten the disease proves fatal. The proper remedies, at the start, especially if the patient is robust and plethoric, are moderate vene- section and leeching, the exhibition of the milder purgatives, as calomel and rhubarb, and mercury with a view to a rapid constitutional impression. When excessive prostration is threatened, brandy, wine, ammonia, and nourishing broths are indicated, and must be administered with a generous hand. Locally, besides leeching, iodine, blisters, and medicated fomentations will be advantageous ; if matter form, early and free incisions are made. g. Still worse than pyemia, because even more fatal, is tetanus. This, however, is fortunately a rare occurrence after operations in this country. It is most comraon in tropical regions. In Europe and North America it is met with chiefly in dissipated persons of a broken-down constitution. It would seem that in India the operation of lithotomy is occasionally followed by this disease, an effect which, so far as I know, has never been witnessed in this country. Excessive loss of blood, severe shock, and exposure to currents of air, undoubtedly predispose to the occurrence of the affection, which usually shows itself within the first five or six days after the operation. The prin- cipal remedies are, anodynes, in full and sustained doses, brandy and ammonia, chloroform, and emollient applications to the wounded parts. h. Life may be assailed by constitutional irritation and profuse discharge, and that, too, long after all apparent danger is over. The patient gradually becomes hectic ; his appetite and sleep fail; the bowels are irregular, at one time constipated and at another relaxed ; and the parts, exhibiting an un- healthy aspect, refuse to heal. Such a state of things, which, in general, but too surely foreshadows an unfavorable result, is to be combated upon the same principles as hectic produced by ordinary causes. i. Patients sometimes die suddenly and unexpectedly after operations with- out any ascertainable cause, and where, at the time, everything seemed to be in a promising condition as to their ultimate recovery. A more sad and dis- tressing occurrence can hardly be thought of, and yet it is one which cannot always, there is reason to believe, be avoided, no matter what precautions raay be observed. Mere loss of blood, or shock, is not always sufficient to account for this unfortunate event, although it, doubtless, in many instances, materially contributes to its production ; for death not unfrequently happens where no 522 OPERATIVE SURGERY. such effects were witnessed. Nor can it be due to the introduction of air into the veins, as, for example, when operations are performed about the neck, inasmuch as, in this case, the patient either perishes instantaneously, or, at any rate, exhibits unmistakable evidence of the accident. Besides, this occurrence is not peculiar to operations upon the cervical region, but has been witnessed in operations upon all parts of the body, even in some of the more insignificant amputations and the removal of small tumors. When there has been much loss of blood, or severe shock, the event is probably due, at least for the most part, to syncope, or actual paralysis of the heart, preventing this organ from transmitting a sufficiency of blood to the brain for the due performance of its functions ; and such an effect is most likely to take place when the patient, through neglect, wilfulness, or mismanagement, sits up in bed, or stands on the floor, thus suddenly depressing the heart's action. In this way life is sometimes instantaneously destroyed in lying-in females, especially in those who have suffered seriously from hemorrhage; and similar results are occasionally witnessed after surgical operations and accidents. In another class of cases, death is probably caused by embolism, that is, by the formation of heart-clots, and of fibrinous concretions in the vessels, impeding the passage of blood, and so arresting, suddenly and unexpectedly, the func- tions of an important organ. It is well known that copious hemorrhage, or severe shock, invariably renders the blood more coagulable, and hence such a state of the system must be regarded as powerfully predisposing to the occurrence of embolism. It is sufficient, for all practical purposes, to know that such an event may occur after operations, without any formal attempt at its solution, which the present state of the science hardly enables us to do. Whatever the cause may be, no efforts should be spared to prevent it. For this purpose, the utmost care should be taken, after all serious operations, not to prop the patient up in bed, or to let him get upon his feet; nay, further, he should not, if he is very w7eak or exhausted, be permitted to move about in bed, or, in short, to do anything calculated to induce syncope, or promote the occur- rence of embolism. The diet should be of a suitable kind, and such medi- cine should be given as shall have a tendency to give tone and strength to the system. Free use, in particular, should be made of brandy and milk. If syncope occur, the head must immediately be placed low, and recourse be had to sinapisms and stimulating injections, to reassure the heart, although this will probably be in vain, especially if the cause of the failure of its action be the presence of a clot, either in its own cavities or in some vessel. As it is impossible to foretell, in any given case, when the patient may be exempt from sudden death, after severe shock, or great loss of blood, the precautions here enjoined should be rigidly observed uutil there is reason to believe that all danger from this cause is passed. j. The mortality of surgical operations is subject to numerous contingencies, some of which have an intimate relation with the patient himself, some with the nature of the injury, or accident necessitating the interference, and some with the surgeon, either directly or indirectly. It may be assumed, as a gene- ral rule, that all the capital operations, as they are termed, are attended with a certain degree of risk to life, while not a few of the minor or more insig- nificant ones have, from causes which it is not always easy to determine, a fatal issue. It has been asserted by an eminent authority, Professor Simpson, that a patient who is about to undergo a severe operation incurs as much danger as a soldier engaged in the most fierce and bloody battle. This is a strong declaration, but I believe it to be fully borne out by facts; nevertheless, it must be received with some degree of reserve. If a man serves as a forlorn hope, he will stand a fair chance of being killed; and so precisely with a patient who submits to the knife on account of sorae terrible accident or dis- MORTALITY. 523 ease. But such cases constitute the exception, not the rule; under ordinary circumstances, if the system is properly prepared, and the operation well per- formed, the surgeon looks with great confidence for a good recovery. If he could always select his cases, the general result wrould be very different. He would then not employ the knife against his judgment, as a dernier resort, with the certainty that there was hardly one chance out of a hundred for a favorable issue; he would let all the bad, desperate, or unpromising cases alone, to get well or perish, as a kind Providence might direct. But so long as a surgeon has any feelings of humanity he cannot do this ; he must take the good, bad and indifferent cases as they present themselves, aud do the best he can with them. It is only when he is guilty of neglect, or of serious mismanagement, that he should be considered culpable. He does not expect to save all; he knows that many must necessarily perish, not so ranch as an effect of the operation as of the injury or disease for which the operation is performed, and in attempting to estimate the probable result of his inter- ference, he does not forget to take into the account the risk which his patient is obliged to incur from hemorrhage, erysipelas, pyemia, tetanus and other in- tercurrent but often unavoidable affections. He is assured that there is no case, however desperate, that may not recover, or one, however insignificant, that may not perish. The following tables will serve to show what has hitherto been the mor- tality after some of the so-called capital operations :— Operations. Cases. Recoveries. Deaths. Proportion. Lithotomy 7,874 6,792 1,082 1 in 7/« Ligation of arteries . 401 287 123 1 in 3i Herniotomy 622 323 296 1 in 2Tiff Amputation of the thigh . 1,642 907 735 1 in 2\ But these results, so humiliating to surgery, refer chiefly to hospital prac- tice, and can, therefore, hardly be considered as affording a fair average of the experience of the profession in general. The great majority of the most desperate cases, both of injury and disease, in all large towns and cities, find their way into public institutions, where they rapidly sink under the joint influence of vitiated air, erysipelas, pyemia, and want of proper attendance. It is a notorious fact that many more patients recover after bad injuries and severe operations in the country than in the city ; and, to go no further, it may confidently be asserted that an experienced operator will lose fewer cases than one who is just commencing his career. 524 PLASTIC SURGERY. CHAPTER XV. PLASTIC SURGERY. Plastic Surgery is that branch of the subject which treats of the resto- ration of lost parts by the transplantation of healthy integument from some neighboring region. Originally restricted to the repair of the nose, it has, during the present century, busied itself, in different ways, with the emenda- tion of various other organs, and has thus greatly enriched the domain of general surgery; having, in fact, created a new department of operative medicine, as fertile in its resources as it has already been brilliant in its re- sults. The perfection which plastic surgery has attained within the last twenty years is truly wonderful, and affords a striking evidence of the inge- nuity, talent, and enterprise of the medical profession in different parts of the world. It has literally been a field of conquests, upon which have been achieved sorae of the proudest triumphs of the human mind in modern times. Among the many names that are honorably associated with this department of surgery, on account of their persevering efforts to advance its interests, those of Carpue, Dieffenbach, Blandin, Zeis, Jobert, Serre, Liston, and Von Ammon, of Europe, and Pancoast, J. M. Warren, and Mutter, of this country, hold deservedly a high rank. Several of these surgeons have com- posed able treatises on plastic surgery, and have thus indelibly identified their names with its history. Various names have been devised to designate this branch of surgery. Thus, Blandin denominates it autoplasty, from a Greek compound literally signifying self-creation. Another French authority, Mons. Velpeau, prefers the word anaplasty, the true meaning of which is reconstruction. By others the term plastic, from the Greek verb to mould, model, or adjust, is used, and this is perhaps less objectionable than any other; at all events, it possesses the advantage of being easily understood. It is exceedingly probable that one branch of plastic surgery has been practised in India from time immemorial. In that country the barbarous custom has existed for ages of punishing certain classes of criminals by cutting off their noses, and there can be uo doubt that sympathy for these poor wretches gradually induced persons to turn their attention to the means of affording them relief. Hence arose rhinoplasty, or the operation of making new noses, pursued chiefly by a low order of native priests, whose ignorance of the healing art was too profound to justify the idea that their efforts were often crowned with success. According to Galen, the ancient Egyptians were well acquainted with rhinoplasty, but self-interest and pride prevented them from communicating a knowledge of it to other nations. Whether the operation was ever performed in Greece and Rome history does not inform us, although it can hardly be supposed that, if it had been, it would have been silent on the subject. In Europe attention was first prominently drawn to the restoration of lost parts by Gaspar Taliacotius, Professor of Anatomy and Surgery in the University of Bologna. In a work on the subject, re- markable for its erudition, and the simplicity of its diction, published at Venice, in 1597, he has described with great minuteness the art of repairing PLASTIC SURGERY. 525 mutilated noses, lips, and ears, illustrated by numerous engravings. It bears the title of " De Curtorum Chirurgia per insitionem," and is curious as fur- nishing a record of the observation and experience of a truly great surgeon soon after the revival of learning. His practice must have been very great as a rhinoplastic surgeon, for it is distinctly stated that patients visited him from all parts of Europe. The pupils of Taliacotius, settling in different parts of the continent, took great pains to disseminate a knowledge of the operation among the profession, although it does not seem to have been often applied in practice, doubtless from fear of failure. The operation, moreover, was doomed to encounter many obstacles from ridicule, which always exerts a powerful influense upon the weak and prejudiced in every country^ and not unfrequently has the effect of throwing a new and useful invention completely into the shade. The method of Taliacotius consists in borrowing the required material from the arm ; the operation is very tedious and complex, and has been almost entirely superseded by the Indian method, in which the flap is taken from the forehead. These two processes will be described in their proper place. Meanwhile, it may be observed that the Oriental operation was first success- fully performed in Europe in 1814, by Mr. Carpue, of London, who, in 1816, published an account of this and of another case, equally fortunate. To Dieffenbach, however, more than to any one else, is due the merit of having first generalized the operation, by pointing out the sphere of its application. The nomenclature of these plastic operations has assumed quite an im- posing character, from the numerous structures to which they are applicable. It is formed by adding the word plasty to the anatomical name of the part concerned, as rhinoplasty, genoplasty, and urethroplasty. Before I proceed to speak of these operations separately, it will be necessary to offer some remarks of a general nature respecting the causes which necessitate them, the preparation of the system, the proper mode of conducting them, and the character of the after-treatment. The causes necessitating these operations are various kinds of accidents and diseases. Thus, in India, as already stated, rhinoplasty is generally re- quired on account of wilful mutilation of the nose as a punishment for crime; in Germany, on the contrary, it is often called for on account of injury sus- tained by the small sword in duelling. The vicious cicatrices left by burns and scalds frequently led to the necessity of their performance ; in fact, a large field for plastic surgery has been opened in this class of lesions, in which good service was rendered by the late Dr. Mutter, since attention was first directed to it. Of the various diseases which may create a necessity for this kind of interference, carcinoma, struma, and syphilis occupy the first rank, these affections not unfrequently destroying the greater portion of the nose and lip, and thus causing the most disgusting deformity. Genoplasty is ge- nerally required on account of ulceration of the cheek from the effects of mercury; and urethroplasty, in consequence of urinary fistule, the result generally of stricture and abscess. Whatever may be the causes leading to the necessity of these operations, none should ever be undertaken without thorough preparation of the system, extending through a number of days, if not several weeks. Upon this sub- ject it is impossible to insist too strongly. I have seen enough of these cases to satisfy me that too little attention is paid to preliminary treatment, and that most of the failures which attend the procedure are due to the neglect of this precaution, for which there is the less excuse, seeing that there is never any need of immediate interference. There is no necessity, unless the patient is very plethoric, for the use of the lancet; light diet, rest, and an occasional purgative will generally suffice to bring down the system to a proper point of tolerance for the approaching ordeal. If the patient is from 526 PLASTIC SURGERY. abroad, he must not be molested until he has recovered frora his fatigue, and become accustomed, in some degree, to his apartment and to those who are to attend to his wants. Above all, let it be seen to that his room is spacious, cheerful, and well-ventilated. If the weather be cold, the temperature must be regulated by the thermometer, uniformity in this respect being of para- mount importance to the success of the enterprise. No operation of this kind should be undertaken in the heat of summer. It is hardly necessary to state that no plastic operation should ever be attempted so long as the disease necessitating it is not completely eradicated from the part and system. It would be the height of folly, for example, to undertake the restoration of a nose lost in consequent of constitutional syphilis if there were any traces of this affection, in any portion of the body, however remote, or however distantly connected with the disfigured organ ; for there could be no possible guarantee here that the disease might not attack the new nose or the adjoining parts of the old, and so frustrate the design of the surgeon. Besides, even supposing that such an untoward occurrence did not take place, still, it would be improper to operate, because the subjects of this disease are not only very prone to erysipelas but wounds in them generally unite with more difficulty than in healthy persons. The same remarks apply to struma, although I have great doubts whether this disease, by itself, ever destroyed any nose, ear, or lip. The mischief that is so often ascribed to it is nearly always done by syphilis, or by a combination of these affections from the transmission of the two poisons from the parent to the offspring. It is different with carcinoma. Here the plastic opera- tion may, in general, be performed immediately after the excision of the specific disease. The manner of performing the operation relates to the position of the patient, the surgeon, and the assistants; the administration of chloroform; the mode of selecting, making, and fastening the flaps; and several other circumstances which it is not necessary to specify. If the operation be very simple, and likely to be soon over, the patient may sit up ; otherwise he should lie down, his head and shoulders being pro- perly supported by pillows. The surgeon and the assistants should dispose themselves in such a manner as may seem most useful for the prompt and successful execution of the operation. An anaesthetic is proper in almost every case, since the operation is frequently not only very tedious, but it is always desirable that the patient should be as passive as possible while it is in progress. There are, as has already been stated, two points from which the integu- ment may be transplanted for filling up the chasm in the mutilated organ; either from the immediate vicinity of the part, or from a distance. Thus, in making a new nose, or mending an old one, the flap may be taken from the forehead, according to the Indian method; or, if the gap be very small, even from the cheek, at a still shorter distance from the nose. Or the surgeon, adopting the plan of Taliacotius, now known as the Italian operation, may borrow the necessary material from the arm, although this method, owing to its tedious and complicated character, has become almost obsolete. In some cases the flap is obtained by a kind of migratory process, being successively transferred from one region to another until it reaches its final destination. Roux, in this manner, attempted to close an opening in the cheek, by in- serting a piece of the lower lip into the upper, and, after a time, when the parts had contracted thorough adhesions and become accustomed to each other, transferring it to the place which it was intended permanently to oc- cupy. Such a procedure would, seem, at first sight, to be puerile, but upon reflection it will readily be seen that cases might arise where it would not only be justifiable but very proper. PLASTIC SURGERY. 527 However obtained, it is important that the integument should, if possible, be perfectly sound ; free, not only from disease, but from scars. The import- ance of attention to this rule is too obvious to require comment. A cicatrice, having only a low vitality, is extremely apt to slough when transplanted. A sickly graft cannot take root on a sound bough, nor will a diseased bough permit the growth of a sound graft. To unite and maintain their future relations, both must be healthy. Another point of consequence is that the flap should be as destitute as possible of hair; for, although it might be divested of this after it has grown fast in its new position, yet it is always best not to incur any risk of unseemliness from this source. The size of the flap must, as a general rule, be at least one-third larger than the opening which it is intended to cover, to allow for the necessary shrinkage. If the integument be very thick the contraction will be less than under opposite circumstances, but even here it is well for the surgeon to be on his guard, lest, wdien the cure is completed, the result should disappoint him. The shrinkage is always gradual, and generally continues for many months after the operation, the part gaining in thickness and density what it loses in circumference. The shape of the flap must accurately correspond with that of the gap which it is destined to close. Hence the best plan is always to define its outline before the operation by means of a pattern, placed upon the surface whence the integument is to be taken, and marked off with ink, nitrate of silver, or, what is better than either, tincture of iodine. The composition of the flap is a matter of importance. It should consist merely of skin and areolar tissue, with a small quantity of adipose substance; muscular fibre, nerves, and veins being carefully excluded. The presence of a thin layer of fat is always conducive to the preservation of the flap, as it tends to protect the subcutaneous vessels, and facilitate adhesion. A large pedicle must always be left, otherwise the part may die from inadequate supply of blood and nervous fluid. No large artery should be embraced in it, as this would convey more blood into it than would be required for its nutrition, or than the veins could return. These preliminaries being disposed of, the surgeon is ready to begin the operation. With a sharp scalpel he now pares the edges of the part to be repaired, vivifying them with great accuracy, and removing all redundant and callous matter ; or he may first dissect up the flap, and do the paring after- wards, as fancy or convenience may dictate. In executing this step of the operation, great care must be taken not to press or pinch, either with the finger or forceps, any portion of the flap or old skin, but to leave everything in as natural a condition as possible, since nothing will so readily promote reunion. The edges may be bevelled off or cut straight, according to circum- stances, as will be more particularly described hereafter. The dissection is frequently attended with smart hemorrhage, but the rule is never to apply any ligature to the flap, lest it should interfere with the adhesive process, although any vessel that may spirt on the wound should at once be secured, and the wound itself promptly closed by suture. More or less gaping will of course remain, but it is astonishing how small a cicatrice is usually left even in the most extensive lesions of this description. All bleeding having ceased, the flap is gently sponged, and accurately stitched to the edges of the chasm which it is designed to close. The most eligible suture will be found to be the interrupted, with an interval of from two to three lines between the threads, the ends being tied with a slip-knot over a narrow roll of adhesive plaster. The advantage of this procedure is that the suture may be loosened at any time if it be found to be too tight. Much harm is often done by placing the stitches too closely, the effect being to cut off the circulation. The twisted suture is objectionable for the reason, 528 PLASTIC SURGERY. first, that the needles are, in many places, difficult of introduction, and, secondly, that they are liable to cause too great a degree of tension. The grooved suture, so happily used in plastic surgery by Professor Pancoast, will be described in connection with rhinoplasty, to which it is more particu- larly applicable. The dressing is completed by covering the edges of the newly related parts with lint, spread with simple cerate, or wet with olive oil, in order to prevent them frora becoming dry and shrivelled, an effect which is very liable to hap- pen when this precaution is not duly attended to. The surface of the flap may be protected with dry lint, or, what is generally preferable, be exposed to the air. If it is very large, it will be necessary to confine it lightly in its place with adhesive plaster and a bandage, but anything like firm pressure must be carefully avoided. The wouud from which the flap has been bor- rowed is dressed w-ith cold water, and a similar application may be made to the amended organ if appearances indicate that there is a likelihood of over- action. The operation being completed, the part is kept at rest in a relaxed and elevated position ; a light, cooling diet is enjoined ; and the air of the apartment is carefully regulated by the thermometer, an equable temperature being of the greatest consequence to the welfare both of the part and system. A full anodyne is given the moment the patient is put to bed ; but, if things go on well, the bowels must not be disturbed under forty-eight hours, when they may be opened by a cooling laxative. The sutures may be removed, on an average, from the third to the fifth day; but so long as they are doing well they should not be disturbed, and there are few cases in which it is proper to take them all away at once. Great attention to cleanliness must be observed, and the best mode of effecting this is to irrigate the parts occasionally with the syringe. If undue swelling and discoloration arise, the patient must be promptly bled and purged, and such local means employed as shall be best calculated to meet the emergency of the case. Leeches may be applied to the neigh- borhood of the flap, but not to the flap itself for fear of exciting erysipelas. Occasionally, a considerable flow of blood raay be obtained by slightly lifting the flap at one or more points, the bleeding being encouraged with a sponge and warm water. The great danger after an operation of this kind is erysipelas, which may be so considerable as to destroy not only the flap but also the patient. Such an occurrence should be promptly met by the topical use of dilute tincture of iodine, and by appropriate internal remedies, especially quinine and iron ; aided, if there be any tendency to a typhoid state of the system, by stimulat- ing drinks and a generous diet. Now and then a patient is lost by pyemia, but such an event is fortunately very uncommon. Gangrene of the flap, either from inadequate nutrition, over-action, or undue constriction, occasionally occurs, and destroys the success of the operation. For a time the flap remains pale and cold, but these symptoms soon subside, and are succeeded by a bluish appearance and an increase of temperature. The circulation is evidently temporarily embarrassed, the arteries conveying blood faster to the part than the veins can remove it. Hence a certain de- gree of stagnation ensues, followed by a bluish, threatening condition of the part, which, however, soon disappears spontaneously. Natural sensation does not return for a long time; it begins first along the edges of the flap, and thence gradually extends over the rest of its surface. For the first few months the transplanted skin may appear unnaturally large and unseemly; gradually, however, it becomes smaller and smaller, and eventually may shrink so much as to answer but imperfectly the objects of the operation. SUBCUTANEOUS SURGERY. 529 CHAPTER XVI. SUBCUTANEOUS SURGERY. Subcutaneous Surgery is one of the creations of modern times, due chiefly to the genius and intrepidity of one man, Dr. Louis Stroraeyer, of Hanover, who was the first to practise, upon a rational and philosophical plan, a subcutaneous operation, the undertaking consisting in the division of the tendo Achillis for the cure of club-foot. The operation was performed in February, 1831, and eventuated in the complete restoration of the use of the limb. Prior to this period several attempts had been made, by different surgeons, as Lorenz, Thilenius, Michaelis, Sartorius, and Delpech, to relieve this complaint, but they had all signally failed, simply because they had not been based upon correct scientific principles. The results of Dr. Stromeyer's observations and experiments were given to the profession in 1838, in a vol- ume replete with interest, entitled Contributions to Operative Orthopaedic Surgery, in which he has described, with circumstantial minuteness, the pro- per method of dividing the different tendons concerned in the production of the various distortions of the foot, with an account of the after-treatment. Since the publication of Stromeyer, the domain of subcutaneous surgery lias been greatly enlarged, by the application of its principles to other parts of the body, for the relief of which it has already performed the most valua- ble services. Dieffenbach, in 1839, gave it a new impulse by devising the operation for strabismus, which, although not practised by him subcutaneously, did much to inspire new confidence in the procedure, and to awaken a new interest in its application. Soon afterwards, however, the section of the muscles of the eye was performed without external wound, and the operation, originally suggested by Guerin, seems to be growing more and more in favor with the profession. The latter surgeon has extended the subcutaneous practice to the treatment of lateral curvature of the spine, by the division of the muscles of the back; and, at a more recent period still, it has been ap- plied to the relief of numerous other affections, which would hardly admit of cure in any other manner. Among the more important operations which have grown out of this branch of surgery are the removal of cartilaginous bodies from the joints, the radical cure of hernia, the reduction of chronic dislocations, the evacuation of abscesses, the cure of anchylosis, and the ob- literation of serous cavities. Too short a time has elapsed since the discovery of subcutaneous surgery to enable us to form a just estimate of its limits, or the extent to which it may with propriety be carried in practice ; but it is not difficult to perceive that in a field affording such unbounded opportuni- ties for the exhibition of display and selfishness, much abuse must creep in, which time alone will be able to rectify. The practice of subcutaneous surgery is founded upon the great law that all wounds and injuries occurring without an opening in the integument unite with very little, or, according to some, with no inflammation, and with no suppuration, differing thus essentially from similar lesions accompanied with a solution of continuity of the skin, which are always followed by considerable inflammation, and also very frequently, if not generally, by a discharge of pus. This law, which is now universally recognized by surgeons, was clearly vol. i—34 530 SUBCUTANEOUS SURGERY. enunciated by Mr. John Hunter, in his writings, near the close of the last century, but did not attract the serious attention of his countrymen until within a very recent period ; not, indeed, until the facts of the subcutaneous section had been placed upon a firm and immutable basis by the practitioners of the continent of Europe. The idea of the illustrious Englishman lay in his writings, like a pebble upon the sea shore, often seen but never observed, until accident directed attention to it years after the establishment, by others, of the great principles which he had so clearly enunciated. One reason, perhaps the chief one, of this was that he himself had never performed a subcutaneous operation: if he had, there is certainly no evidence of the fact in any of his writings. The only passage in his works which has any rele- vancy to the present subject is the following: " The injuries done to sound parts, I shall divide into two sorts, according to the effects of the accident. The first kind consists of those in which the injured parts do not communi- cate externally, as concussions of the whole body or of particular parts, strains, bruises, and simple fractures, either of bone or tendon, which form a large division. The second consists of those which have an external com- munication, comprehending wounds of all kinds, and compound fractures. Bruises which have destroyed the life of the part may be considered as a third division, partaking, at the beginning, of the nature of the first, but finally terminating like the second. The injuries of the first division, in which the parts do not communicate externally, seldom inflame, while those of the second commonly both inflame and suppurate." It is evident, from the tenor of this passage, that Mr. Hunter had carefully studied the influence of the air upon the effects of wounds, but it is not very clear, from aught that appears in it, that he had any conceptions whatever of the nature of sub- cutaneous surgery, properly so called. Several of what are now dignified as subcutaneous operations have been performed for a long time. The mode of evacuating chronic abscesses by a valvular incision, first practised by Mr. Abernethy, early in the present cen- tury, legitimately belongs to this division of surgery, its object, as clearly enunciated by the originator, being the exclusion of the air, it being well known that the contact of this fluid with the pus in the interior of the sac was the cause of the excessive local and constitutional disturbance which so often followed the old mode of opening these collections. Of the value of this procedure there can be no doubt, although the class of cases which it is intended to relieve is, from their very nature, unfortunately too often fatal. The operation of dividing the stricture in strangulated hernia, external to the sac, originated with ,1. L. Petit upwards of a century ago, but has only of late years received the attention it merits. Some of the English practi- tioners, commencing with Mr. Aston Key, have recently bestowed much at- tention upon the subject, and have adduced a body of testimony in its favor highly flattering to this mode of treatment. The object of the operation, whose advantages and disadvantages will be considered in their appropriate place, is, by relieving the bowel subcutaneously, to guard against the occur- rence of the severe inflammation which so frequently attends the ordinary procedure, even in the hands of the best surgeons. The injection of hydro- cele with irritating fluids, as suggested by Sir James Earle, early in the pre- sent century, is another instance of a subcutaneous operation, which has long been familiar to the profession, and been practised by every enlightened surgeon in Europe and America. Sorae recent writers have gone so far as to class the use of the seton in the treatment of ununited fracture among the expedients of subcutaneous surgery ; such an application is certainly carry- ing this department altogether beyond its legitimate limits, and is therefore calculated to do the subject much harm by giving to it a wrong direction. The wound made by a seton is, to all intents and purposes, an open wound, followed not only by high inflammation but by profuse suppuration ; occur- SUBCUTANEOUS SURGERY. 531 rences which it is the peculiar province of subcutaneous surgery to guard against. A better example of a subcutaneous operation, performed for the relief of ununited fracture, is the division without wound, by means of a long, slender knife, of the soft tissues which form around the ends of the broken bone, the raw surfaces being afterwards approximated and maintained by ap- propriate apparatus. On the whole, regarding subcutaneous surgery in its legitimate appli- cation, it appears to me that the cases to which it is adapted are susceptible of being arranged under the following heads : 1. Cases involving the division of tendons, muscles, and aponeuroses for the relief of various distortions, as club-foot, club-hand, spinal curvature, and strabismus; the reduction of dis- locations, especially those of the foot; and the cure of anchylosis of the joints, depending upon contraction of the soft parts. 2. Operations for the radical cure of hernia, whether by puncture or injection; and division of the stricture in strangulated hernia external to the sac. 3. The evacuation of chronic abscesses and of purulent, serous, and sanguineous collections of the chest and other cavities, by a valve-like opening of the skin. 4. The withdrawal of cartilaginous concretions from the joints, as originally suggested by Goy- rand and Syrae. 5. Operations for obliterating serous cavities, when, in consequence of inflammation, they become occupied by serous fluid ; as the vaginal tunic of the testicle, certain synovial burses, especially those about the hand and wrist, and various adventitious cysts, particularly those which are so liable to form in the neck in connection with the thyroid gland. 6. The comminution, by the knife, of diseased lymphatic ganglions, the incision of inflamed periosteum, and the division of morbid adhesions, as those exist- ing in chronic luxations, in depressions of the nose, and similar affections. 7. Forced extension of anchylosed joints, rendered so by the formation of fibro-ligamentous bands. 8. The subcutaneous obliteration of nevi or vas- cular tumors, by ligature or injection. 9. The operation for the radical cure of varicocele. The mode of operating for subcutaneous purposes must vary of course ac- cording to the particular indication which it is designed to fulfil. Whatever, however, the object may be, the rule is to make as small an external wound as possible, consisting, in fact, rather of a puncture than an incision, for it is ever to be borne in mind that one of the cardinal aims of every procedure of the kind is the exclusion of the air. The knife with which the operation is performed must therefore always be very narrow, sharp-pointed, and rather short, a length of edge from half an inch to an inch being a good average. The annexed sketch, fig. 155, represents the knife which I have long been in the habit of using in all my subcutaneous operations. Such Fig- 155- would make too large an opening. Tenotome. If the object be to evacuate an abscess, a medium-sized trocar may be used, the skin having been previously divided with a bistoury. The instrument is then passed for a variable dis- tance—usually from an inch to an inch and a half—through the subcutaneous cellular tissue, when its point is plunged into the pyogenic pouch, its en- trance being denoted by the want of resistance and the escape perhaps of a few drops of thin pus. In extracting cartilaginous concretions from the joints, a delicate knife is carried along under the integument through the capsular ligament and synovial membrane, wdiich are then divided to a suffi- cient extent to admit of the displaceraent of the raorbid growth, previously fixed by the thumb and fingers, into the cellular substance external to the articulation, from which, after the wound is healed, it is removed by a 532 SUBCUTANEOUS SURGERY. secondary operation. The operation for the radical cure of hernia, requiring instruments of particular construction and use, will be described in its proper place, and so in regard to several other procedures which cannot be noticed here. All operations of this kind should be performed with great gentleness and care; and whenever this is done there will be no risk either of severe inflam- mation, or of the division of any important vessels, nerves, or other structures not concerned in the particular affection for the relief of which the procedure is undertaken. I do not agree with those who maintain that tendons and other textures may be cut without the operation being followed by inflamma- tion ; on the contrary, I believe that a certain degree of incited action is present in every instance, and if this view of the case be correct it proves how important it is that it should be kept within proper limits. This sub- ject, however, will again be adverted to in speaking of tenotomy. In general, the little puncture made in the operation unites in a few hours, while the gap which intervenes between the retracted ends of the divided structures is gradually filled up by plastic matter, which is eventually converted into analogous tissue. Most subcutaneous operations are nearly bloodless, and this circumstance constitutes one of their great peculiarities. While open wounds always bleed to a greater or less extent, those made beneath the skin by a narrow, sharp- pointed knife, used with proper care, are almost free from hemorrhage. In dividing the tendo Achillis for club-foot, frequently not more than a few drops of blood are lost. As to shock, or serious depression of the nervous system, consequent upon such an operation, such an occurrence is never witnessed. The proceeding, however, is not always free from pain, especially during the efforts which are sometimes required to straighten the affected part after the division of the faulty structures; and hence it is often useful to administer an anaesthetic, the more so, because this not only prevents suffering, but, by rendering the patient passive, gives the surgeon a more complete control over his own movements. Active preparatory treatment is rarely required in these operations. I have frequently performed the most extensive tenotomy at my clinic upon children whom I had seen for the first time only an hour before, and yet iu no instance, so far as I have been able to learn, have any bad effects followed. The operations, however, for the radical cure of hernia, for breaking up ad- hesions in anchylosis, for the removal of cartilaginous bodies from the joints, and for the relief of some other affections, always demand more or less atten- tion of this kind. The after-treatment, for the first few days, is generally very simple. As soon as the operation is over, the little wound is covered with adhesive strips, to exclude the air, and the part, surrounded by a bandage, is maintained in a perfectly easy, quiet position. If active inflammation arise, which, however, will seldom be the case, the usual antiphlogistics must be employed. After nearly all of these operations suppuration must be prevented at all hazard. When the operation has been practised for the relief of sorae deformity, as club-foot or spinal curvature, the cutting constitutes only a trivial part of the proceeding. The great care and trouble of the case come afterwards, in the fitting and wearing of the necessary apparatus. It is usually recommended that no apparatus should be used until after the lapse of several days, aud this, as a general rule, will be found to be the best practice. I have, how- ever, in many cases, so far deviated from this rule as to confine the affected limb at once, and usually without any disadvantage. Indeed, I have latterly thought that this ought to be the rule, and the delay the exception. As this subject, however, will have to be considered in connection with the various operations to which it relates, any further remarks upon it here would be out of place. AMPUTATIONS IN GENERAL. 533 CHAPTER XVII. AMPUTATIONS IN GENERAL. SECT I.—INTRODUCTORY CONSIDERATIONS. The word amputation was formerly employed, and is occasionally even yet, to signify the removal of various kinds of tumors ; thus, many of the older writers speak of amputation of the breast, amputation of the jaw, and ampu- tation of the scrotum. At the present day, however, the term excision is' generally used as more appropriate in connection with these procedures, while that of amputation is applied exclusively to operations for the removal of the limbs whether in their continuity or at their articulations. I cannot agree with those who have denounced amputations as a disgrace to surgery; it is only when they are performed unnecessarily that they ought to be stigmatized by the profession and the public as an evil. Every pursuit is liable to abuse, to sins of omission and commission, and it would be strange if limbs were not occasionally cut off that might, under judicious management, have been saved. To denounce amputations, and to declare that they afford evidence only of the impotency and imperfection of our art, is to take a very narrow and erroneous view of the subject. It is not intended, as far as our own feeble powers of reflection enable us to comprehend the matter, that man should be able to cure every disease to which "flesh is heir." There are many maladies, as well as accidents, wdiich are of necessity mortal; lesions which no human agency can repair or remedy. Who can save a limb that has been mangled and cut to pieces by the passage of a railway car, by the explosion of a steamboat boiler, by the fierce contact of a cannon ball, or by a fall from the top of a house down upon a heap of stones 1 Where is the surgeon that can prevent mortification from a burn that has charred the flesh, from a cold that has completely frozen the toes and feet, or from a malignant pustule that has inoculated all the tissues of an extremity ? Is surgery to be held responsible because it cannot cure cancer of the bones, scrofula of the joints, and aneurism of the thigh and leg ? So far from imputing blame to it in these and similar cases, we should be grateful for the assistance which it is capable of affording us as a means of relieving suffering and prolonging life. It is under such circumstances, in particular, that we can best appreciate its great and inestimable value. If it were not for the merciful interposition here of the knife, such cases would inevitably be doomed to a rapid and miserable death. Mortification would speedily do its work, the cancerous tumor would steadily spread and finally ulcerate, forming a frightful, disgust- ing, and painful mass of disease, and the scrofulous joint would soon wear out the system by hectic irritation. It is a sad thing to lose a limb, but it is also a sad thing to die; and what rational being, if he could have his choice, would not rather part with an extremity than with his life ? No humane, enlightened, and conscientious surgeon will ever resort to amputa- tion without being satisfied of its entire and perfect necessity; if he is young and inexperienced, he will be sure to avail himself of the best counsel within^ his reach, while, if he is thrown upon his own resources, he will not fail to ^ 534 AMPUTATIONS IN GENERAL. give the case all the consideration and reflection that his own knowledge, wisdom, and judgment, may enable him to bring to his aid for the relief of the poor sufferer whom he is obliged to mutilate in order that he may rescue his life from the dangers which threaten him. I know of no operation which I approach with so much reluctance as the amputation of a limb, or one which gives me more real pain. To cut off an arm at the shoulder on account of an incipient cancerous affection of the head of the humerus, when the elbow, forearm, hand, and fingers are all perfectly natural and glowing with health, unconscious, so to speak, of the fate which awaits them, is enough to sicken the stoutest heart, and to discourage the boldest operator. If there be a more disagreeable task than this, I am ignorant of it; and yet I would not shrink from its performance even when there is but a faint prospect of pro- longing life, if only for a few months. But the case is different, widely dif- ferent, when the surgeon is called upon to amputate a limb crushed and lacerated by machinery; here there is no choice, no question concerning a cure by mere therapeutic measures; the knife is the only remedy, and the sooner it does its work the greater, as a general rule, will be the patient's chance of recovery. The body, it is true, is mutilated, perhaps sadly dis- figured, but life is safe, and surgery, science, and humanity have achieved a real triumph. So long as there are accidents and diseases incurable by medi- cal treatment, so long will there be a necessity for amputation, and happy is he who shall know when and how to perform it to the best advantage for his patient and the greatest credit to the art and science of surgery. SECT. II.—CIRCUMSTANCES DEMANDING AMPUTATION. The circumstances for which amputation may be required are not only numerous but extremely diversified in their character, and therefore deserving of the most careful consideration. They may be comprised under the follow- ing heads. 1. Mortification, however induced. 2. External injury, as wounds, fractures, and dislocations. 3. Morbid growths. 4. Aneurisms. 5. Diseases of the bones and joints. 6. Intractable ulcers. 7. Malforma- tions and deformities. 8. Tetanus. The topics here enumerated comprise almost every kind of morbid action that can arise in the animal economy, and it will be perceived that they afford a wide and complicated field for the exercise of the talents and judgment of the surgeon. Space will not permit me to enter as fully into their details as might, perhaps, be desired; but I shall endeavor to advert briefly to the more important facts included under each head, having already called attention to some of them in the chapters on gangrene and wounds. 1. Mortification.—Mortification, in whatever manner induced, necessarily imperils limb and life, and therefore often becomes the subject of amputation. Hence the question arises, under what circumstances is a resort to the opera- tion advisable and proper ? This question can only be answered satisfac- torily by a consideration of the nature of the mortification. In the chapter on mortification is an account of the several varieties of this affection, the causes under whose influence they take place, their symptoms, and the means required for their relief. By a reference to that portion of the work, it will be found that, as it respects the operation under notice, the great rule, re- cognized by nearly all surgeons at the present day, in acute gangrene, is, to wait for the formation of a line of demarcation between the dead and living parts, on the ground that it is not generally safe to interfere sooner, lest the disease should reappear upon the stump, and thus destroy the patient, or necessitate a repetition of the amputation. Of the propriety of this rule there can be no question, for there is no surgeon of experience who has not CIRCUMSTANCES DEMANDING AMPUTATION. 535 witnessed its beneficial effects in his own practice, as well as in that of his friends, and yet it is equally true that it may occasionally be violated with great advantage. But I would apply to these cases the term " exceptional," comprising under this head those attacks of mortification which are so apt to supervene upon inflamraation caused by external injury, as wounds, frac- tures, and dislocations, wdiich often spread with immense rapidity, hopelessly overwhelming, if they be not promptly arrested, both the part and system in a few hours. It will not do for the surgeon, in such a case, to fold his arms and become an idle spectator; he must have his eyes and wits about him, or his patient is irretrievably lost; whatever is done must be done quickly. The wished-for line of demarcation will be looked for in vain ; the gangrene will rapidly extend to the trunk, and death will soon close the scene. But in spontaneous mortification, or in mortification from erysipelas, carbuncle, and analogous affections, the judicious surgeon waits for the arrest of the morbid action, his chief care being to bring about this event as speedily as possible by appropriate local and constitutional measures. His rule of action is the same in hospital gangrene; in both cases means are employed for supporting the system, or, what is equivalent to the same thing, for improving the con- dition of the fluids and solids, and the knife is used only when the wished-for line of circumvallation is fully established, not a minute before. In senile, chronic, or dry gangrene, the result usually of ossification of the arteries and of their occlusion by fibrinous concretions, thus depriving the tissues of their due supply of blood, the rule has heretofore been to wait for the cessation of the mortification, experience having shown that, when this precaution is neglected, the disease will be certain to reappear in the stump. It is in view of this liability in mortification to recur that some surgeons, of great eminence and experience, have given it as their judgment that the case should always be left entirely to nature's efforts; in other words, that we should wait for spontaneous amputation, shaping the stump after the dead parts have been nearly completely detached from the living, when, it is alleged, the part and system will be better prepared to withstand the shock of the interference. The propriety of such advice is sufficiently obvious when it is considered that this disease occurs nearly always in very old and infirm sub- jects, and that it is essentially dependent upon obstruction of the arteries leading to the affected parts. Such individuals, as I know from personal observation, are usually very feeble, and have consequently very little power of resisting the effect of shock caused by the use of the knife, and the loss even of a small quantity of blood. Hence it often happens that they sink soon after the operation, even when there has been a distinct line of demar- cation, or that the disease speedily breaks out upon the stump, and soon destroys life secondarily. Seeing how common these events are, would it not be wise in the surgeon, the moment he is brought in contact with these cases, to amputate at a great distance from the disease, ere yet the vital powers have been seriously assailed by the morbid action ; to remove, for instance, the thigh at its middle, for senile or chronic gangrene of the toes and foot ? The only objection to such a procedure, it seems to me, would be where oc- clusion of the main artery of the limb reaches above the knee, a circumstance which would readily be determined by a careful previous examination. Where no such disease exists, and the general health has not yet materially suffered, I should not hesitate to resort to the expedient, under the conviction that, however severe, it was perfectly justifiable in a class of cases so unpromising as this confessedly is. 2. Injuries.—There are no lesions for which amputation is so frequently required as for wounds, fractures, and dislocations. Although they differ widely from each other in regard to the nature of the structures involved, these injuries may all be very properly classed under the same head, the more 536 AMPUTATIONS IN GENERAL. especially as they often coexist, thus rendering it difficult to determine which of them is the most serious. Of wounds, properly so called, the only ones which require to be considered in connection with the present subject, are the lacerated, contused, gunshot, and railway. Wounds inflicted by rabid animals occasionally, it is true, demand amputation, particularly when they extend deeply among the bones, as, for example, when they occur in the hands and feet; but even in such instances complete riddance can generally be easily effected by a careful excision of the bitten parts, and the cauterization of the raw surface after the cessation of the hemorrhage. I should certainly hesitate to cut off an arm or leg under such circumstances ; with the knife and saw I should expect to accomplish all that was necessary, in any case, for the safety of the patient. Lacerated wounds, as well as contused and gunshot wounds, of a most frightful, and, at first sight, apparently of the most desperate character, are sometimes recovered from in an extraordinarily short time, and with hardly any unpleasant symptoms. On the other hand, experience shows that the most insignificant injuries of this kind occasionally prove fatal in a manner and under circumstances which render it extremely difficult to account for the result. It would be a fortunate matter, both for the public and for the interests of science, if the surgeon could always form, if not a positive, at least an approximative estimate of the danger involved in each particular case of these wounds, for then it would be comparatively easy for him to adopt a suitable treatment for the relief of his patient; but, as it is, much must be left, in every instance, to the experience and judgment of the practi- tioner. In general, however, it may be observed that all such wounds are fraught with danger, both to limb and life, when they are attended with extensive laceration of the soft parts; when the muscles have been horribly bruised and pulpified, important nerves cut across, the principal arteries, or arteries and veins, torn open, large joints penetrated, and the bones broken in pieces. Under such circumstances there is not even a " forlorn hope," no matter what may have been the previous health and habits of the sufferer; the knife is required, and the sooner it is employed the better. Such cases are absolutely desperate, and no one who has any knowledge of consequences can hesitate as to the course to be pursued. Upon this point there is no discrepancy of opinion whatever among surgeons. But the injury may be of a less severe character, involving, perhaps, merely a considerable contusion of the soft structures with a compound fracture ; or several muscles may be badly lacerated and the principal artery of a limb cut across; or a large nerve, the main trunk, it may be, be divided, and the interior of a large joint exposed. The case now assumes a more trying aspect; the responsi- bility falls upon the surgeon with tenfold force; for the question naturally, and at once arises, What shall be done ? Shall such a limb be immediately amputated, or shall an attempt be made to preserve it ? This is a question which will probably be asked by the patient himself, or by his friends for him, and which it is often extremely embarrassing and difficult to answer; in fact, it can only be answered upon general principles in one sense, and upon special principles in another. Looking at such injuries in a general manner, we might be inclined to give a favorable prognosis, because it is undoubtedly true that recovery from such lesions is by no means uncommon ; but when we come to examine into the particulars of the case, we might not regard it in so auspicious a light. Thus, for example, the patient's ante- cedents may all have been bad, perhaps of the worst possible description; intemperance and dissipation of various kinds raay have undermined his con- stitution, and thus rendered it unfit to bear up under an injury which he would formerly have supported without difficulty; or, instead of this, there may be serious structural disease of sorae vital organ, as the heart, stomach, CIRCUMSTANCES DEMANDING AMPUTATION. 537 or lungs, disqualifying him for enduring the accidental and now heavy burden. All these circumstances must have their weight with the practitioner when he is called upon to sit in judgment respecting the propriety or impropriety of an amputation. Conservative surgery may, and does do much, but it cannot do everything; it has its limits, beyond which it cannot safely go, and there are many points which require to be considered in order that it may do itself justice. A very severe injury, occurring in a stout youth, of healthy constitution and temperate habits, is often promptly recovered frora, while less than one-third of its amount in a sickly, anemic, or dissipated person, will frequently destroy life in a few days, or, at all events, so far endanger it as to cause great anxiety for the result. Gunshot, railroad, and steamboat accidents, and injuries occasioned by the caving in of stone quarries, are extremely liable, if an attempt be made to save the limb, to be followed by the worst results ; and, what is particularly embarrassing in these cases, is the difficulty which the practitioner often en- counters in ascertaining the precise amount of the lesion. The limb, perhaps, is entirely free from contusion and wound, or if there be any injury of this kind, it may be so slight as to be regarded as of no consequence. The mis- chief is deep-seated, and, upon careful examination, it will probably be found to involve nearly every important structure; muscle, tendon, aponeurosis, vessel, nerve, bone, and joint. Such cases obviously require the closest scrutiny with a view to the speedy detection of their true nature and their proper mode of management. Generally the limb is hopelessly injured, and will require removal. Compound fractures and dislocations, and gunshot wounds of the joints, often require amputation, and yet it is remarkable how the parts and system sometimes bear up under such injuries, especially in young and healthy sub- jects. Under the improved methods of management of modern surgery re- coveries occasionally occur, which, in former times, when their treatment was less perfectly understood than it is now, would have astonished the practi- tioner. In this country the treatment of compound fractures an'd dislocations by collodion, thereby converting these lesions into simple accidents, and of the former by extending and counter-extending bands of adhesive plaster, has greatly contributed to this result. The danger of these injuries is much greater, other things being equal, when they occur in the inferior extremity than when they occur in the arm and forearm, and in all cases the risk is much increased when they are accompanied by an open state of an important articulation, as that of the hip, knee, ankle, shoulder, elbow, or wrist. Compound fractures in the continuity of a limb, unless complicated with serious lesion of the soft structures, do not generally require amputation ; if judiciously managed, they will usually get well without much trouble. Gun- shot wounds, occurring in civil practice, are commonly less dangerous than injuries of this kind happening on the field of battle or on shipboard. I have seen enough of the former of these accidents to satisfy me that the pa- tient will often recover with a very good limb, even when there has been ex- tensive loss of substance and great comminution of the bones. In military practice, on the contrary, there will often be much difficulty in preserving the parts, simply because it is frequently impossible to treat the case properly on account of the want of suitable accommodations and a salubrious atmosphere. It is for these reasons that amputation is so often resorted to, during and after engagements, in cases which, if they took place under ordinary circum- stances, would be successfully managed by milder means. When amputation is determined upon, in these and similar accidents, the next question that arises is, when should the operation be executed ? Shall it be performed immediately, or shall we wait until some time has elapsed, until the system has had an opportunity of recovering from the shock of the 538 AMPUTATIONS IN GENERAL. injury ? To use the knife while the patient is in an exhausted, pallid, and perhaps almost pulseless condition, would only serve the more certainly and effectually to seal his fate; the additional shock to the constitution resulting from theloss of blood and nervous fluid could hardly fail to prove most dis- astrous. Hence the rule is always to postpone a resort to the knife until there is satisfactory evidence of reaction; until, in short, warmth and color return to the surface, the pulse beats vigorously at the wrist, and the sufferer regains, in some degree, his consciousness and courage. Now the use of chloroform is well borne, and the limb is removed with comparative impunity. On the other hand, care is taken not to defer the operation until the part and system are assailed by inflammation, which, as experience teaches, often ex- tends with frightful rapidity under such circumstances, placing the case, per- haps, literally beyond the resources of surgery in the course of a few hours. There is, therefore, a time when interference must be avoided, not less than a time when it must be courted. The limits of these two periods are not always well defined, and hence much must be left, in each individual case, to the judgment of the attendant. When amputation is performed immediately after reaction has taken place, it is usually designated by the prefix " primary," while the term "secondary" is used to denote the operation when it is executed after the limb has passed through the different stages of inflammation, an attempt having been made, perhaps well grounded, so far as the interpretation of the symptoms is con- cerned, to save the parts. Such a contingency must necessarily happen rather frequently, especially in civil practice; indeed, it is often altogether unavoidable on account of the obstacles interposed by the patient and his friends, not to say anything of the wavering and indecision of the professional attendant. But, although often unavoidable, such an occurrence is always much to be regretted ; for if the chances of saving limb and life were bad in the first instance, they are now generally much worse; the system has been impaired by fever and perhaps hectic irritation, the secretions are seriously deranged, the patient has little appetite and sleep, the blood is thin and watery, and the whole body is much emaciated. Life may possibly still be preserved, but the probability is that the operation will be attended with much risk, and that ultimate recovery is far off. Moreover, a much larger amount of limb may now have to be sacrificed; originally a foot might have sufficed, whereas now, in consequence of the ravages of the inflammation, the whole leg may perhaps require removal. There is, then, obviously an ad- vantage in a primary over a secondary amputation, provided it is performed at the proper time, that is, after the establishment of reaction and before the occurrence of inflammation; and this circumstance is often eagerly embraced by the military surgeon, whose will is always law with his patients. 3. Morbid Growths.—Amputation is sometimes required on account of morbid growths, or tumors, both benign and malignant. The removal of the forearm is perfectly proper for the cure of carcinoma of the hand, and of the arm at the shoulder for a similar affection of the humerus. No such opera- tion is of course admissible if there is marked constitutional involvement, enlargement of the neighboring lymphatic ganglions, or decided tendency to ulceration; the propitious period has gone by, and interference would only hasten the fatal event. It is not so, however, as long as the general health remains good, and there is no evidence of general or local contamination; under such circumstances the probability is strong that removal of the limb, although it may not prevent a recurrence of the disease, will yet considerably prolong the patient's life. A tumor, wholly divested of malignancy, may, in consequence of acting obstructingly, cause so much functional and other disturbance as to demand removal of the limb upon which it is situated. The procedure will be par- CIRCUMSTANCES DEMANDING AMPUTATION. 539 ticularly called for when the morbid growth is intimately connected with a bone, or deeply and inseparably involved in the soft parts, or prolonged into an important joint, compelling free exposure of its surfaces during the opera- tion. A valuable rule in tumors is to excise the benign, and to get rid of the malignant by amputation. 4. Aneurism.—Neglected aneurisms, seated in the extremities, and una- menable to ordinary treatment, occasionally call for the removal of the limb ; in former times, such operations were sufficiently frequent when the disease occupied the popliteal region, though at present they are seldom, if ever, re- quired, except when mortification sets in after ligation of the femoral artery, or in consequence of the injurious compression exerted by the tumor upon the leg. 5. Affections of Bones and Joints.—Various affections of the bones and joints, as caries, necrosis, morbid growths, aneurism, and anchylosis, may impose the necessity of amputation ; and there is, according to my experi- ence, no class of diseases in which the operation has been more frequently abused, or misapplied. There can be no question that many a limb, merely temporarily crippled by remediable disease, has been ruthlessly sacrificed to ignorance and a desire for eclat; carious joints, now that excision has been revived, can seldom demand so harsh a procedure, and as to necrosis, pure and uncomplicated, it is difficult to conceive of a case justifying the use of the knife. It is only, or mainly, in white swelling, or scrofulous disease of the knee, ankle, and elbow, attended with hectic irritation, excessive pain, and exhausting diarrhoea, that the removal of the limb can be proper, and even then it should not be thought of if it be possible to exsect the affected structures without imperilling life by shock and loss of blood. In whatever manner the offending parts are gotten rid of, it is surprising to witness the great improvement which usually follows the operation ; the profuse sweats and alvine discharges rapidly disappear, the appetite improves, the sleep becomes refreshing, and the patient soon regains his flesh and strength. Un- fortunately, the operation is generally put off to an unreasonable period, so that when it is at length performed, the sufferer too frequently sinks under its effects. Of malignant growths of the bones almost the only one demanding ampu- tation of the limbs is encephaloid ; scirrhus, melanosis, and colloid are ex- tremely infrequent in the osseous tissue, but whenever they occur, and their diagnosis can be determined, the same treatment must be applied to them as to medullary cancer; that is, early and thorough removal by the sacrifice of the suffering extremity, mere incision being always inadequate by reason of the involvement of the soft parts. Temporary relief only is aimed at; sooner or later the disease recurs, either at the cicatrice, or in some neighboring organ, and carries off the patient. Fibrous, fibro-plastic, cartilaginous, and osseous growths, involving the bones, sometimes constitute a legitimate ground for amputation. An exos- tosis, of enormous size, and grotesque form, may render an extremity not only perfectly useless, but a source of the greatest inconvenience and even suffering. The so-called osteo-sarcomatous tumors are, perhaps, of all the morbid growths of the skeleton, the most common causes of amputation of the limbs. Aneurismal formations of the osseous tissue, met with chiefly in the head of the tibia, always demand the same remedy. Finally, amputation may be required on account of anchylosis of a joint, interfering with the comfort and usefulness of the extremity. Thus, in an- chylosis of the knee, the leg may stand off at a right angle with the thigh, so as to interfere materially with the occupation of the individual, and induce a wish for an artificial limb, which, if well constructed, is generally worn with great satisfaction. Stiff and crooked fingers aud toes are often the sub- jects of amputation. 540 AMPUTATIONS IN GENERAL. 6. Ulcers.—Amputation is sometimes performed on account of old and inveterate ulcers of the extremities; the operation, however, is less frequently resorted to now than formerly, and might, with proper management, be almost entirely dispensed with. Unless the sore is of a cancerous character, or caused by burns, scalds, and frost-bites, or complicated with serious lesion of the bones, excessive enlargement of the veins, or great hypertrophy of the integuments, there are few cases, it seems to me, that will not gradually yield under judicious treatment. Of the numerous ulcers of the extremities that have fallen under my observation, embracing, of course, many of the worst description, I have a distinct recollection of only three that required this harsh measure. Whether other practitioners have been equally fortu- nate I am not able to state ; but, judging from the reports of cases in our periodicals, it is highly probable that the operation is still not unfrequently performed on this account. 7. Malformations.—There are certain malformations and deformities for the relief of which amputation may be demanded. An irremediable club- foot, especially if complicated with a painful bunion, and intractable ulcer, or excessive atrophy of the leg, would form a proper subject for such an operation, for there are few men who would not rather run the risk attending its performance than to be incessantly fretted and worried by such a disa- greeable and useless companion. Supernumerary thumbs and fingers are disposed of in the same manner; the operation is usually done within a few months after birth, and I have never known it to be followed by any bad consequences. Amputation is occasionally necessary on account of defor- mity caused by burns and scalds, or badly treated fractures and luxations. 8. Tetanus.—The propriety of amputating in tetanus has been so long doubted by many of the highest authorities in surgery that the question hardly merits serious consideration in a work of this kind. I have certainly not seen anything in my own practice tending to contradict an opinion now almost universally entertained by the profession in this and other countries. If such a measure is ever justifiable, it must be at the very commencement of the disease, before the supervention of the characteristic symptoms. I have seen a very considerable number of instances of acute traumatic tetanus, and, with one solitary exception, they have all proved fatal. This case occurred in a stout, well-fed countryman, aged fifty years, the fore and middle fingers of whose right hand had been badly mashed by the passage of the wheel of a wagon ; symptoms of tetanus came on five weeks after the accident, and, although the disease had existed for five days when I amputated at the raeta- carpo-phalangeal articulation, yet complete recovery followed, not, however, without a slight continuance of the spasms for a short time after. I presume a practitioner would hesitate to cut off a large limb after the development of tetanus in any case ; for, whatever notions we may entertain respecting the pathology of this affection, there can be no doubt that, once fully established, it must be looked upon as a constitutional disorder in the widest sense of that term. SECT. III.—METHODS OF AMPUTATION. Two principal methods are in vogue for performing amputation of the limbs, whether in their continuity or at the joints. These are the circular and the flap, both of which, but especially the former, are of ancient date, and therefore well grounded in the esteem of the profession. To these was added, early in the present century, the oval operation, which, although ex- cellent in its way, has hitherto received but little attention; certainly less than it deserves. Very recently, an opecation, termed the rectangular, has METHODS OF AMPUTATION. 541 been proposed. It is not my object to enter into the history of these different methods, for to do so would carry me back into the regions of doubt and speculation; but it will be expected that I should offer some remarks con- cerning their respective advantages and disadvantages, and this I shall en- deavor to do in as concise and impartial a manner as may be consistent with the great interest and importance of the subject. 1. Circular Method.—The circular operation, the most ancient of all, was originally performed in the most simple manner, the integuments, muscles, and bones being all divided upon the same level. The consequence of this procedure was that the bones, being inadequately covered by the soft parts, or, rather, not covered at all, invariably perished to the distance of several inches, thus sadly protracting the cure, besides subjecting the patient to much suffering and not a little risk in the interval. As surgeons became more enlightened, they endeavored to provide against this contingency by forcibly pulling back the muscles, by means of a peculiar contrivance called a retrac- tor, before using the saw, which was then applied close to the surface of the tissues. At a later period still, and as a decided improvement upon the pre- ceding methods, arose the plan of double incision, devised by Cheselden, better known for his success as a lithotomist than for his exploits as a general operator. It consisted, as, indeed, the name sufficiently indicates, of two stages, in the first of which the integuments were cut and drawn back, while in the second the muscles were divided higher up, the object being to afford more thorough protection to the bone. The operation of the English sur- geon has undergone various modifications, some of which, having only served to render it more complex, have been justly discarded from practice. To this category belong the division of the muscles by two circular incisions, one higher up than the other, and the plan of scooping out the parts as the knife was being swept obliquely around them by cutting from below upwards and from without inwards towards the bone, which thus formed the apex of the hollow cone. The circular operation, as now generally practised, consists, first, in divid- ing the common integuments, dissecting them from the parts beneath, to a variable extent, and then drawing them back, or even turning them up like the cuff of a coat; secondly, in cutting through the muscles on a level with the retracted skin, and after detaching them for some distance from the bone, to hold them also forcibly back; and, thirdly, in sawing off the bone as high up as possible with- out doing violence to the soft structures. In ex- ecuting these several stages of the proceeding the long amputating knife, poised lightly between the thumb and fingers, is carried rapidly round the limb, the point being inserted into its anterior surface, external to the median line, and thence drawn towards the operator in such a manner that the heel of the instrument shall finish the incision. The wound thus made extends simply down to the aponeurosis, and care should be taken that it occupies the same level throughout, unless there be special reasons for carrying it higher or lower at one point than at another, rendered necessary, it may be, by the presence of a vicious cicatrice, ulceration, gangrene, or some morbid growth. The flap is then rapidly disseeted up ^t"™^ either with the same instrument, or a large seal- turned backj and the rauScies cu- pel, and held out of the way, its length being vided down to the bones. Fig. 156. 542 AMPUTATIONS IN GENERAL. regulated by the thickness of the limb, about two inches being a good average. The amputating knife being now resumed, and held as before, is applied closely to the edge of the retracted integuments, and then drawn round the member so as to divide all the muscles down to the bone, as represented in fig. 156. This- part of the operation is usually the work of a few seconds. The next step is to separate the muscles carefully from their connection to the bone, to the distance of at least an inch and a half, if not more, when, being pressed forcibly back by means of a retractor, the bone is sawed off close to their surface. The adjoining cuts, figs. 157 and 158, afford a good illustration of the appearances of the limb, both below and above the stump, after this operation. Fig. 157. Fig- 158. Appearance of the limb below the seat of the ampu- Appearance of the stump in the circular ampu- tation, in the circular operation. tation. In sawing the bone, whether in this or in the flap operation, it is an object of primary importance to inflict as little injury as possible upon the periosteum; for the less the integrity of this membrane is disturbed the less likelihood will there be of necrosis and other bad consequences. When the periosteum is very thick, as in the thigh-bone, it would be well, in view of this circum- stance, to make a circular track in it for the saw, in order that there may be no risk of laceration. The manner of dividing the bone is a matter of some moment. In most of the amputations that I have witnessed the instrument was applied against the front of the bone, instead of being held perpendicu- larly so as to divide the bone from side to side, as it generally should be to avoid fracture, which is so liable to happen if proper care be not taken to support the limb in this stage of the procedure. Particular rules are usually laid down by authors for working the saw. Thus, it is generally stated that the heel alone of the instrument should be used until a track is made for it to move in ; but I consider all such directions to be unnecessary, if not frivo- lous. If the saw is properly set it is of little consequence, according to ray experience, what part is applied first or last, or whether it be moved rapidly or slowly, although, as a matter of choice, I should prefer to finish the opera- tion as quickly as possible. When there are two bones of equal size to be cut, as in amputations of the forearm, they should be divided simultaneously; but if one is thicker than the other, as in the leg, the weaker must always be separated first, lest, if it should remain until the other is sawed through, it METHODS OF AMPUTATION. 543 should be broken or splintered, and so impose the necessity of employing the nippers to smooth off its extremity. When a limb is removed at a joint, the best plan, as a general rule, is to dispense with the use of the saw and pliers altogether, experience having shown that the preservation of the articular cartilages greatly favors the adhesive process, and thereby expedites the cure. Sawing off the ends of the bones exposes the parts to suppuration, erysipelas, caries, necrosis, and even to the danger of pyemia. 2. Flap Method.—Although the flap operation was described, and no doubt practised, by some of the earlier surgeons, yet it does not seem to have received any particular attention until towards the close of the seventeenth century, when Lowdhara, of Oxford, England, published a short tract upon it, setting forth its advantages over the circular method. After this period, it was occa- sionally performed in different parts of Europe, especially in France and Eng- land, but it never fully acquired the confidence of the profession until the time of Mr. Listen, whose teachings and writings brought it into general notice. There are several methods of forming the flaps, the choice of which must be regulated by the particular circumstances of each individual case. Thus, the operation may be performed by transfixion of the limb, and cutting from within outwards, by commencing at the surface, and carrying the knife inwards towards the bone, or, lastly, by making one of the flaps after the former fashion, and the other after the latter. In amputations of the thigh and arm, it is customary to make both flaps by transfixion, as the operation is thus greatly simplified and rendered more expeditious; but in the forearm, hand, fingers, leg, foot, and toes, they are formed either by cutting inwards, or one by cut- ting inwards and the other by cutting outwards. The number of flaps varies; in general there are two, but occasionally there is only one, and, on the other hand, there may be as many as three ; accident, or the situation and structure of the limb, rendering one of these modes preferable to the other. Thus, in one instance, I amputated the thigh at its middle by a solitary flap, and suc- ceeded in effecting an excellent cure. The military surgeon is often com- pelled to form his flaps as best he can, owing to the manner in which the soft parts are injured, and in civil practice the same difficulty sometimes occurs in consequence of the effects of disease. Whatever may be the nature of the case, the rule is never to include any unsound tissues or any portion of bone that is fractured or divested of periosteum. In amputating the thigh and arm at their middle, the flaps are generally cut of the same length ; but in most other situations one is usually made considerably longer than the other, depending upon the greater amount of muscular substance. Their relative length must be regulated by the thickness of the limb, and the quan- tity, laxity, and contractility of the soft parts. It is better, in every case, to have too much substance than too little, but the judicious surgeon will always endeavor so to cut his flaps as to have just enough, and no more, to form a well-shaped and useful stump, redundancy being always unseemly, if not ac- tually iu the way of comfort and convenience. As a general rule, their length should equal about three-fourths of the diameter of the limb, being invariably greater than in a similar operation upon the dead subject, to allow for con- traction and shrinkage. The form of the body of the flaps is commonly somewhat convex, while the extremity is more or less oblique, care being taken that they do not terminate in thin, narrow ends, and that there is always an abundance of integument after they are adjusted over the bone. When the muscular tissue is unusually abundant, as often happens in ampu- tating through the calf of the leg, I have found it advisable to retrench it with the knife, in order to give the stump a more seemly shape, as well as to place it in a better condition for bearing the pressure of an artificial limb. 544 AMPUTATIONS IN GENERAL. In performing the operation the same general rules are to be observed as in the circular method ; hemorrhage is restrained by the same means, and the skin is drawn back by the hands of an assistant, who also retracts the flaps as one after the other is made, and thus holds them out of the way of the knife and saw. Any important vessels that may be bleeding are instantly compressed by the fingers until they can be tied. Before applying the saw the knife is pressed closely around the bone so as to divide every muscular fibre, and also, if possible, the periosteum. The most suitable instrument for removing the larger limbs is a long amputating knife ; for the smaller ones, an ordinary scalpel, bistoury, or catlin will answer best. Separation of the member having been effected, and the vessels carefully secured, the next thing to be done is to cut off the principal nervous trunks a little above the level of the surface of the stump, and, as the operation is one of excessive pain, it should always be performed before the patient has fully recovered from the influence of chloroform. I need not dwell upon the importance of thus dealing with the nerves involved in the flaps ; the necessity of the pro- cedure must be obvious upon the slightest reflection. When it is considered that they always become more or less enlarged and bulbous after all opera- tions of this kind, it is easy to perceive what would be the consequence if they were brought in contact, as some of them almost inevitably would be, with the extremity of the bone, before it has had time to become rounded off. I regard no amputation by the flap method as being finished unless provision has been made against such a contingency. The adjoining cuts, figs. 159 and 160, represent the appearances of the stump and of the limb after its re- moval. Fig. 159. Fig. 160. Fig. 159. The flap operation illustrated in the Fig. 160 The corresponding stump ; intended to thigh. The sloping wounds, whence the flaps exhibit the comparatively small extent of wound have been taken, shown in the amputated part. that remains. 3. Oval Method.—In the oval method, as it is termed by Scoutetten, by whom it has been generalized, or the oblique process, as it has been called by others, the wound has somewhat of the shape of an ovoid, the small ex- tremity of which corresponds to the bone or joint which is the seat of the amputation. The operation holds a kind of intermediate position between the other two, resembling the circular process in the mode of incising the soft parts, and the flap in the form of the wound. It is more especially METHODS OF AMPUTATION. 545 Fig. 161. adapted to amputations of the joints, particularly the smaller, as, for example, the metacarpo-phalangeal, but has also been applied to the joints of the hip and shoulder, especially by Guthrie, Larrey, and Scoutetten, who have de- vised plans which severally bear their names. . In the oval operation the flaps are formed by cutting from withont inwards, or one is formed in this way and the other by cutting in the opposite direc- tion, or from within outwards. It is commenced by making two incisions in the shape of the letter V reversed, the angle of union falling a little above the place where it is intended to saw the bone or effect disarticulation. These incisions are, of course, extended as far as the periosteum, when the knife, drawn closely round behind the bone, is carried downwards on a level with the termination of the two cuts already made, thus connecting them by one thrust, as the instrument sweeps through the intervening tissues. By adopting this plan of procedure the surgeon will have it in his power to leave the principal vessels and nerves until the operation is nearly completed, a cir- cumstance which thus affords him a much better control over the hemorrhage. The oval operation usually makes an excellent stump, there being always an abundance of material for covering the bone ; it is generally a little more tedious than the flap amputation, but this should not be urged as an objection to it, as in all other respects the result is most satisfactory. 4. Rectangidar Flap.—Mr. Teale, of Leeds, has recently modified the double flap operation by substituting a long and a short rectangular flap. The long flap should be made from the portion of the limb which does not contain important bloodvessels and nerves, these being included in the short one. Before proceed- ing to the operation, the lines of the incision should be traced with ink, in order to insure the proper dimensions of the large flap, which should be equal, in its length and breadth, to one-half the circumfe- rence of the limb at the point am- putated. The short flap, which should be made last, should be one-fourth the length of the long one. The lines of incision and the length of the flaps will be more easily understood from the annexed cut, fig. 161, representing an amputation of the thigh. The parts having been dissected off, in close contact with the periosteum, the long flap will be found to be perfectly square, and to contain a sufficient amount of mova- ble soft parts to form a complete cushion for the end of the bone, which must be sawn off perfectly straight, and must be free from spi- cules, in order to prevent ulceration of the soft structures. The arteries having been taken up, the long flap is brought down over the end of the bone, and attached to the short one by several points of the interrupted suture. The short flap is also at- tached to the long flap laterally, as vol. i.—35 Teale's amputation, shown in the thigh, the lines in- dicating the size and form of the flaps. Teale's operation, the flaps being drawn together. 546 AMPUTATIONS IN GENERAL. is also the reflected portion of the long flap to its unreflected portion. The appearances of the parts, when brought together, are shown in fig. 162. Beside the sutures no other dressings are employed. The stump is placed on a pillow covered with a sheet of gutta-percha, and is protected by a wire cage from the pressure of the bedclothes. Should the wound gape during the process of union, a few adhesive strips may be applied, to give the flaps proper support. Absolute rest is enjoined; and the stump should not be disturbed, the discharges being removed from the parts and the gutta-percha cloth by a soft sponge. Mr. Teale publishes a summary of fifty-six cases treated by his method during the last three years. Of these, the whole number of deaths was seven, or in the proportion of one to eight. Eighteen operations were performed on the thigh, twenty-eight on the leg, six on the arm, and four on the fore- arm. Of this whole number, only six cases were of traumatic origin, and of these but one resulted in death. This shows a great contrast with seventeen traumatic operations at the Leeds General Infirmary, by the same surgeons, of which ten died, seven from the effects of purulent infection. Amputation of the thigh for disease by this method exhibits a mortality of nearly one case in six, whilst in the London hospitals it is as one in four and a half, and in the provincial hospitals, as one in four. The rate of mortality in amputations of the leg for disease is one in twenty- seven. In the London hospitals it is one in three and two-thirds, and in the provincial hospitals one in four. Mr. Teale, after carefully analyzing 640 amputations of the thigh and leg, for disease or injury, performed by the ordi- nary methods in the London and provincial hospitals, found the mortality to be nearly one in three. In forty-six amputations of the thigh and leg by the rectangular flap, for injury or disease, the fatality is one in fourteen, showing a most striking contrast with the above facts. SECT. IV.—OPERATION AND AFTER-TREATMENT. The position of the patient and the surgeon, the number and duties of the assistants, and the character of the instruments, must necessarily vary in dif- ferent cases and under different circumstances, and can therefore be pointed out here only in a general manner. Whenever it is practicable, the patient should be placed recumbent, as he will thus be much less liable to become faint, and at the same time bear the effects of chloroform much better than when he sits up. He may, however, put himself in the latter position without any inconvenience during the ampu- tation of a finger or toe, or even of the arm or leg, if he is courageous, and willing to dispense with chloroform, or to take ether in its stead. The limb is generally held horizontally, away from the table, one assistant retracting the integuments, and another supporting the portion to be removed. A third assistant takes charge of the tourniquet, but before applying it care is taken to empty the superficial veins by raising the limb and pressing it from above downwards : or, instead of this, the extremity is tightly bandaged just before the operation. Such a precaution, however, is only of material moment when the patient is very feeble, and therefore ill able to bear the loss of blood. Chloroform having been administered, the instrument is firmly secured round the limb, the frame resting upon a thick, narrow compress, lying directly over the main artery, and, when all pulsation is arrested, the operation is proceeded with in as rapid, orderly, and careful a manner as possible. When the amputation is performed high up near the trunk, the tourniquet may ad- vantageously be replaced by the compression of the hands of an assistant, who trusts either to his thumbs alone, or else makes the requisite pressure by OPERATION AND AFTER-TREATMENT. 547 means of the handle of a stout key, wrapped round with a piece of muslin. The same plan for restraining hemorrhage is adopted in amputating at the hip and shoulder-joints. In separating a large limb, not less than five assist- ants are generally necessary ; one for administering chloroform, a second to take charge of the tourniquet, a third to hold up the flaps, one to support the distal portion of the member, and a fifth to hand the instruments and sponges, and aid in securing the arteries. A small number will of course suffice when we remove a finger or other insignificant part. The different methods of amputation are described in the preceding section. The one which I prefer is that by flap, though it cannot be denied that a most excellent stump raay be made by the circular operation. The rectangu- lar method I have never performed, but it seems to me to be a procedure well worthy of attention, as the arrangement of the long flap not only thoroughly protects the bone, but, what is a matter of great consequence, admits of ready drainage. The oval operation is admirably adapted to amputations at the joints and to resections of the bones. My reasons for preferring the flap to the circular operation, are, first, be- cause it is more simple and easy of execution ; secondly, because it makes, as a general rule, a much better covering for the bone, and, lastly, because the patient experiences much greater comfort in wearing an artificial limb. Mr. Palmer, who has for many years been en- gaged in the manufacture of arti- ficial legs, assures me that stumps made by the circular operation seldom answer well for the adapta- tion of an artificial substitute. The principal instruments re- quired for the operation are, for the larger limbs, a tourniquet, an amputating knife, a catlin, saw, and pliers, which are properly arranged upon a tray in the order in which they will be needed. For removing the fingers, hand, toes, and foot, an ordinary scalpel will commonly suffice. The tourniquet in general use is that of Petit, the construction and arrangement of which may be readily learned from the annexed sketch, fig. 163, a circumstance which, besides the fact that it is found in every cutler's shop, will render any formal description of it unnecessary. The tourniquet of Petit was re- cently modified by Mr. Tiemann, of New York, in such a manner as to concentrate a much greater amount of pressure upon the artery, at the same time that it does not embar- rass the venous circulation. The pad is placed either horizontally or crosswise upon the vessel, and the strap, carried round the limb, is passed through the two side Petit's tourniquet. Tiemann's improved tourniquet. n 548 AMPUTATIONS IN GENERAL. apertures in the metallic plate, after which the ends are drawn very tight, and fastened on the protruding hooks. The arrangement of the different pieces of the instrument is seen in fig. 164. Fig. 165 represents an arterial compressor which I devised several years ago, as a convenient substitute for the ordinary tourniquet, over which, I conceive, it possesses several decided advantages; first, in the facility of its Fig. 165. Author's artery compressor. application ; secondly, in the amount of pressure which it is capable of ex- erting ; thirdly, in its ready adaptation to limbs of different dimensions; fourthly, in the circumstance that it makes pressure only at two points, that is, over the artery, and at the spot immediately opposite to the artery; and, lastly, the facility with which it may be slackened or removed at any stage of the operation. With a little modification, the instrument may readily be adapted to the femoral artery as it emerges from beneath Poupart's liga- ment, or even to the external iliac just above this ligament, in amputation at the hip-joint, and also to the axillary artery, in disarticulation of the shoul- der-joint. By a reference to the cut, it will be seen that the instrument is composed of two blades, differing in the degree of their curvatures, united by a screw, and regulated by a rachet. Each short blade is provided with a pad, capa- ble of being worked by a screw, and designed to rest upon the artery which it is intended to compress. By this arrangement two tourniquets are pro- duced : a large one for the thigh, and a small one for the arm, or the thigh of a small subject. The ordinary amputating knife, seen in fig. 166, is from nine to twelve inches in length, by about five lines in width, with a moderately thick back, spear-pointed, and furnished with a stout, rough, ebony handle to prevent Fig. 166. Amputating knife. , it from dropping out of the hand if it should become smeared with blood. The principal edge should extend the whole length of the blade, and be in the best possible condition for executing its important office, well tempered, and perfectly sharp. The edge upon the back should not be longer than an inch and a half. With such an instrument properly managed, nearly all the amputations in the body may be performed with great neatness and despatch. OPERATION AND AFTER-TREATMENT. 549 The catlin, shown in fig. 167, is a double-edged knife, used principally in removing the forearm and leg, and for dividing the interosseous muscles and ligaments; I cannot see, however, that it possesses any special advantage, even in these cases, over the larger knife just described. Fig. 167. Catlin, or double-edged knife. Every amputating case contains a large saw, resembling the common dove-tail saw of the cabinet-maker. The adjoining sketch, fig. 168, repre- Fig. 168. Amputating saw. sents the form of the instrument which I am myself in the habit of using. The blade, which is very firm, is ten inches and a half in length at the cut- ting edge, by two inches and one eighth in breadth, exclusive of the back, whfch fs very thick and convex, in order to afford the proper degree of strength which such an implement should always possess. The handle is rough, and sufficiently large to receive two fingers, while the thumb and fore- finger are applied to its surfaces, parallel with the upper border, to keep it steady while engaged in the discharge of its duty. The teeth are rather large but sharp, set crossways on the edge, that the instrument may not hang or hitch as it works its way through the bone. The manner of using the saw has already been described. A small saw, such as is represented in fig. 169, will be of great service in amputations of the hand and foot. Fig. 169. Small amputating saw. Cutting-pliers, seen in fig. 170, of various sizes and forms, must be at hand ; they should be short but rather slender in the blades, and very long Fig. 170. Bone nippers. and strong in the handle. Although I never use these instruments wdien it is possible to employ the saw, on account of their tendency to bruise the 550 AMPUTATIONS IN GENERAL. osseous tissue, yet they are of great convenience for removing sharp spicula, and cutting off certain pieces of the skeleton, as the phalanges of the toes and fingers, the ribs, and jaws. As it respects the permanent dressings after amputation, they should be of the lightest and most simple character. In the larger operations they should not, as a general rule, be applied before the lapse of four or five hours, by which time the surfaces of the wound will usually be glazed with lymph, and all danger of hemorrhage be past. I can conceive of nothing more awkward for the surgeon or disagreeable to the patient, than the necessity of undoing the dressings, some hours after the removal of a limb, for the purpose of searching for bleeding vessels. Such a procedure is sure to cause alarm and suffering; and, although it is always desirable to complete the dressings as early as possible in ordinary cases, yet after a large amputation, involving vast and numerous muscles liable to conceal arteries of considerable size, I regard it as a matter of great consequence not to hazard the necessity of their removal. During the period that intervenes between the operation and the permanent dressings, the limb should be placed in an easy and elevated position, and the flaps should either be loosely approximated with a few adhesive strips, or, what is better, left apart, and covered with light com- presses wet with cold water, and frequently irrigated ; not changed, unless soaked with blood, as this would only lead to exposure and irritation of the parts. All bleeding and danger of bleeding having ceased, the flaps are carefully stitched in place, the ligatures are brought out at the nearest points, and the intervals between the sutures are covered with long and rather narrow strips of plaster, to admit of sufficient drainage. This should be still further favored, when the breach is very large and deep, by the insertion of a slender tent in the lower angle of the wound, and strict attention to the position of the stump. To a want of these precautions are unquestionably to be ascribed some of the bad effects of these operations, as pyemia, profuse suppuration, and the death of the extremity of the bone. The wound being firmly closed at all points, the matter, of which there is nearly always more or less after all large amputations, accumulates in the depths of the stump, around the bone, and among the muscles, thus causing necrosis of the former, and affording the veins and lymphatics of the latter an opportunity of conveying the fluid into the system, and thereby inducing secondary abscesses. Now, all this risk may be effectually prevented by adopting the plan here suggested of keeping a long, slender, aud well-oiled tent in the lower part of the wound for the first thirty-six or forty-eight hours; at the end of this time it may be carefully removed, and any pus that may be present gently pressed out. A gum-elastic tube may now, if necessary, take the place of the tent, with a view to a more ready and steady drainage; or, if the suppurative crisis is passed, the foreign body may be dispensed with, and the case managed in the ordinary way. The adhesive strips must, if possible, extend four or five inches beyond the upper extremity of each flap, especially in the larger amputations, so as to prevent the retraction of the integuments; and for the purpose also of quieting the muscles and bringing them well forward over the bone. I have been in the habit for many years of beginning the application of the roller at the part of the limb nearest the trunk, carrying it firmly and equably down- ward to the very verge of the stump, which is then enveloped by a few crucial turns of the bandage, to give it greater support. No other dressing is necessary. The limb is now placed in an easy and slightly elevated position, over a sheet of gutta-percha, and kept constantly wet with cold water, applied by means of a light porous napkin, substitution being employed only in the event of the cloth becoming bloody or offensive. If suppuration be threat- SYNCHRONOUS AMPUTATION. 551 ened, pr the cold is disagreeable and chilling in its effects, the most eligible remedy will be an emollient cataplasm or the warm water-dressing. Provi- sion is of course made to protect the stump from the contact of the bedclothes. As soon as the operation is over, a full anodyne is ordered, for the twofold purpose of relieving pain and preventing spasm ; and the dose is afterwards repeated from time to time as circumstances may seem to demand its exhibi- tion. • The diet should be light but rather nourishing than otherwise ; and, with the exception of a mild aperient on the second day, no medicine what- ever should be given unless it is absolutely necessary on account of the violence of the traumatic fever, or the danger of exhaustion from shock and hemorrhage. When the system is much depressed at the time of the opera- tion, it will be well, as a general rule, to put the patient at once upon a generous diet, and perhaps even upon the use of milk punch. I am satisfied, from what I have seen of these cases, that the worst possible plan that can be pursued is starvation ; this not only weakens the system still farther but tends powerfully to the production of pyemia and typhoid fever. The dressings may require removal within forty-eight hours after the opera- tion, or not under three or four days, according to the condition of the parts. When the adhesive action is progressing favorably, the less interference there is the better; any discharge that may collect upon the surface of the stump may be easily soaked up with a soft sponge. If considerable swelling and pain take place, or profuse suppuration set in, the change cannot be effected too soon ; and it need hardly be added, that, while it is being made, the stump should be well supported by an assistant, and that all pressure and unnecessary manipulation should be avoided. Any tendency to bagging that may show itself is to be counteracted by the judicious application of the ad- hesive strips and bandage. The sutures should not be cut out too soon ; as long as they are affording support they should be permitted to remain. After the wound has healed, the stump should be protected for some time with a piece of soft flannel, to prevent the ill effects that might otherwise arise from atmospheric vicissitudes ; and all pressure upon its surface should be carefully avoided until the parts have regained their natural sensibility. SYNCHRONOUS AMPUTATION. In cases of accident, as well as in certain diseases, but especially in the former, it occasionally becomes necessary to amputate two limbs simultane- ously, or in immediate succession, the circumstances which call for the re- moval of the one demanding the separation of the other. This constitutes what is termed the synchronous double operation. It is founded upon the assumption that the recovery is more rapid when two limbs are cut off simul- taneously than at two separate aud distinct periods; that the loss of blood will be comparatively little more from two amputations thus performed than from one alone; that there will be, in the aggregate, much less pain, shock, and inconvenience ; and, lastly, that the patient will thus escape the harass- ing anxiety of mind growing out of the knowledge that he will be obliged to submit to another operation. Synchronous double amputation has occa- sionally been performed in various parts of this country and Europe; but so far as ray information extends it was first adopted, as a rule of practice, by the surgeons of the Hotel-Dieu, at Quebec, the first case having occurred, many years ago, in the hands of Dr. M orris, of that city. Within the last ten years the operation has also been performed several times by Dr. Carnochan, of New York. But the most remarkable instance of the kind of which I have any knowledge, occurred in 1847, at Schuylkill Haven, Pennsylvania, in the hands of Dr. John G. Koehler, who removed simultaneously, on account of a railroad injury, both legs and one arm from a lad, aged thirteen years, 552 AMPUTATIONS IN GENERAL. recovery taking place without the supervention of any serious symptoms. The limbs were frightfully crushed, and the operation was performed within a short time after the accident. The arm being removed first, the pulse immediately sank, but under the influence of stimulants it rose sufficiently in five minutes to justify amputation of both legs below the knee. So excessive had been the shock of the system that the boy hardly experienced any pain during the operation. The synchronous double operation raay be performed by two surgeons, or by one alone, the latter being perhaps the preferable method. In either event, it is a matter of paramount importance to protect the patient from the loss of blood, the slightest effusion of which might prove prejudicial to his safety. Dr. Carnochan is in the habit of cutting off both limbs before he ties any vessels, and this is undoubtedly the preferable plan if we can be cer- tain of having perfect control over the hemorrhage, as we may be if we have proper assistants, and the removal is effected rapidly by the flap operation. SECT. V.—AFFECTIONS OF THE STUMP. These affections are either of a primary or consecutive character, and both may be purely of a local, or of a local and constitutional origin. The pri- mary consists of hemorrhage, spasm of the muscles, excessive pain, undue inflammation, osteomyelitis, and inordinate retraction of the soft parts, thereby permitting exposure of the bone. Among the secondary effects raay be men- tioned necrosis and exfoliation of the bone, degeneration of the nerves and neuralgic pain, aneurisraal enlargement of the vessels, and contraction of the tendons in the neighborhood of the stump, by which the latter is drawn on of its proper position, and so made a source of inconvenience and discom- fort. 1. PRIMARY AFFECTIONS. a. Hemorrhage may come on soon after the dressing of the stump, or not until some time has elapsed; perhaps not for several clays. It is usually occasioned by the want of a sufficient number of ligatures, in consequence of the retraction of some of the smaller arteries, thereby escaping the surgeon's attention while he is looking out for the principal and more accessible branches; or it may be that the vessel has been cut obliquely, and that it has not been tied high enough up ; or, finally, that the arterial tunics are so much diseased as to give way under the pressure of the cord before the formation of an adequate internal clot, as when the bleeding supervenes several days after the operation. However induced, or whatever may be the circum- stances which give rise to the hemorrhage, the proper remedy consists in ex- posing the open artery, and securing it with the ligature, either by separating the flaps, or, if adhesion is already far advanced by dilating the canal along which the blood flows over a grooved director. The main artery of the limb is not tied unless it be found impossible, on account of disease, or some other cause, to make the application of the ligature at the stump. Sometimes the hemorrhage is purely venous, the blood flowing away lazily, in a dark purple stream, without any jet; and when this is the case it will generally be found to depend upon the want of accurate coaptation of the flaps, or some defective application in the bandage, making either too little or too much pressure; in the former case enabling the vessels to remain open and gaping, and in the latter interfering with the passage of their con- tents. Occasionally the blood oozes out at different points, as water oozes out of a sponge, and this may take place either from the soft parts, or from the Haversian canals of the bones, or from the medullary membrane and the AFFECTIONS OF THE STUMP. 553 marrow. Arrest of the bleeding is usually effected simply by compression of the stump, the compress and roller being made to bear steadily against the offending vessels, aided by elevation and cold applications; when this fails, the ligature may be required, or, what is preferable, because altogether free from the danger of phlebitis, constriction of the vein by inclusion in the surrounding tissues. For this purpose, after being carefully dissected from its attachments, it is transfixed by a curved needle, armed with a small double cord, and drawn through an opening made for it in one of the adjoining muscles. Both ends of the cord are then brought out at the nearest angle of the wound, and retained for twenty-four hours, or removed at once, if there be no probability that the vessel will lose its hold. When the vein has been cut off unusually high up, so as not to admit of this procedure, I never hesitate to tie it, even if it be one of large size, such, for instance, as the femoral, although the operation should always, if possible, be avoided for the reason just stated. When the blood proceeds from the Haversian canals it will generally be necessary to undo the flaps, and apply a compress directly to the surface of the bone, the wound being kept open until the flow is arrested. Caustic applications must not be used for fear of causing necrosis. b. Spasm of the muscles, which is frequently a source of great distress, and which presents itself in the form of jerks or twitchings, usually sets in within a few hours after the operation, and is generally most severe in persons of a nervous, irritable temperament. No patient, however, is ever entirely exempt from it after amputation, and it is always sure to be materially aggra- vated on the occurrence of inflammation. In regard to treatment much is to be done in the way of prophylaxis; by the judicious use of the roller to give equable support to the muscles of the stump, together with elevation of the part to favor venous return, and also by the early exhibition of a full anodyne. The use of morphia, or of morphia and antimony, along with warm fomentations, will be required if the spasm is at all severe when no such precautionary measures have been adopted. c. The degree and continuance of the pain which follows an amputation will be influenced very materially by the character of the case, the size of the limb, the presence or absence of complications, and, above all, by the temperament of the patient. Coming on usually as the system emerges from the influence of chloroform, it is sometimes remarkably slight, while at other times it is so severe as to require large quantities of anodyne medicines for its subjugation. When the pain is complicated with spasmodic twitching of the stump, as it generally is during the first twenty-four hours, it must be promptly met with morphia and antimony. In order to render these two phenomena as light as possible, I have long been in the habit of administer- ing a full anodyne, generally a grain and a half of morphia, about two hours before the operation, and have never been disappointed in my expectations. d. The inflammation consequent upon an operation of this kind may be either of the ordinary character, or it may be erysipelatous, the determining circumstances not being always appreciable. In general, however, the danger of erysipelatous action will be considerable when there has been severe shock, or excessive loss of blood, conjoined with previous bad health or habits of intemperance. It usually makes its appearance within the first forty-eight hours, and is characterized by the ordinary phenomena, such as a red dusky state of the skin, more or less throbbing, a sense of tension, and burning, smarting pain, with marked disorder of the general system. Whatever may be the degree or character of the inflammation, it is always hostile to the adhesive process; sorae parts raay, it is true, unite in this way, but suppura- tion will be almost certain to follow, so as to lead to the necessity of healing the greater portion of the wound by granulation. In persons of a very dilapidated constitution the inflammation may pass into gangrene. I have 554 AMPUTATIONS IN GENERAL. found this termination raost commonly in patients of a scrofulous habit of body and in those whose system has been contaminated by syphilis. The treatment of this disease must be conducted upon general antiphlo- gistic principles. Special attention must be paid to the state of the system, and with this view it will generally be necessary to employ a mildly stimu- lating course, consisting of quinine and milk punch, with blue mass and ipecacuanha to evacuate the bowels and correct the secretions. Morphia is given in liberal doses to allay pain and procure sleep. The best local reme- dies are the dilute tincture of iodine, with fomentations, or cataplasms, medi- cated with solutions of acetate of lead and opium. Leeches will generally prove prejudicial. Sometimes the disease is promptly arrested by the appli- cation of a large blister. If mortification is threatened, the parts are freely touched with nitrate of silver, sulphate of copper, or the dilute acid nitrate of mercury, and enveloped in a fermenting poultice. The chlorides are used for allaying fetor, and the syringe for washing away secretions from beneath the flaps. e. Bad effects occasionally follow amputation in consequence of the de- velopment of osteomyelitis; an affection which has only recently begun to attract particular attention. In the Crimean war it was of such frequent oc- currence that the question was seriously debated by a number of surgeons whether it would not be best to abandon amputation altogether in the con- tinuity of the larger bones, and resort to disarticulation as a substitute. The disease is also sufficiently common in hospital and private practice, especially in cases of railway and other severe accidents, attended with violent concus- sion of the osseous tissues. The probability is that it is occasionally caused by injury inflicted in the act of sawing off the bone. However induced, it generally sets in within a short period after the operation, so that by the time the dressings are removed, as they usually are on the fourth or fifth day, it is found to have already made considerable progress, the marrow being of a brownish, blackish, or greenish appearance, of a soft, putrilaginous consist- ence, excessively fetid, and partially detached from the bone, which is itself either dead, or in a dying state, and more or less denuded of periosteum. The disease is generally attended with considerable pain, although in some of the cases that I have seen there was almost an entire absence of local suffer- ing; it is not unfrequently coincident with pyemia and erysipelas. Hence the prognosis is often exceedingly unfavorable. The treatment of osteomyelitis must be conducted upon general antiphlo- gistic principles, modified by the peculiarity of the constitutional symptoms. Great attention must be paid to cleanliness; the dressings must be frequently changed, and free use must be made of the chlorides. The judicious applica- tion of the nitrate of silver to the affected structures might possiblv assist in circumscribing and ultimately arresting the morbid action. If the"bone die, no attempt should be made to remove it until the part and system have sufficiently recovered from the effects of the disease to bear the shock of the operation. /. Finally, amputation is occasionally followed by inordinate retraction of the muscles, so as to uncover the bone, and perhaps lead to the necessity of its removal. The accident is most liable to happen after amputation of the thigh, in consequence of the action of the numerous, large, and strong muscles in that situation, and cannot always be prevented even when more than ordi- nary care is taken in forming the stump. The occurrence is always to be deprecated, inasmuch as it not only interferes with the union of the flaps but is very apt to cause the death of the bone. The remedy consists in bandag- ing the limb firmly from above downwards, preceded by the application of long adhesive strips, and in placing the parts in the best condition for relax- ing the affected muscles. When these means are unavailing, we raay, pro- AFFECTIONS OF THE STUMP. 555 vided the bone remains sound, divide some of the muscles of the stump sub- cutaneously, and then draw them forward, either with or without incision of the integuments, as the case may seem to demand. If the bone, however, be diseased, the best plan will be to saw it off higher up; but such an opera- tion is often more hazardous than the original one, and should, therefore, always, if possible, be avoided. Fig. 171. 2. SECONDARY AFFECTIONS. The most comraon, as well as the most serious, secondary defects of ampu- tation are, as was previously stated, necrosis of the bone, neuralgia, develop- ment of synovial bursae, varicose enlargement of the arteries, and permanent shortening of the tendons in the vicinity of the stump. a. Disease of the bone, eventuating in a loss of its vitality, is induced in various ways; in general, it is caused by injury inflicted upon it during the operation, consisting either in the laceration and separation of the periosteum, or in the violent and destructive jarring of its substance. Uncovering of the bone, in consequence of too great a brevity of flap, aud the accumulation around its extremity of pus, are also very apt to produce it. In rare cases it would seem to perish from excess of inflammatory action. The loss of vitality is indicated by the peculiar whitish or pale yellowish aspect of the bone, the absence of bloody points upon its surface, and the fact that it emits a characteristic hollow noise when it is struck with the handle of the knife. The marrow and its enveloping membrane generally retain their vitality for a short time after the osseous tissue has died, and this is the more likely to happen if the bone perishes only in a part of its circumference. I believe it will be found that necrosis, as a result of amputation, is more liable to occur in the thigh-bone than in any other piece of the skeleton, depending proba- bly npon some peculiarity of organization. The tibia is also occasionally affected, and a similar oc- currence is sometimes met with in the humerus. The dead bone may come off in the form, first, of an exfoliation, consisting merely of a part of its outer compact substance ; or, secondly, as an osse- ous ring, with long, narrow, sharp spicula; or, finally, as a complete cylinder, as when it involves the entire circumference of the bone over an extent of several inches in length. The more common appearances exhibited by the necrosed bone are well displayed in fig. 171. The management of these cases must be left very much to the operation of time, especially when the bone has perished high up, and when, in order to reach it, extensive dissection would be required. If, on the other hand, the necrosis is very limited, an attempt may be made to get rid of it with the saw, cutting-forceps, or trephine; but too much caution cannot be used even in such an operation, trifling though it may seem. I have seen death produced by it in two cases, and similar instances have been witnessed by others. It would seem, when a bone is thus affected, as if the system were more than usually intolerant of instrumental interference and loss of blood ; the parts are generally excessively irritable, and the constitution rarely fails to sympathize with them in the most lively manner. Besides, the operation is necessarily attended with some de- The sequester detached ; at its lower part, a, including the whole thickness of the bone, but gradually shelving upwards, as such pieces usually do. 556 AMPUTATIONS IN GENERAL. gree of hemorrhage, and I am not certain that a patient may not be de- stroyed in this way alone, especially if he be very feeble and irritable at the time. Instances occur in which the dead bone, or sequester, is firmly, and even obstinately, imprisoned by the remains of the living, or, more properly speak- ing, by the new matter thrown out upon its surfaces ; thus occasioning great difficulty in regard to its removal. Dr. Markoe, of the New York Hospital, had the kindness, a few years ago, to communicate to me the particulars of a case, wherein the sequester, consisting of an inner shell of the femur, was retained for many months by a spur of new osseous substance extending through an opening in its sides, in such a manner as to nail the dead and living parts together, but at the same time allowing the former to be moved freely backwards and forwards upon the latter. It was not until after several attempts had been made at extraction, attended with much pain and consti- tutional suffering, that riddance was finally effected by means of the chisel and forceps. For some very ingenious notions respecting the causes of ne- crosis in the bones of the stump after amputation, the reader is referred to a short paper by Dr. Markoe, in the Louisville Medical Review for July, 1856. b. Another disagreeable, frequently, indeed, a most distressing effect of this operation, is neuralgia, coming on at a variable period after its perform- ance, and often continuing, despite the most judicious and persevering efforts at relief, to molest the patient during the remainder of his life. Supervening generally without any assignable cause, it is usually most common in nervous, irritable persons, wdio are subject to the disease in other parts of the body. Females are more prone to it than men, and in them the attack frequently coincides with the eruption of the menses. Sometimes the disease is peri- odical, especially in residents in malarious regions, the paroxysms coming and going very much as in intermittent fever. Most commonly, however, the pain is omnipresent, one portion of the day being as liable to bring it on as another. It is generally of a darting, shooting nature, or dull, heavy, and aching, and is invariably aggravated by damp states of the atmosphere, fatigue, and disorder of the digestive apparatus. In the more violent forms of this affection the immediate cause of the diffi- culty is a bulbous enlargement of the nerves ramifying through the stump, as in fig. 172. This degeneration takes place, to a greater or less extent, after nearly every amputation, and is therefore to be considered as a disease only when it exists in excess. Under such circumstances the tumor, which sometimes attains the size of a hickory nut, or even of a pullet's egg, is of a firm, dense consistence, and is com- posed of a strong fibrous stroma, inlaid with hypertrophied and curiously inter- laced nervous trunks and filaments. It is, in fact, a true neuroma. The accompany- ing pain is exquisite, and the part is so sensitive as to be intolerant of the slightest touch ; the general health is much affected, and the patient is remarkably susceptible of atmospheric vicissitudes, every change in the weather from warm to cold and dry to wet being followed by an increase of suffering. The malady is of a much more serious character than the other, and requires proportionably stronger mea- sures. In general, nothing short of removal will avail; by excision, if the Fig. 172. Neuromata of stump, after amputation of the arm. A large mass at a; opposite b, the tumors are more defined. ^k CONSTITUTIONAL EFFECTS OF AMPUTATIONS. 557 tumor be single and easily accessible, by amputation, if it be multiple and deep seated. For the milder varieties of neuralgia the ordinary remedies will sometimes suffice, the same as in neuralgia in other parts of the body; especially qui- nine, or, if the patient be anemic, quinine and iron, combined, in either case, with strychnine and arsenious acid, belladonna, stramonium, or aconite ; the effects of the articles being studiously watched, lest an overdose be given, and life placed in jeopardy. Sometimes good effects accrue from the exhi- bition of colchicum and morphia, administered in full doses at bedtime, as one drachm of the wine to a grain of the salt. The remedy is particularly valu- able in subjects of a rheumatic state of the system. Locally, iodine, blisters, issues, and other counter-irritants are used, along with anodyne embrocations. The stump is well protected from cold, friction, and pressure. c. A burse sometimes forms upon the stump, generally immediately over the end of the bone, in consequence of the long-continued pressure of an ill- constructed and ill-adapted artificial leg. The tumor, in time, becomes ex- quisitely tender and painful, compelling the patient to seek relief. The seat and character of the disease are usually pointed out by the discoloration and swelling of the part, which often fluctuates on pressure. The history of the case, aided by the exploring needle, will readily serve to distinguish it from abscess, the only lesion with which it is likely to be confounded. The proper remedy is excision in the severer grades of the affection, and in the milder a more happy adaptation of the artificial to the natural limb. d. Varicose enlargement of the arteries of the stump is extremely rare, only a few instances of it being upon record. Unless the disease is unusually extensive, which, however, it is not likely to be, nothing need be done for its relief, as it does not generally act even as an inconvenience. e. Permanent shortening of the tendons in the immediate vicinity of the stump is sometimes a source of great discomfort, as well as of serious inter- ference with the usefulness of the limb. The accident is most liable to happen in the tendons of the hamstring muscles after amputation of the leg, and in the tendo Achillis after removal of the foot by Chopart's method. Much may be done, in both cases, in the way of prevention by attention to position during the after-treatment; it is, in fact, the neglect of this precau- tion that usually occasions the difficulty. When the accident is unavoidable, or is already fully established when first brought under the notice of the surgeon, rectification is attempted, generally with a fair prospect of success, by the subcutaneous section of the shortened tendons, and the subsequent use of an extending apparatus, constructed on the principle of the double inclined plane, with such modifications as may be required to adapt it to each parti- cular case. SECT. VI__CONSTITUTIONAL EFFECTS OF AMPUTATIONS. The most common constitutional occurrences after amputations, especially of the larger limbs, are excessive prostration, traumatic fever, pyemia, con- gestion of the lungs, tetanus, retention of urine, and, as a secondary conse- quence, hectic irritation. a. The shock, consequent upon amputation, is frequently extremely severe, and may be due, either partly or exclusively, to mere depression of the nerv- ous system, caused by the extent, violence, and duration of the operation, to loss of blood, or to the effects of anaesthetic agents, or to all these circum- stances combined. More or less nervous depression will almost necessarily occur during such an operation, however slight, but it generally passes off without any particular treatment, simply under the influence of repose, expo- 558 AMPUTATIONS IN GENERAL. sure to the air, and a drink of cold water. In the more severe forms of the affection, however, it may endanger life by its long-continuance or excess, and then demands prompt attention. The most appropriate remedies are lowering of the head, so as to facilitate the flow of blood to the brain; the administration of brandy and ammonia, by the mouth, if the patient can swallow, or by the rectum, if the power of deglutition be lost; a full dose of morphia; and sinapisms to the spine, extremities, and precordial region. b. Traumatic fever generally sets in within from six to twelve hours after the operation, and will be violent or otherwise according to circumstances, of which the most important are, the extent of the previous shock and the loss of blood, and the temperament, habits, and state of health of the patient. It is characterized by heat and dryness of the skin, flushed countenance, suf- fusion of the eyes, headache, restlessness, excessive thirst, rapid respiration, and a frequent, hard, and irritable state of the pulse, attended, when there has been much hemorrhage, by a peculiar jarring impulse. These symptoms, in the milder cases, will often speedily subside spontaneously, but under opposite circumstances they will require attention, and, if the surgeon is not fully on his guard, he will be very apt to do a great deal more than is either necessary or proper. The fact is, this is not unfrequently the critical point in such cases; if we do too much, the patient is irretrievably gone, the con- sequence being death either from exhaustion, pyemia, erysipelas, or a low state of fever, which nothing can cure. Hence the greatest caution is to be observed ; the symptoms must be watched, and the utmost care must be taken that they do not deceive us by their violence, which is often rather apparent than real, and therefore extremely apt to entrap the unwary and inexperi- enced. In general, it will suffice to administer a mild aperient, as a little Epsom salts, or a Seidlitz powder, to sponge the surface frequently with tepid water, and to give cooling, acidulated drinks, which are always very grateful in these cases. If the fever threatens to be obstinate, a little anti- mony is prescribed, either alone or in union with morphia, to promote per- spiration, allay the heart's action, and induce sleep. The lancet is scrupu- lously withheld, unless the symptoms are of extraordinary urgency, and the patient is very plethoric, without having been weakened by shock and loss of blood. Then a vein in the arm may be opened, and the effect of the stream carefully watched, the bleeding being arrested as soon as the pulse evinces signs of flagging. Very often after amputations of the larger limbs, especially those performed for compound fractures and dislocations, gunshot wounds, and railway acci- dents, a low form of fever ensues, the system reacting badly, the countenance looking pale and haggard, the skin being icterode, cold, and doughy, and the pulse shattered, with great depression of spirits, and an utter indifference on the part of the patient as to his fate. It is difficult to say what is the real condition of the system under such circumstances, but if we may be allowed to indulge in conjecture, we may suppose that the disorder is mainly due to the loss of blood and nervous fluid consequent upon the excessive shock to the system at the time of the accident, heightened, perhaps, by the effect of the operation. However this may be, the system being depressed and withered, the issue is usually most disastrous, very few persons recover- ing, no matter what course may be adopted for their relief. Our chief reli- ance must obviously be upon stimulants, as brandy, quinine, ammonia, and nutritious broths and jellies, with opium to allay pain and procure sleep. c. Amputations, especially those of the thigh, are often followed by reten- tion of urine, caused apparently by partial paralysis of the bladder, or, rather, as it seems to me, by a want of proper volition, the bladder retaining its power, but the patient being unable to call it into action. It usually super- venes within the first twenty-four hours after the operation, and seldom lasts CONSTITUTIONAL EFFECTS OF AMPUTATIONS. 559 less than two or three days, when it gradually passes off. From what I have seen of this affection, in this class of cases, I am not disposed to ascribe to it, as some have done, an inflammatory origin; that such a condition occa- sionally exists is certain, but, in general, I am sure it does not. Knowing how frequent retention of urine is after this and other capital operations, the attendant should be diligently on the watch for it, and promptly use the catheter, if it should arise. d. A not unfrequent event after amputation is pyemia. Experience shows that it is most to be dreaded in cases preceded by excessive shock of the system; hence it is very common after gunshot, railroad, and steamboat accidents, attended with extensive laceration of the soft parts, and after com- pound fractures and dislocations. From an interesting paper "On the Causes of Death after Amputation," by Mr. Thomas Bryant, of London, it appears that of 300 cases of this operation collected from Guy's Hospital, pyemia occasioned death in 42 per cent, of all the fatal cases, and in 10 per cent, of the entire number, the affection having been most frequent after amputation of expediency, and least so after secondary amputation. The attack generally conies on within the first six or seven days, being ushered in by violent rigors alternating with flushes of heat, and followed by a bad state of the stump with aching pains in the limbs and joints, excessive thirst, restlessness, and a tendency to delirium even early in the disease. When the joints are involved there is commonly an erysipelatous blush upon the overlying skin, with great tenderness on pressure and exquisite pain on motion. The case generally proves fatal in less than a week from its com- mencement, and examination after death usually reveals the existence of small and ill-defined abscesses in some of the internal organs, particularly in the lungs, liver, and spleen. The treatment is by stimulants and tonics, as brandy and milk, quinine, and opium, given in large quantity to support the rapidly sinking powers of nature. Mercury, in the form of calomel, is sometimes useful, administered in doses of, three grains every four or six hours, with a view, if possible, of touching the gums. The bowels are moved by enemas, all active purgation being inadmissible. Locally, the ordinary remedies are employed, generally only such as are of a soothing character. e. Congestion of the lungs, if not actual inflamraation of these organs, is another effect of this operation, occurring either alone, or in conjunction with pyemia, erysipelas, or an adynamic state of the system. It generally comes on in a slow, insidious manner, and is therefore apt to make serious, if not fatal, inroads before its true nature is even suspected, none of the cha- racteristic signs of pneumonic disease being present. The only way in which it is usually detected is by auscultation and percussion, or by the changes perceptible in the respiratory movements and the sounds of the chest. These changes are generally most conspicuous .in the lower and posterior portions of the lungs, where the greatest amount of blood, in debilitated states of the system, is, in obedience to the laws of gravity, most liable to accumulate, and, consequently, to produce the greatest degree of mischief. In most of the cases of pulmonary congestion that I have met with after amputation of the larger limbs, there was either an entire absence of pain and cough, or these symptoms were so trivial as, of themselves, to attract hardly any atten- tion. The patient is able to lie upon his back or on either side, and it is not often that the respiration is materially hurried or embarrassed. Cupping and blistering are the most reliable local remedies, and the system must be sup- ported with stimulants and tonics, aided by morphia and minute doses of tartrate of antimony and potassa. The prognosis is generally unfavorable, especially if the disease has made considerable progress and the patient is much exhausted. 560 AMPUTATIONS IN GENERAL. /. The occurrence of tetanus after amputation is uncommon, especially in the more temperate regions of this and other countries. Air. Curling, in his work on this disease, gives a table of 128 cases of traumatic tetanus, three of which only were caused by amputation. The affection is much more fre- quent in military than in civil practice, and is most liable to be produced in persons of a nervous, irritable temperament, in consequence of exposure to direct currents of cold air. A few years ago I lost a man on the third day after an amputation of the thigh solely from this cause; he had been moved, during my absence from the hospital, to an open door, so as to allow the wind to blow upon him in a full stream. I am familiar with the history of other cases that have been induced in a similar manner; and I refer to the fact in order to attract special attention to it. The treatment of this disease being discussed elsewhere, it is unnecessary to refer to it here. g. Hectic irritation is observed only, or chiefly, as a secondary effect of amputation, being caused either by profuse suppuration, or a poisoned state of the blood and solids, from shock, hemorrhage, or the absorption of pus. The symptoms are characteristic, and the treatment consists of such means as are calculated to sustain the flagging powers of the system, especially quinine and iron, with aromatic sulphuric acid, milk punch, and nutritious food. SECT. VII.—ARTIFICIAL LIMBS. Fig. 173. The stump, after the cicatrization of the wound, gradually undergoes, as might be expected, important changes in its several structures, so as to adapt it the better for the various hardships which it is destined to experience in the daily routine of a business life, and especially for the support of an arti- ficial limb. The muscles, deprived of the power of motion, soon become pale and wasted, and are eventually transformed into hard, dense, cellulo-fibrous bands, entirely destitute of their primitive properties. The bloodvessels are obliterated as high up as their first large colla- teral branches, and converted into solid, rigid cords; the extremities of the nerves are ex- panded into large bulbous masses, of an elon- gated, cylindrical shape, exhibiting more of a fibrous than of a nervous structure; and the ends of the bones are rounded off, and covered in by a thin shell of osseous matter, which thus effectually closes the medullary canal, as seen in fig. 173. The cellulo-adipose substance gradu- ally disappears, and the skin, unless habitually subjected to pressure, is rendered abnormally thin and sensitive. These changes are, of course, the work of time, and hence they are always more conspicuous in proportion to the age of the stump. The period at which the stump may be in a condition for the reception and support of an ar- tificial limb must necessarily vary according to circumstances; if the operation has been well done, and the cicatrization has gone on favorably, the substitute may be used as early as the sixth or eighth week, though in general it will be better to wait some time longer, inasmuch as too early a recourse to it will be likely to render the parts sore and sensitive, if not the seat of ulceration and severe pain. So much, indeed, is the patient's comfort influenced by attention to this point that it is hardly possible to be too cautious respecting it. The Appearances of bony stump after amputation. ARTIFICIAL LIMBS. 561 stump should be tightly bandaged for several weeks previous to the applica- tion of the artificial limb, to promote absorption of redundant material, and thus impart to it a somewhat conical shape. Washing it well several times a day with a strong solution of tannin and alum will have the effect of hard- ening the integuments, so as to moderate their sensibility and prevent ex- coriation. Great improvement has of late years been effected in the construction and adaptation of artificial limbs, and there is reason to believe that the inconve- nience and suffering occasioned by their use are more frequently attributable to the misconduct of the surgeon than to the want of skill on the part of the manufacturer of the substitute. It has been only within a comparatively recent period that operators have hit upon the correct principles of making good and serviceable stumps; Allanson, nearly three-quarters of a century ago, understood the subject much better than it has been understood since, if we except the last ten or fifteen years. He strongly insisted upon a long and well-shaped stump, and exerted himself with great ability, but in vain, to induce the profession generally to follow his example. The happy changes which have lately been introduced into this department of operative surgery are, I believe, mainly due to the manufacturers of artificial limbs, who, with an ingenuity and a perseverance worthy of so good a cause, have reduced the whole process to one of principles founded upon the study of anatomy and mechanical philosophy. It would be difficult to conceive of any appa- ratus more beautiful in its construction, or more admirably adapted to the end proposed, than the artificial substitutes of Mr. Palmer, of this city, who obtained the prize medal at the great exhibition in London in 1851. Com- bining lightness with strength, and neatness with symmetry, they are worn with great comfort and satisfaction, and are apparently as perfect as any piece of human mechanism of the kind can well be made. The joints, constructed on the principle of the ball and socket articulation, are situated at the proper points, and their surfaces being well secured, move upon each other with great accuracy and facility, through the intervention of cords, wires, springs, and levers, the whole arrangement being a close imitation of the natural muscles and tendons, if not in shape, at least in position and function. The socket is made with special care, neatly fitting the stump, in every portion of its extent, and is well pad- Fig- 174. ded to prevent friction and excoriation, the pressure being diffused over the entire circumference of the stump, while the extremity of the latter is perfectly free in the interior of the former. The annexed cut, fig. 174, affords an illustration of this apparatus. To enable the patient to wear his artificial limb with comfort and convenience, it is necessary that he should have a good long stump, well covered, per- fectly even, and of proper shape, being neither too square and fleshy, on the one hand, nor too thin and conical, on the other. A short, thick, ill-formed stump is a great evil, from which the patient can promise himself no good ; but which can hardly fail to be a constant source of annoyance and pain, be- coming sore and excoriated under the slightest exer- cise. The duty of the surgeon is, therefore, one of great responsibility, and cannot be discharged with- out properly weighing, in every instance, the probable consequences of the operation. When he has his choice, his invariable aim should be to make a long stump, so as to afford an vol. i.—36 562 AMPUTATIONS IN GENERAL. abundant leverage and support for the artificial contrivance. In the leg and thigh its length should not, if possible, be less than nine or ten inches; hence the place of election, for the former, should be only about from three inches to three inches and a half above the ankle, and for the latter about the same distance above the knee. It is not always by any means, however, in the power of the surgeon to select the point where he might otherwise cut off the limb, and under such circumstances he must be contented in leaving as much substance as he can. If the leg is amputated very high up, the weight of the body may be supported upon the knee, especially if the patient's social position is such as to prevent him from wearing an expensive substitute, and this will be the more necessary because it is often very difficult, if not impos- sible, to preserve the straightness and flexibility of the joint in the event of a very short stump, on account of its incessant tendency to retraction and anchylosis. It is for this reason that some surgeons have advised amputation of the thigh just above the knee, when accident or disease interferes with the formation of a suitable stump below ; but, if we consider the difference in the danger of the two operations, we should hesitate before we give our sanction to such counsel, not forgetting that the risk increases with every inch the nearer we approach the trunk. In amputation of the thigh, the principal pressure of the artificial limb upon the stump is concentrated near the body, but care is taken not to apply any direct pressure to the perineum, lest it should produce excoriation. I subjoin Mr. Palmer's instructions for the formation of suitable stumps in amputations of the leg and thigh, as they are now generally acted upon by the more accomplished operators of the country. For the leg, the first choice is the inferior third or fourth of the limb ; the second, the lowest point be- tween this place and the upper third of the leg; and the last, immediately below the tuberosity of the tibia, if not practicable to save four inches below the patella with the full use of the knee-joint. Whatever the seat of the operation may be, the best stump will be one made of flaps. In amputations of the thigh, the first point of election is the lower third of the limb, so as to give at least ten inches from the perineum ; if performed near to or at the knee, there must be complete removal of the condyles of the femur. Secondly, if necessary to go above this point, the object should be to save as much of the thigh as possible. In either case, the flap operation makes the best stump for the comfortable use of an artificial substitute. In amputations in children, the development of the limb is always partially arrested, so that, by the time the individual attains his full stature, it will be several inches shorter, as well as thinner, than its fellow of the opposite side. Now, surgeons in applying this knowledge to amputations of the inferior extremity, have advised that it should never be cut off below the knee, but at the lower third of the thigh, on the ground that, if this precaution be neglected, one knee will ultimately be elevated a considerable distance above the other, thereby imparting to the gait a peculiar grotesque appearance. Experience, however, has shown that amputation of the leg, even if the stump is only a few inches in length, instead of being an objection, is a decided ad- vantage, the limb thus affording a much longer leverage than when it is cut off through the thigh, for the adaptation of the artificial substitute, the knee- joint of which can always be made to correspond, in situation, with that of the sound limb. Moreover, by adopting this procedure, the weight of the body, provided the stump is not too long, is supported upon the knee; another most important desideratum under such circumstances. An ingenious artificial limb was recently devised by Dr. Bly, of Roches- ter. Besides combining lightness with elegance, durability, and strength of construction, it claims the advantage of admitting of lateral motion at the MORTALITY AFTER AMPUTATIONS. 563 ankle-joint, with a view of facilitating progression. The contrivance appears well in the model, and is said to work admirably in practice. The annexed drawing, fig. 175, conveys a good idea of the artificial limb usually worn by the laboring classes Fig. 175. after the loss of a leg or thigh. It may be made very light, and, when the stump is of proper length, affords an admirable substitute, the person being able to walk nearly with the same facility as in the natural state. Various attempts have been made to construct arti- ficial hands and arms. Mr. Palmer, after many trials, Fig. 176. has at length devised a limb, fig. 176, which, in point of neatness and adapt- ability, leaves hardly anything to be desired upon the subject. SECT. VIII.—MORTALITY AFTER AMPUTATIONS, The mortality from amputations is so much influenced by extraneous and intrinsic circumstances, and requires such a vast amount of statistical material for comparison and contrast, that it is extremely difficult, if not impossible, in the existing state of the science, to arrive at any satisfactory conclusions respecting it. It has long been known that the danger of the operation is greater in proportion to its proximity to the trunk and the size of the limb. Hence, amputation of the leg is less hazardous than amputation of the thigh, and of the thigh in its continuity than of the thigh at the hip-joint. The mortality of the operation is also greater, as a general rule, in hospital than in private practice, in military than in civil practice, and in private practice in cities than in the country. Amputations on account of railway accidents are extremely dangerous, and are liable to be followed by the worst conse- quences, even in subjects perfectly healthy at the time of the accident, owing to the excessive tendency to mortification and pyemia. The circumstances which mainly influence the mortality after amputation may be conveniently arranged into four classes, one of which refers to the age, previous health, and social position of the patient; the second to the causes necessitating the operation ; the third to the nature, seat, and extent of the operation ; and the last to the after-treatment. 1. It will readily be granted that the condition of the patient at the time of the accident rendering amputation necessary must exert an important in- fluence upon his fate. If he be old, broken in constitution, or in a state of poverty, so as to preclude the possibility of receiving proper attention after the operation has been performed, the chances are that he will die, either 564 AMPUTATIONS IN GENERAL. from shock, erysipelas, pyemia, or congestion of the lungs. The previous state of his health exerts no little influence upon the recovery; not, perhaps, however, to the extent that is generally imagined. A person who is in bad health at the time he is severely injured cannot be expected to bear the shock of an amputation with the same impunity as one whose health is good. The system, exhausted by previous suffering, is ill qualified in such a case to react favorably after the nervous depression consequent upon a severe operation. Age also exerts considerable influence over recovery. Children, as a general rule, bear amputation better than adults and elderly persons, being less subject to attacks of erysipelas and pyemia, and making a more rapid recovery. The parts, too, unite more frequently by the first intention. At the Hopital des Enfants in Paris, Guersant, who annually performs from fifteen to twenty operations of this kind, including all the larger limbs, and also occasionally the hip and shoulder joints, does not lose more than one out of about nine cases. He ascribes his extraordinary success mainly to two circumstances ; first, a thorough preparation of the system, and secondly, the use of an abundance of good, wholesome, and nutritious food immediately after the operation, on the well-known principle that children do not tolerate abstinence nearly as well as adults. It should be added that nearly all the cases in this Institution demanding amputation are of a scrofulous nature. The social position, or the habits and occupation of the patient, will influ- ence the result of an amputation. The poor man cannot command the same care and attention as the rich ; he often suffers for want of proper food and nursing, and even medicine, at a time, perhaps, when he is most in need of them, and there is no doubt that many patients perish from this cause alone that might otherwise be saved. Intemperance in eating and drinking, and unwholesome occupations must necessarily produce a prejudicial influence upon the result. 2. The influence of the causes necessitating amputation has long been a subject of remark on the part of practitioners, both in private and public. Thus, it is an established fact that a person who undergoes amputation of one of the larger limbs on account of a severe injury, as a compound fracture, or a lacerated and contused wound, is much more likely to perish from its effects than one who loses a limb on account of chronic disease. The system, in the former case, deeply depressed by the shock of the accident, often reacts very slowly and imperfectly, and is therefore ill prepared for the approaching ordeal of another severe commotion, the effect of which is felt by every organ and tissue of the body. In disease, on the contrary, the constitution, although perhaps extensively implicated, has become inured to suffering, and, unless too much prostrated, will generally be immensely benefited by the removal of the offending parts. The chief exception to this rule is in malignant affec- tions, in which, in consequence of the vitiated state of the solids and fluids, amputation is often followed, and that very rapidly, by the worst results. 3. In considering the probable result of a case of amputation, we must not forget to take into view the nature, seat, and extent of the operation. Expe- rience has proved that, in civil practice, primary amputation is, other things being equal, a decidedly more dangerous procedure than secondary. The very fact that such an operation is required shows that the accident for which it is performed must have been a severe one, involving, perhaps, the most dreadful lesions of the bones, muscles, joints, and bloodvessels, with frightful depression of the nervous system. Now, it is surely impossible that a patient thus circumstanced should be in a favorable condition to submit to another severe shock, such as must necessarily attend the removal of the affected limb, within a short time after reaction has been established. The statistics, both of private and hospital practice, in America and Europe, are decisive upon this subject, proving beyond the possibility of doubt, the greater mortality f w MORTALITY AFTER AMPUTATIONS. 565 after primary than secondary amputations. Thus, of 48 primary amputations of the thigh, leg, and arm, performed in the London hospitals from June, 1855, to June, 1856, inclusive, 26 terminated fatally, or upwards of one-half, while in 156 secondary ones the number of deaths was only 35, or in the ratio of about 1 to 41. In military practice, on the contrary, the results of amputations are reversed, the primary being incomparably more favorable than the secondary. This has been the result of the experience of surgeons in all ages and in all countries since the invention and use of gunpowder. Larrey and Guthrie saved three- fourths of their cases after primary operations, and the returns of the British surgeons in the Crimea are of a similar character, although the rate of mor- tality here was considerably higher, owing to the fact that most of the wounds were inflicted with the conical ball; whereas, in the campaigns of Bonaparte, and in the Peninsular war, they were made with the round ball, the effects of which are, as a general rule, much less destructive than those of the former. The differences between the results of primary and secondary amputations in civil and military practice, are no doubt due to the circumstances under which they are performed and the causes which lead to their necessity. In the first place, there is generally less shock in injuries received on the field of battle than in those received in civil life. Secondly, the soldier usually submits to the removal of his limb with greater sang-froid than the civilian, and often glories in his loss, believing that the world will regard it as an evidence of his prowess and patriotism ; whereas, the latter finds in his misfortune nothing but regret and private calamity. Thirdly, the operation is commonly more promptly performed in military than in civil practice, delay, in the latter case, being frequently occasioned by the doubts of the surgeon and the interfer- ence of the patient and of his friends; and, lastly, a soldier has not much chance of recovery from an amputation, when, an attempt being made to save his limb, he is subjected to rough and tedious transportation, and is afterwards obliged, when the operation has been performed, to breathe the contaminated atmosphere of a crowded hospital, tenanted by persons borne down by simi- lar accidents. Under such circumstances the mortality from erysipelas, py- emia, and typhoid fever will, other things being equal, be much greater than in private practice. Faure, frora these and other causes, lost 270 out of 300 secondary amputations consequent upon injuries received in battle. The size and situation of the wound exert an important influence upon the recovery. Here again the statistics furnished by various authorities are most eloquent and decisive. They have conclusively established the fact, now re- garded as a great general law, that the larger the wound is and the nearer it is to the trunk, the greater is the danger to life. Thus, Malgaigne, in his statistics of amputations of all kinds in the hospitals of Paris, found that the mortality after removal of the great toe was in the ratio of one to six, whereas that of one of the smaller toes was only as one to twenty-six. In amputations of the foot the proportion of deaths was about twenty-five per cent., of the leg fifty-six per cent., and of the thigh sixty-two per cent. These results have been abundantly verified by the statistics of other institutions, as well as by those of military and private experience, and they are full of interest, as establishing a law, which should never, if possible, be violated in practice. The causes which induce this difference in the larger and smaller amputa- tions are chiefly shock, hemorrhage, pulmonary congestion, pyemia, erysipelas, profuse suppuration, and gangrene of the stump. Tetanus, too, is more fre- quent after the former than the latter, although the mortality from this affec- tion is not great under any circumstances, especially in the more temperate regions of this and other countries. It is certainly not difficult to understand the reason why the removal of a large limb should be attended with so much more risk than that of a small one. In the former case, the patient has to 566 AMPUTATIONS IN GENERAL. contend not only with the shock of the accident necessitating amputation, which is often of itself almost sufficient to destroy him, but as soon as reaction is established he is subjected to another source of depression, perhaps almost equally great, from the operation, frequently involving copious hemorrhage, and liable to be followed by profuse suppuration and high febrile excitement, all tending to depress and exhaust the vital powers. In the latter, on the contrary, there is little or no shock, either from the accident or the operation; the loss of blood is inconsiderable; and the inflammatory effects, local and constitutional, are comparatively trivial. In short, there is no disorganization of the blood as there is in the former, and hence no predisposition to pyemia, or purulent infection, and pulmonary congestion, which are a source of so much mortality after the large amputations performed for severe injuries. The result of an amputation may be materially affected by the situation at which the bone is divided. Experience has shown that, in the femur, tibia, and humerus, more particularly, the danger is much greater when the bone is sawn through its shaft than when it is cut off at its articular extremity, owing to the injury inflicted upon the endosteum, and the consequent liability of this membrane to diffuse suppuration, and other bad effects. 4. Finally, it needs no labored argument to prove that the mortality from amputation must be materially affected by the nature of the after-treatment. That many persons perish after such an operation from sheer neglect, bad nursing, or bad surgical management, is a fact too well known to require comment. This is true both of private and of hospital practice, but the remark applies with increased force when it is made with reference to military practice, which, however well the surgical staff of an army raay be organized, must often, from the very necessity of the circumstances in which the opera- tions are performed, and the difficulty of conducting the after-treatment in a proper and satisfactory manner, be followed by the most disastrous results, many lives being lost that might, under more auspicious circumstances, as to locality, comfort, and convenience, be saved. The state of the atmosphere, as it respects purity and temperature, the prevalence of epidemic diseases, mental depression, want of proper diet, severe depletion, and inattention to the dressings, all exert a more or less powerful influence upon the issue of such an operation. The crowded wards of hospitals in large cities, inces- santly pervaded by foul air, are notoriously prejudicial to recovery after amputations; gangrene, exhausting suppuration, erysipelas, and pyemia are the common lot of such patients, and the consequence is that many of them perish. Hence it is that private practice, especially that of the country, always shows a much more favorable result than that of large public institu- tions, or that of large towns and cities. During epidemic diseases, the per- centage of deaths from amputations always exhibits a great increase; for it is then that patients are particularly prone to erysipelas, pyemia, and con- gestive pneumonia. Starvation and depletion are a serious source of mor- tality after this operation, establishing, as it does, a tendency to purulent infection and a typhoid state of the system, from which often no stimulants, however powerful and well-directed, can afterwards rouse it. I regard such treatment after amputation of a large limb, as, indeed, after every other capital operation, as a great evil, and one which, in my judgment, demands thorough reform on the part of our civil and military practitioners. Finally, I may mention, as another source of mortality, want of attention to the dress- ings, which, if allowed to remain on too long, not only taint the surrounding atmosphere, but favor the absorption of pus, much to the detriment both of the part and system. I subjoin the following summary of the statistics of the amputations per- formed at the Pennsylvania, New York, and Massachusetts Hospitals, be- cause it seems to place the whole subject of the mortality after these operations MORTALITY AFTER AMPUTATIONS. 567 in a clear and satisfactory light. It is founded upon the reports of Dr. Norris, Dr. Lente, and Dr. Hayward, and embraces the results of five hundred and forty-six cases. Dr. Norris's statistics of amputations at the Pennsylvania Hospital com- prise a period of twenty years, extending from 1831 to 1850 inclusive. The whole number of operations upon large limbs is 174, of which 44 proved fatal, thus exhibiting a mortality of 25.2 per cent. The whole number of amputations of the thigh was 33, of which 8 were fatal, or nearly one in four ; of the leg 69, with a mortality of 29, or 42 per cent.; of the knee 1, which was successful; of the arm 32, of which 5 perished, or one in six and a third; and of the shoulder-joint 6, of which 1 proved fatal. Of 52 primary amputations of the lower extremity 25 were fatal, while of 28 secondary operations only 8 were fatal, thus exhibiting a mortality of 28.6 per cent, as compared with 48 of the former. Of 22 amputations of the inferior extremity for disease 4 were fatal, yielding a mortality of 18.1 per cent. The ages of the patients operated upon were as follows: — Of 49 under 20 years, 4 died ; of 56 between 20 and 30, 11 died ; of 47 between 30 and 40, 18 died ; of 37 between 40 and 50, 13 died ; and of 5 over 50, 1 died. The above summary will be found, on comparison, to differ essentially, in one particular, from that given by Dr. Norris himself, in his statistics. Thus, he makes 115 primary amputations of the thigh, leg, arm, and forearm, yield a mortality only of 27, or at the rate of 23.4 per cent., while 41 secondary amputations of the same limbs afford a mortality of 16, or at the rate of 39.3 per cent. Now such a result is, as is well known, wholly at variance with general experience, for it is universally admitted that secondary am- putations are less fatal than primary; and it must always be so frora the fact that primary amputations are commonly performed for more serious injuries than secondary, injuries which are often of themselves almost inevitably fatal under any treatment, such as the crushing of limbs by railway cars, heavily-loaded wagons, ferry-crossings, high falls, and gunshot wounds, in- volving joints, large vessels, and other important structures. On the other hand, the very circumstance of waiting for secondary amputation indicates a comparatively slighter lesion, and generally a fair prospect not only of saving life but of limb also. But the explanation in the discrepancy in Dr. Norris's statistics is discovered in the fact that he classes as primary only those cases in which the operation was performed during the first twenty-four hours after the occurrence of the accident, whereas the general rule is to regard every instance as primary until a sufficient degree of reaction has taken place to justify the use of the knife, without taking lapse of time into account at all. Thus, if we wait for the system to come up, an amputation performed on the second day has as much claim to be classed as primary as though it had been performed on the first day, and, indeed, it seems almost impossible, if we re- ject Dr. Norris's rule, to specify any certain demarcation, as to time, between a primary and a secondary operation. We therefore consider those amputa- tions as secondary which are performed after the occurrence of inflammation, or of inflammation and suppuration. Thus, many of the amputations at the New York Hospital, classed as primary, were performed on the second, third, or fourth day, and some even as late as the sixth or seventh. Frequently the delay was caused only by the circumstance that the patient had to be con- veyed from a long distance in the country to the hospital; the shock of the injury and the fatigue of the journey preventing such a degree of reaction as % to constitute inflammation. It would certainly be improper, and lead to much confusion, in attempts at classification and generalization, to rank such operations as secondary merely on account of lapse of time. In order, there- fore, to make a useful comparison of Dr. Norris's very extensive and valuable 568 AMPUTATIONS IN GENERAL. tables with those of other statisticans, I have taken the liberty of drawing my own deductions. It may also be noticed that no distinction has been made between the relative mortality of primary and secondary amputations of the upper extremity in its continuity, because the mortality is so small as to render such a distinction practically useless. Dr. Lente's account of the amputations at the New York Hospital em- braces a period of eighteen years, commencing in 1839, and terminating in 1857. The whole number of cases was 305, of which 139, or 45.5 per cent., proved fatal. The thigh was amputated in 97 cases, of which 51 were fatal, showing a mortality of 52.5 per cent.; the leg in 102, with a mortality of about 34 per cent.; the arm in 58, with a mortality of 15 cases, or at the rate of nearly one in four; and the forearm in 39, with a loss of 8, or at the rate of 20.5 per cent. Of 4 cases of amputation at the hip-joint all were fatal; of 9 at the knee-joint 4 died ; and of 19 cases at the shoulder-joint 11 proved fatal. It will thus be seen that the number of cases of amputation of the lower extremity was 212, of which 86 terminated fatally, showing a mortality of 40.6 per cent.; and of the upper extremity 106, of which 31 died, the rate of mortality being 30 per cent. Of the amputations of the thigh 33 were by the double flap method, with a loss of 14, or at the rate of 42.4 per cent.; and 28 by the circular, with a loss of 15, or 53.6 per cent. Of the operations upon the legs 21 were by the flap method, and 58 by the circular, the mortality in the former being 38.1 per cent., and of the latter 22.4 per cent. Of 70 primary amputations of the thigh and leg, 39 were fatal, exhibiting a mortality of 55 per cent.; and of 73 secondary 32 were fatal, or 24.1 per cent. The ages of the patients operated upon, with their respective mortality, were as follows : For the lower extremity, under 10 years, 2 cases, both re- covered ; between 10 and 20, 18 cures and 14 deaths; between 20 and 30, 23 cures aud 18 deaths; between 30 and 40, 15 cures and 12 deaths; be- tween 40 and 50, 7 cures and 10 deaths; over 50, 2 cures and 2 deaths. It would seem that the ratio of mortality after amputations at the New York Hospital, during the above period, was very different in different years. Thus, from 1848 to 1851, of seventeen operations upon the thigh, only four were successful. From 1851 to 1857, the number of amputations of the thigh was forty-six, of which eighteen were cured. During the three years above alluded to, there was a remarkable fatality attending all operations at the institution, owing to the prevalence of erysipelas, hospital gangrene, puru- lent infection, and kindred diseases. This circumstance led to a remodelling and rebuilding of the establishment, and the good effect is seen in the very great decrease in the mortality which has since occurred. Similar facts have been noticed, from time to time, in other hospitals, both in America and Europe. The statistics of the Massachusetts General Hospital have been furnished by Dr. Hayward, of Boston, and relate to amputations of the large limbs which occurred from the opening of the establishment to January 1, 1840, the whole number of cases being 67, of which 15 proved fatal, the mortality being thus 22.4 per cent. Of these cases 34 were amputations of the thigh, of which 9 proved fatal, or at the rate of 26.5 per cent.; 23 of the leg, with a mortality of 5, or 21.7 per cent.; 4 of the arm, which all recovered; and 6 of the forearm, of which one proved fatal. Of 10 primary amputations of the lower extremity 5 were fatal, and of 10 secondary 4 were fatal. Of 37 operations performed for disease 5 died, and it is worthy of note that 23 of these cases were amputations of the thigh. MORTALITY AFTER AMPUTATIONS. 569 The ages were as follows:—Under 20 years, 13, of which 1 died; frora 20 to 30, 31, of which 8 died ; from 30 to 40, 9, of which 3 died; from 40 to 50, 10, of which 2 died; from 50 to 60, 3, of which 1 died; and over 70, 1, which recovered. Having thus given the results of amputations at each of the above hospi- tals, it will not be uninteresting to state their aggregate results. The whole number of cases, as already mentioned, is 546, of which 198 proved fatal, thus showing a mortality of 36.2 per cent. The thigh was amputated in 164 cases, of which 68 died, or 41.4 per cent.; the leg in 194 cases, of which 68, or 35 per cent., perished; the arm in 94, of which 20 died, or 21.2 per cent.; and the forearm in 85, with a mortality of 11, or 12.9 per cent. Of 133 primary amputations of the lower extremity in its continuity 69 died, or 51.9 per cent.; while of 111 secondary amputations only 44 were lost, or 39.6 per cent. Of 117 operations performed for disease 23 died, that is, 19.5 per cent. These cases include several double operations of the legs, and of these a majority recovered. Four amputations at the hip-joint are included in the tables, and all these proved fatal. Of 10 amputations at the knee 5 were lost. Five of the ten were primary, one secondary, and three for disease; of the first two died, of the second one, and of the third two. The shoulder-joint was the seat of operation in 25 cases, of which 12 were fatal, or 48 per cent. In regard to the ages of the patients operated upon in the three hospitals, the mortality in all under 2,0 years, was 20 per cent.; between 20 and 30, 29 per cent.; between 30 and 40, 40 per cent.; between 40 and 50, 40 per cent.; and over 50, 33.3 per cent.; the number of cases, however, being only 12, and therefore too small to justify any general deduction as to the rate of mortality. Respecting the relative mortality of the circular and flap operations, the statistics of the Pennsylvania and Massachusetts General Hospitals are silent, and I am therefore unable to compare it with that of the New York Hos- pital. A comparison may next be instituted between the mortality of amputations in the practice of American and European surgeons. In doing this, I shall take as my guide the statistics of the above establishments, and those fur- nished by Mr. Benjamin Phillips, of London. Of 545 cases, analyzed by the English author, embracing primary and secondary amputations, and am- putations for various diseases, of the thigh, leg, arm, and forearm, in France, Germany, and Great Britain, 127 proved fatal, thus exhibiting a mortality of about 23 per cent. Of 491 cases in the three American hospitals, 134 died, giving a mortality of 27.30 per cent., a result somewhat higher than the foreign practice. It is worthy of remark, however, that a number of Mr. Phillips's cases were taken frora the private practice of European hospital surgeons, and if we bear in mind the fact that the mortality after amputations is always, for obvious reasons, less, the world over, in private than in hospi- tal practice, it will be found that the ratio of mortality is about the same in the two countries, that is, about 23 per cent. 570 EXCISION OF THE BONES AND JOINTS. CHAPTER XVIII. EXCISION OF THE BONES AND JOINTS. The term excision serves to denote the removal of a bone whether in its continuity or at its extremity, whether it be limited to a portion of its extent or embrace its totality. When only the head of a bone is concerned in the operation, the word decapitation is occasionally used, and, as meaning the same thing, some authors have adopted the name of exsection. Excision differs from amputation in this, that, while in the latter the bone is removed along with the soft parts which surround it, in the former the bone alone is cut away, the integuments, muscles, and other tissues being retained, in order that they may contribute to the future usefulness of the limb ; or, in other and more comprehensive language, while in the one case all the structures are destroyed, in the other as many of them as possible are preserved. Hence this department of surgery has very appropriately been denominated conserv- ative surgery, and it is most gratifying to know that it constitutes one of the leading characteristics of the healing art of the present day. It is not to be expected that excision of the bones and joiuts will ever entirely supersede the necessity of amputation, for as long as the various tissues of the body are subject to disease and accident, so long will they require removal by the knife, in order to prevent the extension of their effects; but that the frequency of the operation will eventually be greatly diminished, the experience 01 the last fifteen years abundantly attests. Conservative surgery is still in its infancy, and it is needless to conceal the fact that it will take a long time to determine its legitimate limits. Up to the present moment we have no adequate statis- tical information respecting excision of any of the bones and joints to justify us in delivering a definite judgment upon its true value. The facts that have transpired in relation to the operation are too widely scattered to render them available for the purposes of a rigid and faithful analysis. Such a task would involve a profound consideration of the history of the operation, in all its varied bearings, and would demand an amount of time, labor, and talent, which few professional men are able to command. Dr. Oskar Heyfelder, of Vienna, in his work on resections, published in 1861, has tabulated 2,662 cases of these operations, in 2,241 of which only, however, the result is known. Among these cases there were 452 deaths, and 1,616 complete cures; in 1,789 cases life has been preserved, and 173 cases have been unsuccessful. Although incidental mention of excision of the bones occurs in the writings of some of the earlier surgeons, yet it is probable that, if such an operation was ever performed by them, it was in great measure, if not entirely, limited to the removal of the protruding ends of fractured bones. However this may be, it is certain that there is no well authenticated case of excision of the heads of any of the bones until 1762, when Mr. Filkin, of Northwich, removed those of the knee-joint. Soon after this a similar service was per- formed for the superior extremity of the humerus by Vigaroux, David, and White. In 1781, Mr. Park, of Liverpool, repeated Filkin's operation, and, from the gratifying success attending it, he was led to propose its extension to all the principal articulations, much to the surprise of most of his contem- EXCISION OF THE BONES AND JOINTS. 571 poraries, who looked upon the measure as harsh and reckless. The conse- quence was that the proceeding met with much opposition, and it might even have been entirely lost sight of if it had not been for the boldness and skill of Moreau, the elder, of Bar-sur-Ornain, who, towards the close of the last century, exsected, in rapid succession, the articular extremities of the shoul- der, knee, and elbow. The success of the French surgeon was followed up by that of his son and successor, who obtained great celebrity for his opera- tions upon the joints, attracting patients from all parts of France, and who, at various intervals, embodied the results of his observation and experience in separate monographs addressed to the Academy of Surgery at Paris and other learned societies. In the early part of the present century excision of the joints received a powerful and salutary impulse from the French army surgeons, particularly Larrey, Percy, Willaume, and Bottin, who repeatedly performed extirpation of the heads of the bones, especially those of the shoulder, on account of gunshot injury. The operation, indeed, was per- formed, at one time, upon a large scale, and many limbs, as well as lives, were doubtless saved by it. Notwithstanding this, however, the procedure was generally regarded with suspicion in Great Britain, where, although it originated there, it made no real progress until thirty years ago, when, chiefly through the example of Mr. Listen and Mr. Syme, it began to attract the universal attention of medical men. During the last few years the operation has been performed in numerous instances, by surgeons of the highest emi- nence, upon nearly all the principal articulations, and the results have been such as to warrant the belief that this department of the healing art is des- tined rapidly to undergo a most salutary change. In this country excision of the joints has hitherto been greatly neglected, both in hospital and private practice ; that this, however, will be the case any longer is not at all probable when we reflect upon the intelligence, zeal, and skill of our surgeons. All innovations require time for their adoption, and what De Condillac said of another subject is equally true of this. " U est rare que l'on arrive tout-a- coup a l'evidence: dans toutes les sciences et dans tous les arts, on a com- mence par une espece de talonnement." Excision of the bones iu their continuity has been practised, for various purposes, for a long time, and modern surgery is indebted to it for many of its most brilliant exploits. It is in this department, more particularly, that American operators have displayed their greatest skill. Commencing with excision of the inferior jaw by Dr. Deadrick, of Tennessee, in 1810, we may with just pride point to the operations of Mott upon the clavicle, of Mussey, McClellan, and Gilbert upon the scapula, of Butt and Carnochan upon the ulna, and of the latter upon the radius, not to mention numerous minor cases, which, although less known, have reflected the highest credit upon the scien- tific character of the profession, and conferred the greatest benefit upon a class of sufferers who would otherwise have been doomed to loss of limb and life. Instruments___Various instruments are required for the ready and success- ful performance of this operation, and it is always desirable to have rather too many than too few, so that every emergency may be promptly met as it arises. The incisions through the skin and muscles are^made with ordinary scalpels, but for detaching the bones from the soft parts and dividing the ligaments, stout, probe-pointed knives, with broad, steel handles, convex and semi-sharp at the end, will be necessary. Excision of the bone is effected with a hand-saw, a pair of pliers, or the gouge and chisel, according to the structure, size, and situation of the affected piece. The saw, which may be a common amputating one, should be from six to ten inches in length by from three to twelve lines in width, its teeth being sharp and widely set, and its handle long and thick. A saw, lately introduced by Mr. Butcher, of Dublin, 572 EXCISION OF THE BONES AND JOINTS. and bearing his name, will be found very useful, especially when there is but little space, or when it is necessary to divide the bone obliquely. It has, as will Butcher's saw. be perceived by a reference to the engraving, a very narrow blade, the angle of which can be changed at pleasure. In addition to these instruments, it will Fig. 178. Hey's saw. be well to have upon the tray a Hey's saw, fig. 178, and also a very narrow concave saw, fig. 179, with a blunt end, in the event of its being necessary Fig. 179. Curved saw for small bones. to divide the bone from behind forwards. As to the chain saw, fig. 180, even in its most approved forms, it may well be dispensed with, as its use is gene- rally only productive of delay, vexation, and disappointment. Bone forceps or pliers, figs. 181—2—3, usually known as Liston's, although long ago described and delineated by Scultetus, should be at hand, of various shapes and sizes, as they may frequently be used with great advantage in places where it is impossible to introduce and work the saw. The surgeon should also be provided with several gouges and chisels, a strong mallet, trephines, scrapers, and a large ele- vator, together with a thick leather strap or leaden spatula for protecting the soft parts during the division of the bone, suit- able instruments for holding the flaps apart, and a syringe for washing out the wound or clearing away sawdust and the debris of diseased bone and cartilage. From this catalogue of instruments I chain saw. have purposely excluded the tourniquet, EXCISION OF THE BONES AND JOINTS. 573 which is not only unnecessary, but absolutely hurtful in excision of the bones and joints. If proper care be used, the surgeon will seldom lay open any of Fig. 181. Fig. 182. Fig. 183. Bone forceps. the more important arteries, none certainly which may not be readily secured by the ligature; there is, therefore, no need of such an instrument, which would only serve to dam up the blood in the larger veins, and thus cause injurious waste. Position of the Patient.—The position of the patient, the surgeon, and the assistants, as well as the number of the latter, varies in different cases and under different circumstances, and does not admit of any precise rule. Generally speaking, the recumbent posture will be the most suitable, especially if chloroform is given and the operation is at all likely to prove tedious. In cases of any magnitude, as in exsectiou of the knee-joint, the number of assistants should not be less than five or six; one administering the anaesthetic, two holding the limb, one handling instruments and tying arteries, and another having charge of the sponges. As it respects the operation itself, it may be conveniently considered as consisting of three stages, the division of the soft parts, the excision of the bone, and the dressing of the wound. Incisions.—In planning the incisions, care must of course be taken not to interfere with any structures, the division of which might compromise in any way the result of the operation. The sheaths of the tendons are to be espe- cially avoided. To lay them open would be to invite inflammation and plastic deposit, which could not fail to impair their usefulness. The nervous trunks are turned aside, out of harm's way, and the larger vessels, both arterial and venous, are studiously protected from injury. The number and direction of the incisions will necessarily vary in different cases. Sometimes a single longitudinal cut will be sufficient, even in such a joint as that of the shoulder; in general, however, they should be so arranged as to enable us to form a good-sized flap, either of a semi-lunar, horseshoe, or square shape, as this will afford more ready access to the affected bone, as well as greater facility for sawing it. Incisions made after the manner of some of those depicted in the chapter on minor surgery will afford the sur- geon an opportunity of adapting his operations to any case that will be likely to come under his observation. The elliptical incision may be adopted, if it be necessary to remove any integument on account of disease. Whatever plan be pursued, the great rule 574 EXCISION OF THE BONES AND JOINTS. is to sacrifice as little soft substance as possible. Even when the flap is verv large and unseemly, it must not be retrenched, experience having proved that it will always contract down to the proper dimensions during the progress of the cure. In separating the bone from its muscular and ligamentous connec- tions, the knife must be kept as close as possible to its surface; any deviation from this rule will be likely to be followed by the division of structures which should not be meddled with, especially important bloodvessels. Removal of the Bone.—Insulation of the bone having been effected, it is next to be pushed through the wound, and sawn off, the parts around being carefully protected from injury by a piece of leather, or a metallic spatula placed underneath. Whenever it is feasible, I prefer sawing off the bone to cutting it away with the pliers, as the surface thus made is more smooth, as well as less bruised, and, consequently, more liable to heal well. In operat- ing upon the smaller bones, as those of the carpus and tarsus, we are gene- rally obliged to make free use of the gouge and chisel. In whatever manner the excision be accomplished, the invariable rule is to cut through the healthy structure ; and this is applicable even when the bone is merely denuded of its periosteum, observation having shown that, when the osseous tissue is divested of its natural covering, it is either already dead, or will soon die. In excision of the long bones, the condition of the medullary canal and its contents should always be carefully scrutinized, with a view of ascertaining wdiether the part should be still further retrenched or not. Imperfect excision is worse than useless, as no thorough cure can take place after it without an- other operation. Finally, when two bones require to be removed, as, for example, in excision of the tibia and fibula, they should be sawn off upon the same level, otherwise the limb will be apt to be forced to one side, and so be rendered comparatively worthless. Dressing.—Bleeding having been arrested, the wound is washed out with cool water thrown in with a large syringe, in order to get rid of the sawdust, which, if allowed to remain, never fails to act as a foreign substance, liable to provoke suppuration and erysipelas, if not worse consequences. Any sinuses that may exist are also pared or laid open. The edges of the wound are then approximated by the interrupted suture and adhesive plaster, aided, if necessary, by a compress and bandage. The most dependent portion of the wound, however, should always be kept patent by means of a small tent or tube, to admit of the necessary drainage. If this precaution be neglected, the result will be that the secretions, which are always more or less profuse after such an operation, will accumulate in the wound, thus not only impeding the cure, but often inducing necrosis of the bones, and affording an oppor- tunity for the easy entrance of pus into the system. Before the patient is returned to bed, the limb should be placed in the position in which it is to rest during the after-treatment, and kept perfectly quiet by means of appropriate apparatus. In excision of the inferior ex- tremity osseous union is usually desired, as the limb would hardly be useful without it, and hence it will not be proper, as a general rule, to make passive motion. In the upper extremity, however, this rule is not applicable ; here motion is both sought for and attained at all hazard, an auchylosed wrist, elbow, or shoulder being of little value. The great sources of danger after excision of the bones and joints, are excessive suppuration, pyemia, and erysipelas. These accidents are to be carefully guarded against by the ordinary means, and treated upon general principles in the event of their occurrence. If the convalescence be unusually protracted, and especially if the wound be slow in healing, if sinuses form, or if there be much discharge of an unhealthy character, there will be reason to suspect that the bones have again become diseased, and that further inter- ference will be required before a cure can finally be brought about. ANESTHETICS, OR THE MEANS OF AVERTING PAIN. 575 CHAPTER XIX. ANAESTHETICS, OR THE MEANS OF AVERTING PAIN. The prevention of pain in surgical operations has been an object of anxious solicitude with practitioners from time immemorial, and we accordingly find that suggestions, more or less plausible, have been made at different periods with a view of meeting this important end. One of the most remarkable of these suggestions, inasmuch as it was a clear foreshadowing of the anaesthe- tics of the present day, occurs in the surgical writing of Theodoric, in the latter part of the thirteenth century. The means recommended by him con- sisted in thoroughly impregnating a sponge with a strong aqueous extract of various anodyne articles, especially opium, hemlock, hyoscyamus, lettuce, and mandragora, and then, after having been immersed for an hour in warm water, holding it to the nose until the patient fell asleep, when the operation was proceeded with. In order to rouse him when the operation was over, another sponge, dipped in vinegar, took the place of the "spongia somnifera," as the former was denominated ; if this expedient failed, the juice of the root of fenugreek was freely injected into the nostrils. In India, the extract of the hemp plant, cannabis Indica, indigenous to that country, has been employed for the same purpose for ages past. Near the close of the last century, great hopes were entertained that a successful agent had at length been found in the inhalation of nitrous oxide gas, either alone, or variously combined with other vapors, but after numerous experiments, in which Sir Humphrey Davy and other eminent philosophers took an active part, the project was at length abandoned as chimerical. Some time prior to this period, Mr. Moore, of London, had suggested the possibility of diminishing pain in surgical opera- tions, especially in amputations, by compression of the principal nerves, by means of an instrument, somewhat similar to a tourniquet, but so constructed as to touch the limb only at two points, one of the pads being regulated by a screw. The experiment was tried at St. George's Hospital, by Mr. John Hunter, upon a man whose leg was cut off below the knee on account of a' large irritable ulcer of the foot, and the suffering is said to have been exceed- ingly slight. Very few, however, seemed inclined to repeat it, and the con- sequence was that it was soon given up ; a result which might have been anticipated by the originator of the plan, as the instrument used for the com- pression was not only uncertain in its operation but productive of great uneasiness during its application. In 1819, Mr. James Wardrop, of London, proposed to diminish the sensi- bility of the patient in surgical operations by means of copious venesection, and in a paper which he published on the subject in the tenth volume of the Medico-Chirurgical Transactions he cites several cases illustrative of its bene- ficial influence. He thought the practice particularly adapted to persons of a nervous, irritable temperament, and he recommended that it should be carried to the extent of syncope, so as completely to annul all sensation during the dissection. In one of his cases, he bled the patient, a young robust woman, to fifty ounces before he began the operation, which consisted in the extirpation of a small tumor from the orbitar plate of the frontal bone, during which she remained perfectly unconscious, expressing great surprise 576 ANESTHETICS, OR THE MEANS OF AVERTING PAIN. when she found it was over. As might have been expected, however, she remained very weak for several days after the operation, although she made a rapid recovery. I am not aware that this recommendation met with any particular favor. The administration of the different preparations of opium for the purpose of lessening the pain of surgical operations is an old practice, highly lauded by some, and as greatly condemned by others. I was myself in the habit of employing it for many years in almost every case that fell into my hands pre- viously to the discovery of anaesthetics; I generally preferred morphia to laudanum or opium in substance, and always gave it in full doses, either alone, or, when the patient was strong and plethoric, combined with a moderate quantity of tartrate of antimony and potassa, with a view of inducing a greater degree of relaxation and insensibility. I became very fond of the practice, and never, so far as I could determine, experienced any bad effects from it; on the contrary, I knew that it was commonly productive of great benefit, not only blunting sensibility but preventing shock, and, consequently, severe reaction. Notwithstanding these various attempts to prevent suffering in surgical operations, no anaesthetic agent, using the term in its legitimate sense, was discovered until 1844, when Dr. Horace Wells, a dentist of Hartford, Con- necticut, wishing to have a tooth extracted, rendered himself completely in- sensible by inhaling nitrous oxide gas; and he soon afterwards administered the same remedy to several of his patients with effects equally gratifying. Shortly after this, Dr. Wells repeated his experiments before the Medical Faculty and Students of Harvard University, at Boston, but owing to mis- management either in the apparatus or in the gas itself, the "attempt signally failed, and the only reward which he received for his pains was ridicule, which, in his case, was the more cruel, because he was a man of uncommon sensi- bility. Two years after this, Dr. Morton, also a dentist, who had been a pupil of Wells, resorted to the inhalation of sulphuric ether, first in his own person, and afterwards in some of his patients, until he became convinced that it might be taken not only with impunity, but with the raost perfect cer- tainty of preventing pain in any operation, however severe or protracted. Fortified with this knowledge, he applied at the Massachusetts General Hos- pital, at Boston, for permission to repeat his experiments upon a man who was about to undergo an operation for the removal of a tumor of the neck by Dr. John C. Warren. The result was everything that could have been desired. The next day, Morton etherized a patient for Dr. Hayward; and the news of the remedy rapidly spreading, its use soon became general, both in the United States and in Europe. In the latter country, the subject attracted perhaps even greater attention than at home, and soon led to the discovery of chloroform by Dr. Simpson, of Edinburgh, in 1847. Various other articles possess anaesthetic properties ; of this description are chloride of hydrocarbon, nitrate of ethyl, aldehyde, benzin, the Dutch liquid—a com- pound of chlorine and defiant gas—bisulphuret of carbon, amylene, and kerosoline; but, with the exception of the latter two, it is questionable whether any of them are sufficiently innocuous to justify their exhibition. Practically it is of no importance to know who the discoverer of anaesthe- tics was; but, if we carefully inquire into the history of the matter, we cannot fail to award to Dr. Wells the credit of having made the first successful ap- plication of this class of agents for the prevention of pain during a surgical operation. Nearly fifty years previously, Sir Humphrey Davy had, it is true, employed nitrous oxide gas for the relief of a severe headache, brought on by the intoxication caused by the rapid drinking of a bottle of wine for ex- perimental purposes, and afterwards as a means of preventing the pain of cutting a wisdom tooth ; but, as every one knows, no further use was made HISTORICAL NOTICES. 577 of the remedy, until it was resumed by Dr. Wells, and applied with express reference to the production of its anaesthetic effects. He was beyond doubt the first to establish the possibility of preventing pain in surgical operations ; and had his experiments at Boston not eventuated in chagrin and disappoint- ment, he would unquestionably have pushed his researches much farther, and perhaps speedily hit upon the very articles which were afterwards found by Dr. Morton and Professor Simpson to possess such valuable properties. To both the latter gentlemen the world owes an immense debt of gratitude for having brought to light the wonderful anaesthetic effects of ether and chloro- form. It is somewhat singular that the two countries in which the anaesthetic virtues of ether and chloroform were discovered should each, respectively, prefer its own remedy ; America, ether, and Great Britain chloroform. There are, however, in the United States, numerous practitioners who prefer the latter article, both in surgical and obstetrical practice, and I have myself constantly used it ever since its introduction among us in 1848, believing it to possess decided advantages over ether, although its administration un- questionably requires greater care and attention. Among the more im- portant of these advantages are, first, the more rapid manifestation of the anaesthetic action of the remedy, the system becoming affected much sooner, as a general rule, than it does by ether ; secondly, a smaller amount of laryn- geal and bronchial irritation ; thirdly, the more easy maintenance of the anaesthetic influence, after the system has once been fairly affected ; and, lastly, the less liability to cause vomiting and other unpleasant consequences. The very odor of ether is to many persons excessively offensive, and there are very few in whom the inhalation does not produce more or less cough and vomiting. On the other hand, it certainly requires less caution in its ad- ministration, and thus far it has furnished but few deaths, whereas the mor- tality from chloroform already reaches about a hundred. Dr. Maddin, of Nashville, who has carefully investigated the subject, finds that most of the fatal cases of anaesthesia have occurred in minor surgery, or in operations of a comparatively trifling nature, and in which, consequently, the remedy might probably have been entirely dispensed with. For a number of these cases the dentist is accountable, nearly all the earlier and not a few also of the later having happened during the extraction of teeth, probably from the want of precaution in not sufficiently depressing the head during the operation. It is remarkable that most of the fatal cases have happened in private practice, or in small institutions, a circumstance which would seem to show that there had been some fault in the mode of administration of the remedy. At Guy's Hospital, London, chloroform had been used in upwards of 12,000 cases before there was any serious accident; and in the war in the Crimea, according to the testimony of Mons. Flourens, it was administered more than 25,000 times without a single death. It has been asserted by the opponents of chloroform that the rate of mortality in the great operations of surgery has been essentially increased since the introduction of that article into prac- tice, and Mr. Arnott, of London, has taken pains to collect elaborate statis- tics with a view of establishing the fact upon an irrefragable basis. On the other hand, the statistics of Dr. Simpson, the discoverer of the anaesthetic properties of chloroform, go to show that the number of deaths is not only not increased, but absolutely diminished. Perhaps the truth lies between these two statements. Dr. Macleod, in his Notes on the Surgery of the War in the Crimea, recently published, declares it as his conscientious belief that the use of chloroform in the British army saved many lives, and that numerous operations were performed by its assistance which could not other- wise have been attempted. It is not improbable that, if there has really been an increase in the mortality after operations since the introduction of anaes- vol. i.—37 578 ANAESTHETICS, OR THE MEANS OF AVERTING PAIN. thetics, it has been owing, not to the pernicious effects of the remedy, bnt to the fact that surgeons have been emboldened to undertake operations in cases which were formerly regarded as unfit for the employment of the knife, and, above all, to the circumstance that of late years there has been a fearful increase of railway and other terrible accidents, many of which are necessarily fatal, no matter to what treatment they may be subjected. I have now given chloroform for more than ten years, and during all that time no serious accident has befallen me. There was one case, however, in which I experienced much alarm ; the patient was a boy, thirteen years of age, who was about to undergo an operation for the repair of his lips and cheek, which had been much mutilated by salivation. He took chloroform very badly, and had tried my patience for an unusual length of time, when, determined to make him inhale more rapidly, I began my incisions. In- stantly his struggles became furious, compelling me to suspend further pro- ceedings. Provoked at the occurrence, I requested the assistant to hold the sponge closely over the nose, while I carefully watched the pulse and respira- tion. Fifteen seconds had hardly elapsed, when they both ceased, the face assuming at the same time a pale, livid aspect, too clearly denotive of asphyxia. In an instant the boy was turned upon his side, and artificial respiration in- stituted ; cold water was dashed upon his body, and a free access of cold air invited by raising the windows of the apartment. Animation was speedily re-established, and the operation proceeded with, chloroform being again given towards its close, but of course with great caution. In this case it is evident that the patient was on the very verge of dissolution; but whose fault was it ? Certainly not that of the chloroform, but the manner in which it was administered. I ascribe my good luck in the use of chloroform to the great caution with which, except in the above case, it has always been given in my practice, and to the purity of the article employed by me. During my residence at Louis- ville, Dr. D. D. Thomson for many years superintended the inhalation in almost every important operation that I performed, either in private or pub- lic, and when he was not present, I either gave it myself or confided the task to a trustworthy assistant. The mortality from anaesthetics has lately been placed in a very satisfactory light by Dr. Charles Kidd. In a paper in the London Medical Times and Gazette for May, 1860, he states that, up to that period, about 125 cases of death from chloroform had occurred in Europe, 25 from ether, and several from amylene. Of 121 deaths from chloroform, 54 happened immediately before operations; 42 during the operations ; and 25 after the operations. The statistics of Dr. Kidd show that the mortality from chloroform has hitherto been more than twice as large in males as in females, and that the danger from the inhalation of this substance, as had been previously ascer- tained by Dr. Maddin, is much greater in trivial than in large, tedious ope- rations, the latter establishing apparently a chloroform tolerance. Of the number of deaths from chloroform and other anaesthetics in this country, we have no accurate data, but it is much less than in Europe. As an offset to the above fatal cases, it may be stated that chloroform, the use of which is unquestionably more dangerous than ether, has now been administered in hundreds of thousands of operations with perfect safety. Anaesthetics not only prevent pain and thus save a vast amount of suffer- ing, but by placing the patient in a passive condition give the surgeon a con- trol over him which he could not possibly obtain in any other manner. De- prived of sensibility and consciousness, the former is virtually dead to all external impressions, and the latter is therefore enabled to conduct his dis- sections and other manual processes with as much ease and deliberation as if he were operating upon the cadaver. The advantages thus gained are ab- CHLOROFORM. 579 solutely incalculable, and he who would fully appreciate them must be able to put himself in the twofold situation of patient and surgeon, and then, in imagination, contrast their condition with that of the patient and surgeon of former times, before the discovery of anaesthetics, when the one was writhin"- in pain and agony during a tedious dissection, and the other had his progress incessantly interrupted by the cries and struggles of the sufferer. The exhibition of anaesthetics is important not merely as a preventive of pain, but as a means which enables us to examine our cases more thoroughly prior to operation. Sounding for stone in the bladder, formerly a source of so much suffering, may now be performed without the slightest uneasiness, and the same is true of stricture of the urethra, diseased bones, affections of the anus and rectum, and of various other lesions. The use of anaesthetics affords immense advantages in the examination of dislocations and fractures, enabling us to handle the parts more satisfactorily than formerly, and there- fore often leading to a much more certain diagnosis. There are some operations in which the use of anaesthetics is usually re- garded as inadmissible; thus, in harelip, excision of the tongue, and removal of the jaw, the patient, as a general rule, should be under the influence of these remedies only at the beginning of the operation; after the dissection has been fairly commenced, he should be sufficiently conscious to enable him to co-operate with the surgeon, otherwise the blood, passing down into the windpipe, might cause severe cough and other inconvenience, seriously em- barrassing the procedure. The same remark applies to excision of the tonsils, although I have frequently removed these organs while the patient was so far under the influence of chloroform as to render him incapable of offering any resistance. Extirpation of the jaws I have repeatedly performed under similar circumstances, passing through the different stages of the opera- tion while the person was in a state of perfect unconsciousness. Even the more delicate operations upon the eye, as the establishment of an artificial pupil, and the extraction of cataract, may be safely performed with the aid of anaesthetics; as it respects the latter, however, it should not be forgotten that the vomiting which occasionally attends their use might destroy the organ. An advantage which has often been claimed for anaesthetics is that there is apt to be less hemorrhage during operations; I am, however, in doubt whether this is true, and, even if it were, any good that might thus accrue would be more than counterbalanced by the liability to secondary bleeding, caused apparently by a partial loss of tone in the smaller vessels, interfering with the formation of protective clots. Possibly the blood itself may be more or less at fault. Chloroform, a terchloride of formyl, is a clear, colorless liquid, very vola- tile, of an agreeable, aromatic odor, of a pungent, saccharine taste, very dense, of the specific gravity of 1.497, almost insoluble in water, non-inflammable, and perfectly neutral, neither reddening nor bleaching litmus paper. It is a compound of two atoms of carbon, one of hydrogen, and three of chlorine. Various impurities are liable to be mixed up with it, especially the chlori- nated pyrogenous oils, ether, and alcohol. The presence of oils is readily detected by pure, strong sulphuric acid, to which they impart a change of color, varying from yellowish to reddish brown, according to the quantity of the extraneous substances. A still more simple test consists in pouring the suspected fluid upon the hand, where, rapidly evaporating, it deposits its oily impurities, which are easily recognizable by their offensive smell. Dropped upon white paper, pure chloroform speedily disappears without leaving any stain. The existence of alcohol is detected by dropping a small quantity of chloroform into distilled water; if pure, it will retain its transparency at the bottom of the glass, whereas, if the reverse be the case, each globule will ac- 580 ANASTHETICS, OR THE MEANS OF AVERTING PAIN. quire a railky appearance. The presence of ether may be detected by a lighted taper, or the inflammable character of the fluid. It is practically important to know that chloroform deteriorates by exposure to heat and to a strong light. The most reliable article is that prepared with methylated spirit. Mode of Administration.—There are five principal circumstances which should be closely attended to during the exhibition of chloroform, and if this be done it will be difficult, unless the article be a bad one, or the patient have some idiosyncrasy, to produce any unpleasant effects with it. These are recumbency, an empty state of the stomach, a free play of the diaphragm, an abundance of atmospheric air, and a gradual administration. 1st. During etherization the patient may sit up with impunity, but this is not the case during the inhalation of chloroform, owing, apparently, to the greater relaxation of the muscles, and, consequently, to the greater difficulty in maintaining the circulation of the brain through the influence of the heart's action. Not only should the body be recumbent, but care should be taken to depress the head and shoulders, bringing them nearly to a level with the trunk. Lying upon the side, when this is practicable, is perhaps the safest posture of all, as the breathing will then be less likely to be interfered with by the falling back of the tongue. 2d. An empty state of the stomach is desirable for two reasons; first, be- cause if chloroform be giveu soon after a hearty meal it will be almost certain to induce vomiting; and, secondly, because a crowded condition of the organ interferes materially with the movements of the diaphragm. Food must not be taken for at least four hours before the exhibition ; but, on the other hand, the interval should not be too protracted, lest serious exhaustion result from the want of the necessary stimulus. 3d. Care must be taken, before the inhalation is commenced, that the patient's clothes are sufficiently loose to prevent constriction of the chest and abdomen. Any compression from this source would necessarily impede the action of the diaphragm, and might thus become a cause of mischief. 4th. The importance of having an abundance of atmospheric air during the inhalation of an article so potent as chloroform is self-evident; in ether- ization this is of comparatively little consequence, but in the exhibition of chloroform for surgical aud obstetrical purposes, it is absolutely indispensa- ble to the safety of the patient. 5th. The inhalation must be effected gradually, not hurriedly, time being allowed to the system to accommodate itself to the influence of the remedy, thus avoiding the shock which might otherwise result to the heart and brain. From six to eight minutes should usually be spent in producing the full effects of the anaesthetic. When the patient is very feeble, or pale and timid, it will be advisable to give him, immediately before the operation, from half an ounce to an ounce of brandy ; and the dose may afterwards be repeated, if the effect is obliged to be maintained for an unusual length of time, sufficient consciousness being permitted for the performance of deglutition. The best mode of administering chloroform is to pour the fluid upon a napkin or handkerchief, previously folded into a kind of cup-shaped hollow, and held securely in the hand. Or, instead of this, a small, hollow sponge may be used. As to the various inhalers that have been devised for the pur- pose, they are all objectionable on account of their inconvenience and the difficulty of obtaining a sufficiency of atmospheric air. The patient having taken his place upon the table, and emptied his lungs by a deep and protracted expiration, the napkin, impregnated with a drachm of chloroform, is held over the mouth and nose, at a distance of about two inches, being gradually brought nearer and nearer until it is within half an inch, beyond which it MODE OF ADMINISTRATION. 581 should not be carried, the chest being at the same time regularly and power- fully distended. The pungent effect of the liquid upon the skin should be prevented by anointing the face with some protective unguent, otherwise vesi- cation might arise. All unnecessary conversation is avoided, lest the atten- tion of the patient should thereby be unduly distracted. The assistant having charge of the administration gives it his earnest and undivided care ; wetting the napkin from time to time with the fluid, and seeing that the patient gets an abundance of air, his vigilance increasing as the effects of the medicine become more and more apparent. As soon as the sensibility is completely abolished, the operation is commenced, a return to consciousness being pre- vented by holding the napkin, wet with a small quantity of the vapor, occa- sionally before the nose, and thus the impression is maintained, steadily and cautiously, not only until the knife has fully accomplished its object, but until the principal arteries have been secured, and, in some cases, even until the dressings have been applied. As soon as the inhalation has.been fairly entered upon, one of the attend- ants should sedulously watch the state of the pulse, of the respiration, and of the countenance. Any sudden failure in any one of these should at once create alarm, and induce a suspension of the operation, or provision for the admission of a greater quantity of atmospheric air. I do not deem it neces- sary that a finger should be constantly kept upon the pulse, for the color of the face and the nature of the breathing will always sufficiently indicate the effects which the anaesthetic is exerting upon the system, and thus afford abundant opportunity for preventing any unpleasant occurrence. The quantity of chloroform required during an operation, and the time during which its effects may be safely maintained, must, of course, vary accord- ing to the exigencies of each particular case. In general, from half an ounce to an ounce may be regarded as a fair average, but very frequently it takes three or even five times that amount, depending upon the severity and dura- tion of the operation, and the susceptibility of the individual. In some in- stances almost an incredibly small portion answers the purpose. Children usually require comparatively little ; and it is well known that women are, as a general rule, more susceptible to its influence than men. Persons exhausted by hemorrhage are very easily affected by it, owing to the rapidity of its ab- sorption, and hence it should always be administered to them with unusual care. In obstetric practice, the effects of chloroform may be maintained, with impunity, for many hours together, and the same remark is true of severe and tedious surgical operations. Thus, in an attempt to reduce a chronic dislocation of the shoulder-joint, I kept the patient steadily under the influ- ence of the remedy for two hours, during which time not less than twenty ounces were given. Age is no bar to the use of anaesthetics. I have given chloroform repeat- edly to very young children, and, in one instance, I administered it, with ex- cellent effect, to an infant under two months. Old persons also bear the inhalation well. Certain diseases are usually regarded as contra-indicating the employment of anaesthetics, particularly organic lesions of the heart and brain ; but, for my own part, I have never allowed any affection whatever to stand in ray way, and I can really, upon general physiological principles, see no reason why they should, since, by tranquillizing the system, they effectu- ally prevent the mental and bodily perturbation which is so apt to attend operations performed without the aid of these agents. In giving chloroform to infants and very young children, only a few drops should be poured upon the napkin at a time, and care should be taken to hold the cloth at a considerable distance from the mouth and nose, so that the fluid may enter the lungs well diluted with atmospheric air. 582 ANAESTHETICS, OR THE MEANS OF AVERTING PAIN. Effects.—The effects of chloroform upon the system may, for practical purposes, be divided into two stages, namely, that of excitement, and that of insensibility. The first begins soon after the commencement of the inha- lation, and is characterized by various cries and struggles, as if the patient, feeling alarmed, were anxious to escape from the table. The face becomes flushed, the eye has a wild and staring expression, the pulse is preternatu- rally frequent, and the mind is incoherent; as the effects increase, the brain falls into a species of exhilaration closely akin to that of intoxication. It is now that the individual usually exhibits his peculiarities of temperament and habit. Thus, if he be of a boisterous disposition, he will be very apt to be noisy, to swear, or to fight, and to make the most violent efforts to disengage himself from the assistants. One man will laugh and joke; an- other will weep, or moan and sigh ; the sportsman will fancy himself occu- pied in the pleasures of the chase ; the wily craftsman in driving a good bargain ; the lawyer in addressing a jury ; the preacher in exhorting his con- gregation, and the physician in prescribing for his patient. The mind is in a dreamy, perverted condition, and whatever is most predominant at the time in thought and feeling is sure to exhibit itself in expression. This excitement varies much both in degree and duration ; in many cases it is very slight and transient, while in some it is even entirely wanting, the patient being perfectly tranquil throughout. When considerable, it is very liable to be reproduced, to a greater or less extent, as the effects of the re- medy wear off, so that the individual will perhaps be quite as boisterous after the inhalation is over as he was soon after its commencement. In very nerv- ous, excitable persons the intoxication may last for several hours, although this is uncommraon. In the second stage, which succeeds imperceptibly to the first, the indi- vidual gradually lapses into a state of entire unconsciousness ; the muscles, thoroughly relaxed, are no longer under the control of the will, the limbs retaining any position in which they may be placed ; the eyelids are closed and the balls turned up, the pupils being contracted, and insensible to light; the respiration is calm and easy; and the pulse is soft and undisturbed, or, if it be at all changed, it is rather below than above the normal frequency. Feeling and intellection are suspended, and everything indicates that the patient is in a quiet and pleasant sleep, wholly unconscious of surrounding objects, and therefore completely insensible to pain. If this state be carried a little farther, coma will arise; the patient will snore as if he were apoplec- tic, the pulse and respiration will diminish in force and frequency, and the pupil will become notably dilated. As yet, all is safe, but a few more whiffs, and an important link in the chain of life may give way, and the patient be sent into eternity. In the administration of chloroform we should always strive to prevent coma. The most unexceptionable form of anaesthetization unquestionably is that in which there is a perfect suspension of sensibility without the complete abolition of consciousness ; but it need hardly be added that it is, practically, extremely difficult to produce such a nice result in any case. In general, the patient, on recovering from the effects of the remedy, has no distinct recollection of anything that passed while he was under its influence. The effects of chloroform seldom completely disappear under several hours. After the more characteristic symptoms have gone off, the mind will still remain somewhat bewildered, the muscles relaxed, and the feelings per- verted. In some cases, especially in children, the patient, after having passed through a most severe operation, will fall into a tranquil sleep, and perhaps not wake up fully for an hour or two. In other cases, again, the effects will go off very rapidly, and the individual will not only be roused to a state of consciousness, but to severe pain. If the vapor has been inhaled largely, EFFECTS OF CHLOROFORM. 583 there will frequently be some degree of nausea or even vomiting, either dur- ing the operation, or at its close, upon the return of consciousness. Emesis is raost frequent in children and in persons of a nervous, irritable tempera- ment. Headache, although not common, is occasionally met with, and some- times lasts for a number of hours. It is most liable to come on if the chlo- roform is impure. Chloroform, inhaled to excess, sometimes produces effects which disappear only after a considerable length of time ; as abolition of the sense of smell, perversion of taste, and loss of power in the bladder and rectum. In two cases, observed by Dr. Happoldt, of South Carolina, these effects did not completely wear off for two months. Although chloroform is one of the greatest boons which a kind and bene- ficent Providence has bestowed upon man for the prevention and alleviation of pain, yet, like every other remedy, it is capable, when abused, or injudi- ciously administered, of producing the raost deadly effects. These effects are those of a narcotic poison ; and as they may follow, in persons of unu- sual susceptibility, the inhalation of the smallest quantity of the liquid, it is of the utmost importance that they should never, for a moment, be lost sight of in the use of the article. An over-dose may destroy life almost instanta- neously, or death may occur at a variable period after the exhibition ; some- times after partial reaction has taken place. The phenomena indicative of danger are, stertorous respiration, a small and feeble pulse, lividity of the features, dilatation of the pupils, relaxation of the sphincters, and rapid diminution of the temperature of the body. It seems probable, although the question does not admit of positive adjudication, that these effects are mainly, if not wholly, due to the action of the carbonic acid gas contained in the chloroform primarily upon the blood and nervous centres, and secondarily upon the respiratory organs, thereby disqualifying them for the performance of their functions, death being caused by asphyxia. What corroborates this view of the subject is the fact that the danger from the inhalation of chloro- form is generally in proportion to the impurity of the article, or the quan- tity of its pyrogenous oils, and the want of a sufficiency of atmospheric air, or the raost essential constituent of this fluid, namely, oxygen, during the administration of the remedy. The treatment for the relief of the poisoning consequent upon an over-dose of chloroform must be prompt and efficient; for everything depends upon the presence of mind of the surgeon and the rapidity and energy with which he applies his remedies. The first thing to be done is to desist from the further administration of the remedy; the second, to draw the tongue out of the mouth with a tenaculum, so as to lift it away from the glottis; the third, to cause a full access of cold air, by throwing open the doors and windows of the apartment, and making free use of the fan ; the fourth, to dash cold water upon the body, or, still better, to pour it from a height of several feet; the fifth, to institute artificial respiration, by introducing a tube into the wind- pipe, and percussing the body or by blowing air into the mouth ; the sixth, to stimulate the surface, especially over the spine and heart, with hot mustard water, or dilute spirits of hartshorn ; the seventh, to administer an injection of turpentine; and the last, to apply galvanic electricity, passed through needles inserted in different parts of the body. As soon as the patient is able to swallow, free use is made of brandy and ammonia. These means should be employed with great diligence and regularity until it is perfectly evident that life is irrecoverably extinct. For the minor effects of chloroform very little is necessary, beyond a dis- continuance of the inhalation, sprinkling the face and chest with cold water, allowing a free access of cold air, and holding a smelling bottle near the nose, but not to it. If vomiting occur, the patient must immediately be turned 584 ANAESTHETICS, OR THE MEANS OF AVERTING PAIN. upon his side—not on his abdomen, lest the action of the diaphragm be impeded—with the head inclining downwards, otherwise the contents of the stomach, as they are lazily ejected from the oesophagus and fauces, might easily descend into the larynx, and thus induce suffocation. I cannot conclude these remarks upon the subject of anaesthetics without expressing a hope that practitioners of every description will cease to admi- nister these remedies to females except in the presence of witnesses. The cases of the two dentists, the one of this city and the other of Montreal, which have lately created so much excitement both in and out of the profession, should serve to inculcate proper caution in this particular, without which no man's reputation and character, however pure or exalted, may altogether escape censure, if, indeed, ruin. The remarkable instance which, a few years ago, occurred at the Philadelphia Hospital, of a woman who, while under the influence of anaesthesia, went through all the movements of the sexual con- gress, and analogous examples reported in the medical journals, clearly show how strongly the imagination of the patient may be impressed in this way, while thus affected, and how vividly the idea may remain after the effects of the remedy have passed off. The case that occurred, not long ago, at Louis- ville, might have been followed by a vexatious and disgraceful law suit, if it had not fortunately been witnessed by several medical gentlemen. Practi- tioners should take care of their own character not less than of the lives of their patients. Inhalation of Ether.—The inhalation of ether is best effected by means of a large hollow sponge held closely over the nose and mouth, although a folded napkin will be found to answer the purpose sufficiently well. No special attention need be paid to the admission of atmospheric air, as this fluid pos- sesses none of the poisonous qualities of chloroform and other kindred articles. Not less than half an ounce should be poured upon the sponge at a time, and the administration should be diligently maintained until a full anaesthetic effect is produced, which usually requires a considerably longer period than in the case of chloroform. At first a short cough is generally provoked, but this soon subsides, and the system gradually lapses into a calm, quiet condi- tion, attended with muscular relaxation, closure of the eyelids, and mental unconsciousness, followed, in many cases, by stertorous respiration. The quantity of ether consumed in an ordinary operation is seldom less than from four to eight ounces, while in the more protracted cases twice or even thrice that amount may be necessary. Sickness and vomiting are com- mon effects of the use of this agent, and there is also not unfrequently a great deal of headache after the patient has recovered from his unconsciousness, sometimes lasting upwards of twenty-four hours. In administering chloro- form the patient always lies down ; in etherization, on the contrary, he may sit up, or be recumbent, as may be most convenient to the operator, no injury resulting even from the protracted maintenance of the erect position. The inhalation too may be carried on more rapidly, and, as already stated, without any special reference to the admixture of atmospheric air, a sufficiency always entering through the sponge. Any bad effects that may arise from etheriza- tion should be treated upon the same general principles as those produced by an over-dose of chloroform. The cold douche in particular will be of much service in recalling the patient to consciousness. All the different varieties of ether possess anaesthetic properties ; but the one universally pre- ferred is the sulphuric, thoroughly washed, and divested of impurities. It is the article which Dr. Morton originally introduced to the notice of the pro- fession under the name of letheon, or pain-destroyer, and which is now so much employed in surgical and midwifery practice in this country. Some practitioners prefer a mixture of ether and chloroform to either of these articles alone, considering it as equally efficient, and at the same time AMYLENE — KEROSOLINE—LOCAL ANAESTHESIA. 585 more safe. I have myself frequently employed them in this way, and regard the combination as unobjectionable in every respect. The ordinary propor- tion is three parts of sulphuric ether to one of chloroform ; but the quantity of either agent raay be increased or diminished, according to the exigencies of the case, or the whim, fancy, or caprice of the surgeon. A mixture, com- posed of equal parts of chloroform and alcohol, was recommended by Dr. Snow, and is generally regarded as a very safe and efficient anaesthetic. In administering it to very young children, it may be diluted with rectified spirits, although, if proper care be taken, this is not at all essential, either to safety or convenience. Amylene.—With amylene, as an anaesthetic agent, I have no experience. The article has seldom been employed either in Europe or in this country, and future observation must determine its merits and the degree of confidence to be reposed in it. It has been condemned by the Academy of Medicine of Paris, as too hazardous for inhalation ; and it is well known that two fatal cases occurred from its exhibition in the hands of Dr. Snow, soon after he introduced the remedy to the notice of the profession in 1856, and after he had administered it successfully in one hundred and forty-three cases. He was inclined to believe that it occasioned death by inducing paralysis of the heart. It produces anaesthesia more rapidly and in smaller quantity than chloroform, at the same time that it is less liable to cause vomiting, cough- ing, struggling, muscular rigidity, or profound coma. The patient generally wakes up from its effects in a few minutes after the discontinuance of its use. Its odor is extremely offensive. The same care should be exercised in its exhibition as in that of chloroform. » Kerosoline.—Within the last few months kerosoline has been presented to the notice of the profession of this country, as a new anaesthetic, by Dr. E. Cutter and Professor H. J. Bigelow, of Massachusetts. Its effects are sud- den and powerful, but pleasant, pervading the whole system, and diminishing the force of the pulse and respiration. In a few cases it has caused slight convulsions. It is administered in the same manner and with the same pre- caution as chloroform, from one to two ounces being required to produce complete insensibility. Kerosoline is a beautiful, colorless, volatile liquid, of the specific gravity of about .634, highly inflammable, tasteless, and of a faint odor, not unlike that of chloroform, but much more readily dissipated by the air. It seems to be a very pure hydrocarbon, analogous to highly rectified naphtha, and as it does not contain any oxygen, it should be used with great care. Its entire safety as an anaesthetic has not been fully determined. Local Anesthesia.—Various plans have been tried for the purpose of in- ducing local anaesthesia, bat the results have not been such as to hold out much encouragement for their practical application. Wrhen we consider the absorbent powers of the skin, it might reasonably be supposed that the en- dermic use of the more potent anodynes, as opium and its different prepara- tions, aconite, belladonna, hyoscyamus, and other kindred articles, might be employed beneficially in this wise, but experience has proved that any effect of this kind that they may possess is exceedingly transient and altogether incapable of serving as a preventive of pain during the application of the knife. The employment of ice, or frigorific mixtures, recommended by Mr. James Arnott, of London, is hardly entitled to more confidence; my expe- rience with it is, it is true, very limited, but I have seen enough of it to satisfy myself that its value has been greatly overrated by its best advocates, and it can never, except, perhaps, in the most trivial cases of injury and dis- ease, be carried to a sufficient extent to prevent pain in surgical operations. I tried it on one occasion upon an old lady during the removal of the mam- mary gland; and, although the skin and subcutaneous cellular tissue were 586 ANAESTHETICS, OR TnE MEANS OF AVERTING PAIN. partially congealed, the ice in the latter producing a crackling noise, yet she suffered most severely, especially during the dissection of the deeper struc- tures, where the effects of the freezing mixture had evidently not penetrated. No one can deny that, in this case, the remedy had not been carried to a sufficient extent, and yet it certainly exercised but a very feeble influence as an anaesthetic. Besides, the application is not without risk, as the part, if not carefully watched, may be frost-bitten, and thus occasion unpleasant second- ary effects. Mr. Arnott's freezing mixture consists of two parts of ice and one of com- mon salt, the former being previously reduced to a fine powder in a canvas bag, pounded with a flat-iron. The latter should also be pulverized. The two articles are then thoroughly and quickly mixed, either with a knife, or by stirring them together in a gutta-percha or other non-conducting vessel. The mixture is now inclosed in thin gauze netting, and as soon as the action of the salt upon the ice is rendered apparent by the dripping of the brine, it is placed upon the part to be benumbed, which is held in a horizontal position during the application. The netting should occasionally be raised to Match and equalize the effect of the remedy. About a quarter of a pound of ice and half that quantity of salt suffice for an ordinary application. The first effect of the remedy is to chill the part, but this rapidly disap- pears, and is succeeded by pallor of the surface and a sense of numbness. Very soon the skin is found to be notably shrunken, and to assume a deadly, tallow-like appearance, at the same time that it is rendered somewhat stiff and perfectly insensible. If the application be continued longer, the subcu- taneous cellular and fatty tissues become partially congealed, as is proved by the fact that they feel hard, and crackle slightly under the finger. When the application is properly made, that is, gradually and cautiously, the netting being occasionally raised for the purpose of inspection, it is perfectly harmless and almost unattended with suffering. It is only when it is continued too long that it is likely to be productive of mischief. Ordinarily from fifteen minutes to half an hour will be required to afford the desired anaesthetic effect. PART SECOND. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. PART SECOND. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. CHAPTER I. DISEASES AND INJURIES OF THE SKIN AND CELLULO- ADIPOSE TISSUE. SECT. I.—ERYSIPELAS. Erysipelas is so frequent and formidable an occurrence that every practi- tioner should be perfectly familiar with its nature and symptoms. Produced by various causes, both local and constitutional, it may exist as a primary affection, or show itself as a complication of other lesions, modifying their character, interfering with their evolution, and even, at times, entirely sup- planting them. Observed from time immemorial, it is distinctly mentioned hy Hippocrates, and has been a subject of particular investigation in the present century, as is evinced by the numerous papers and monographs that have been published respecting it during the last fifty years. The names and titles alone of these productions would fill many pages. Erysipelas was at one time supposed to be peculiar to the skin and cellular tissue, but this is not the fact, modern researches having shown that it is liable to attack various other structures, particularly the mucous and serous. By dermatologists this affection is usually ranked among the exanthematous diseases, on account of the discoloration which forms so striking a feature in its symptomatology. The term by which it is commonly designated is a Greek compound, signifying a tendency to spread. The disease is generally arranged under different heads, according to the symptoms which attend it, or the parts of the body which it implicates. Thus, there may be erysipelas of the head, face, trunk, genital organs, and extremities. The most common, as well as the most proper, division, how- ever, is into simple, phlegmonous, and cedematous. To this some authors have added a fourth, namely, the gangrenous. To such an arrangement no valid objection can be made, provided it be borne in mind that it is alto- gether artificial, and that it is intended to denote merely a difference in the degree, but not in the kind, of the morbid action. There is reason to believe that this distinction has not been sufficiently heeded in practice. Erysipelas is said to be idiopathic or traumatic, according as it depends upon some constitutional vice, or upon external injury. The malady occurs at all periods of life, and in both sexes, but in what ratio has not been ascertained. The idiopathic variety is perhaps most 590 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. common in women, the traumatic iu men, owing to the greater liability of the latter to all kinds of injury. There are no facts to show that temperament exerts any influence in the production of this disease. Bilious, or bilio-sanguineons, and nervous, irri- table persons are said to be most prone to it; but in what proportion, or for what reason, remains to be determined. The malady is more frequent, at least in America, in the latter part of autumn, in winter, and early in the spring than at any other season of the year, not a day of which, however, is anywhere exempt from its invasion in either of its two forms. Locality, doubtless, exerts an important influence in its causation; it is well known that it is particularly liable to occur in the narrow, crowded, and filthy streets of large cities, in the confined and ill-ventilated wards of hospitals, and in marshy, malarious districts. The effect of occupation in producing erysipelas has not been determined; but there is no question that cooks, blacksmiths, foundrymen, and persons habitually exposed to dry heat are particularly obnoxious to its attacks. No region of the body is exempt from this affection, though some are more liable to it than others. The idiopathic form is most frequent in the face, scalp, neck, and trunk, while the traumatic appears to be most common in the extremities, particularly the inferior. It has been observed by most writers that the eyelids, nose, and forehead are especially prone to be at- tacked ; a fact for which it is impossible, in the existing state of the science, to assign any satisfactory reason. Old, decrepit subjects, and persons worn out by intemperance and disease, often suffer from erysipelas of the scrotum, the vulva, feet, and legs. In infants a very common seat of the disease is the lower part of the abdomen, around the umbilicus. Injuries of the scalp, tendons, and aponeuroses frequently give rise to erysipelas, and are liable, in consequence, to be followed, in many cases, by the worst results. Erysipelas occasionally assumes an epidemic type. Hippocrates had already observed this fact. During the middle ages a gangrenous erysipelas repeat- edly ravaged France, where, from its excessive violence, the disease was called the plague of fire. In times of war erysipelas has occasionally pre- vailed as an endemic in camps, barracks, hospitals, and prisons. In modern times it has been observed in both of these forms in various localities. Dr. Gregory expresses the belief that there is not a single hospital in London which has not, occasionally, been visited by the endemic variety of the dis- ease. At St. George's Hospital, in that city, he has repeatedly seen erysi- pelas so prevalent that all important surgical operations were obliged to be postponed for fear of the supervention of the malady. The inmates of the Hotel-Dieu, of Paris, are frequently assailed in this way, and the mortality thence arising is said to be quite great. Calmiel states that there are periods when erysipelas prevails so extensively in the lunatic asylums of the French metropolis that the physicians of those institutions are compelled to suspend all treatment by counter-irritants, as blisters, setons, issues, and moxas, be- cause it is almost certain to be followed by an outbreak of this affection. Velpeau describes an epidemic erysipelas which prevailed at La Pitie in 1831. In 1844, '5, and '6, the disease was so common in the Louisville Hospital, and also throughout the city of Louisville, that I was obliged, on numerous occasions, to postpone the performance of all operations in which delay was admissible, for fear of giving rise to it. Such was the tendency, at that period, to its occurrence, that the most trivial incision, the slightest puncture, and the most insignificant scratch were almost sure to be followed by an attack. For a long time we were obliged, in consequence of this pro- clivity, to refrain from the application of blisters and leeches, venesection, the introduction of setons, aud the establishment of issues. Chancres, buboes, and common ulcers were often invaded in the same manner. But the epi- ERYSIPELAS. 591 demic was not confined to that city; it prevailed more or less extensively in different sections of the Union, and carried off an immense number of all classes of people. In many localities there was a marked connection between the affection and puerperal peritonitis, the latter of which proved very fatal. The question as to the contagiousness of this disease is not fully settled. Much may be said both against and in favor of such a view. My own opinion, founded upon considerable experience, is that the affection, at times, possesses such a character. It is very well known that it is inoculable. Thus, a sponge impregnated with the matter of an erysipelatous sore will very readily communicate the disease to an ulcer or an abraded surface in a sound person, and the same thing is true of poultices, salves, and other dress- ings. Facts which show that the nurses and friends of individuals affected with erysipelas often contract the disease are of frequent occurrence. In this way whole families are sometimes cut down. A gentleman in Davies County, Kentucky, in 1852, lost his only son by this disease. A cousin and a female acquaintance who attended on him soon became ill with it, and both died ; it then spread to other members of the family, producing serious ravages before it was finally arrested. In 1846, when erysipelas reigned as an epi- demic at Louisville, a man was received into the Louisville Hospital with an ulcerated bubo, and about the same time a woman, who had been his mistress, was also admitted with the prevailing distemper. In consequence of an ina- bility to obtain a female nurse, the man was permitted to attend upon her in that capacity. He soon cohabited with her ; in a few days he became exces- sively ill, the sore in the groin assumed an erysipelatous aspect, and in less than a week from the time of his admission he died from the effects of the malady. In the wards of hospitals erysipelas often spreads from one person to another, and in private practice the disease, there is reason to believe, is occasionally carried by the physician from one house to another. In this way it is no doubt sometimes communicated by the accoucheur to parturient females. Causes.—The causes of erysipelas are too numerous and diversified to admit of any very definite specification. As a general rule, it may be assumed that whatever has a tendency to disorder the digestive, hepatic, or, in short, any other important function, is capable of producing the disease. So true is this that there is seldom, if ever, a case of the complaint in which such de- rangement does not play a more or less conspicuous part. The fact is im- portant, as leading to valuable therapeutic considerations. Certain articles of diet either predispose to or induce the malady. Thus, there are some persons who can never eat shell-fish or particular kinds of fruits, as straw- berries, nuts, and similar substances, without suffering an attack. The reten- tion of vitiated secretions and undigested food in the alimentary canal often leads to similar results. Derangement of the uterine function, suppression of the cutaneous perspiration, great mental excitement, the habitual use of ardent spirits, loss of sleep, hard study, inordinate sexual indulgence, and whatever else has a tendency to weaken the corporeal faculties, may be enu- merated as so many causes of the disease. A vitiated state of the atmosphere, as is witnessed in hospitals and other charities, often powerfully predisposes to its attacks and its continuance. Erysipelas frequently supervenes upon wounds, both accidental and artifi- cial, interfering with the healing process, and, at times, seriously compromising both part and system. The period at which this occurs varies from twenty- four hours to several days, according to the nature and extent of the lesion, the presence or absence of complications, the habits of the patient, the con- dition of the system, and the state of the atmosphere. Lacerated, punctured, gunshot, and poisoned wounds are much more liable to be assailed in this manner than incised wounds, though the latter are by no means exempt from 592 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. it, especially if they involve the scalp, hands, or feet, or if they affect old, in- temperate, or debilitated individuals. When the disease is epidemic, it often shows itself within a very short time after the reception of an injury, however slight or insignificant. Under such circumstances, indeed, I have, as already stated, known it to follow upon the raost trifling wound, scratch, or puncture, as a leech-bite, venesec- tion, vaccination, or the application of a blister. Fractures, dislocations, sprains, contusions, and various other injuries not unfrequently give rise to it. Ulcers, whether common or specific, are often invaded by it, especially when the patients are of a broken-down constitution. Lying-in females are, in certain conditions of the atmosphere, particularly prone to suffer from erysipelas of the uterus and pelvic veins. Finally, erysipelas frequently ingrafts itself upon other diseases. During the winter of 1851, when the malady was endemic in this city, a number of instances occurred where it supervened upon measles, scarlatina, and typhoid fever. During an outbreak of epidemic erysipelas in Louisville, in 1844, '5, and '6, every case of disease that was admitted into the public hospital of that city received its peculiar impress, and wore, for a time, its peculiar livery. When the affection was raging at its fullest height in the institution, many of the patients who were convalescing from other maladies were suddenly seized with diarrhoea, pneumonia, and bronchitis, over which the usual remedies exercised no control, and which generally proved fatal in a few days. When erysipelas supervenes upon wounds, its approach is usually denoted by an arrest of the adhesive process, by a tensive, burning sensation in the affected part, by a discharge of thin, sanious matter, or an entire suspension of secretion, and by an cedematous appearance of the surrounding structures. Finally, the characteristic blush occurs, and gradually diffusing itself often spreads over a considerable extent of surface. When erysipelas seizes upon ulcers, as it may do at any time, whether they be benign or malignant, simple or specific, the local symptoms closely resem- ble those which characterize the complaint when it follows upon wounds and contusions. The granulations, if any exist, assume a pale, glossy, unhealthy aspect, the pus is replaced by a thin, ichorous fluid, the part is rendered un- commonly painful, and the edges of the sore, along with the adjacent surface, exhibit a reddish, cedematous appearance. In chancres and dissection wounds the presence of the malady is indicated by reddish, tender lines, formed by superficial lymphatic vessels, generally extending as high up as the neighbor- ing ganglions, which, in turn, become swollen and exquisitely painful. The morbid action may, in both cases, be simple or phlegmonous, and is almost always dependent upon derangement of the digestive organs, or the suppres- sion of some habitual discharge. Erysipelas, consequent upon fractures and dislocations, generally displays itself within the first forty-eight hours after the reception of the injury, and often spreads very rapidly over a large extent of surface, as the greater por- tion of a limb, one side of the trunk, or the whole scalp and face. The acci- dent is particularly liable to supervene upon the compound forms of these lesions, and is always to be viewed with distrust, as it not unfrequently com- promises the patient's recovery. Erysipelas of the scalp, caused by wounds or fracture of the skull, generally appears frora the second to the third day, and often proves dangerous by its extension to the brain and its envelops, through the intervascular communications between the pericranium and the dura mater. Such cases always demand the greatest vigilance on the part of the practitioner. Varieties.—Erysipelas occurs under several varieties of form, as the simple, phlegmonous, and cedematous, each of which merits brief attention. To this ERYSIPELAS. 593 division may be added erratic erysipelas, so called from its disposition to wander from one part to another. The term simple is employed to designate that form of the disease which is confined exclusively to the skin. It manifests itself in a bright, vivid, almost scarlet discoloration of the skin, a pungent, smarting, or burning pain, and a sense of stiffness, with, perhaps, here and there a little vesicle, not larger than the head of a pin, and filled with a serous fluid. The swelling is very slight, and, unless the extent of disease is considerable, there is no particular constitutional disturbance. The attack is usually of short dura- tion, and the subsidence of the local disease is always followed by a furfura- ceous desquamation of the epidermis. Phlegmonous erysipelas is a much more serious lesion than the simple, all the symptoms existing in a higher degree, and the disease often terminating in extensive suppuration, abscess, and even gangrene. The discoloration varies from scarlet to deep purple; there is extensive swelling; vesication soon arises; and the pain is of a violent, burning, tensive, and throbbing character, the part feeling heavy, stiff, numb, and as if it were on fire. The inflammation extends deeply into the different tissues, affecting skin, cellular substance, muscle, and, in short, everything that comes in its way. As it progresses, suppuration takes place, leading to the formation of extensive abscesses, and the destruction of large portions of the cellular and adipose tissues. If the morbid action be very intense, mortification will be apt to arise, its approach being indicated by the development of large blebs, filled with bloody or muddy serum, and by a dark, livid, brownish, or ash-colored appearance of the skin. The constitution sympathizes early and deeply, the symptoms being at first of a sthenic character, but soon becoming typhoid. The ozdematous variety depends entirely upon accidental circumstances, its name being derived from the circumstance of the parts being infiltrated with serosity, and, consequently, pitting under pressure. It is most commonly met with in the eyelids, scrotum, prepuce, vulva, and inferior extremities, in persons who are debilitated by previous disease, or who naturally possess a feeble constitution. The swelling is often considerable, but the discoloration and pain are comparatively trivial. The diseased surface has a glossy, dis- tended appearance, and retains the mark of the finger for some time after it has been withdrawn. The inflammation is attended by constitutional dis- order, generally of a typhoid character, and is apt to terminate in mortifica- tion rather than in abscess, though the latter is often present in the more severe cases. Erratic erysipelas is characterized, as the name imports, by a disposition to extend from one point to another; it is most commonly met with on the face and forehead, from which it frequently spreads, on the one hand, to the hairy scalp, and, on the other, to the neck and ears. I recollect a case of this form of erysipelas, which, commencing on the left nates, finally extended over the whole trunk. The disease is generally superficial, and is character- ized by an erythematous appearance of the surface, with pungent pain but little swelling. If a dissection be made of a limb in a state of erysipelas, it will exhibit various appearances, according to the amount of the diseased action. In the milder grades, there will merely be some degree of induration of the skin, unusual distension of the vessels, and slight effusion of serum, or of serum and lymph, in the subjacent cellular substance. In the phlegmonous variety, there is generally extensive infiltration of the ordinary inflammatory products; the lymph has a spoiled and unnatural appearance, looking like lard or a mixture of flour and water; abscesses exist in various situations ; the cellular tissue is converted into grayish, or ash-colored sloughs; and the muscles are vol. i.—38 594 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. extensively separated from each other. In a case which occurred in the Louisville Hospital in 1846, during the prevalence of epidemic erysipelas, the abscess reached from the hip to the ankle, extensively detaching the muscles from each other and from the bones, which might have been lifted almost bodily from the diseased mass, so completely were they severed from their connections. Pure blood is sometimes extravasated in considerable quantity; and the matter, which varies much in its color and consistence, is often excessively offensive. Metastatic abscesses are occasionally found in the internal viscera, and effusions in the serous cavities. An epidemic erysipelas, of a very singular character, prevailed in various sections of this country, from 1842 to 1841, its first appearance having been noticed in Vermont and ^ew Hampshire. It had previously shown itself in Canada, and soon after it broke out in the southwestern States, where, as well as in other parts, it proved exceedingly fatal. In Louisville, where I then resided, it prevailed for several years, and afforded me an excellent opportunity of studying its character. It usually began in the throat and fauces, or simultaneously in these parts and upon the cranio-facial region, in the form of a deep red, glossy, cedematous swelling, which gradually extended until it involved the whole of the neighboring structures, the countenance being generally distorted in the most hideous manner, so that the patient could hardly be recognized even by his most intimate acquaintances. The tongue, uvula, and tonsils were enormously swollen, deglutition and breathing were extremely difficult, and death was often produced by suffocation. De- lirium and excessive prostration were early and prominent symptoms, and many of the cases perished within the first five days. The disease remained generally confined to the parts originally affected. If the patient survived any time, profuse suppuration, and soraetimes even extensive sloughing, occurred ; abscesses formed in various regions of the body ; and, after much suffering, the patient either recovered, or died from exhaustion. In some of the persons whom I attended there was extensive ulceration of the tonsils and arches of the palate; and, in several, complete destruction of the parotid gland of one side. In one case, almost the whole of the occipital bone was stripped of its pericranium. Dissection disclosed deep engorgement of the lungs, accompanied, iu many cases, by inflammation of the bronchial tubes, and even of the pulmonary parenchyma, and by effusion of serum, or of serum and pus, in the pleura and arachnoid sac. The abdominal and pelvic viscera were generally sound, except in lying-in females, who usually exhi- bited high evidence of peritonitis, metritis, and phlebitis. In one instance, which occurred quite early in the epidemic, the immediate cause of death was a large metastatic abscess in the left lung, the erysipelas being seated in the corresponding leg. The disease which I have thus briefly described was generally known in the west under the name of "black-tongue," "swelled head," or "erysipela- tous fever." It seldom attacked any one under fifteen years, but from that period up it was indiscriminate in its selection of subjects. Females seemed to suffer quite as frequently as men. The poor and the intemperate were its most common victims. Constitutional Symptoms.—Whatever form it may assume, erysipelas is usually preceded by symptoms denotive of general indisposition, such as a feeling of malaise, or discomfort, creeping, chilly sensations, lassitude, pain in the head and limbs, impaired appetite, and an indisposition to exertion. After continuing in this state for a period varying from twenty-four to thirty- six hours, the disease declares itself in a more open manner. The patient is now suddenly seized with shivering, or violent rigors, followed by, or alter- nating with, excessive heat, and accompanied by severe cephalalgia, nausea, intense thirst, restlessness, and a great sense of muscular prostration. The ERYSIPELAS. 595 tongue is dry and coated, the skin hot, the pulse strong and frequent, the urine high-colored and scanty. As the disease progresses, the system becomes more and more exhausted, the mind wanders, and the case soon assumes a typhoid character. Or, typhoid symptoms may be present almost from the very commencement, especially if the patient be old, or depressed by previous suffering. In the milder forms of erysipelas, there is often very little, if any, constitutional disturbance. If blood be drawn during the progess of the disease, it will generally be found to exhibit a sizy appearance. Sometimes it is deeply buffed and even cupped. What internal, or intrinsic changes, the mass of blood undergoes in this affection has not been satisfactorily determined. Diagnosis.—Erysipelas is generally so well marked as to render it impos- sible to confound it with any other disease. The only form which is liable to cause error of diagnosis is the simple, which may be mistaken for erythema, which it certainly very much resembles. The signs of discrimination are, the peculiar character of the pain, which is sharp, pungent, and smarting in erysipelas, and almost absent in erythema; the deeper redness in the former than in the latter, and the tendency also to the evolution of vesicles, which does not exist in erythema. Pathology.—The pathology of erysipelas has been a fruitful subject of discussion almost from time immemorial, and yet, notwithstanding all that has been said and written about it, it is still involved in impenetrable ob- scurity. How it is induced, what is its seat, or where it originates, are points concerning which we are wholly ignorant. We only know that it has a peculiar predilection for the dermoid and cellular tissues, and that it is usually, if not invariably, connected with disorder of the general system, affecting, probably, both solids and fluids. So thoroughly am I convinced of the latter fact, that I do not believe it would be possible for erysipelas ever to appear in a perfectly sound individual. If this be true, as I think multiplied and carefully conducted observation authorizes me to affirm, then derangement of the general health, especially as displayed in a vitiated con- dition of the digestive organs, must be regarded as a most important element in the pathology of this affection, and one which must exert a marked influ- ence upon our curative agents. The opportunities constantly afforded the surgeon, in cases of accidents and operations, of testing this point, peculiarly qualify him for pronouncing upon the question. I am not now, of course, speaking of epidemic erysipelas, to which every one is more or less liable, but of the ordinary form, the development of which, as is well known, is so much influenced by intrinsic and extraneous circumstances, as the health and habits of the patient, his residence, the nature of his diet, and the state of his mind. When a person is intemperate, breathes a foul air, eats bad food, or has a troubled mind, the most trivial injury, as the merest prick of the finger, is often followed by a fatal attack of the disease, whereas another, although severely hurt but enjoying better health, will, perhaps, escape en- tirely, or suffer only in a slight degree. The surgeon, aware of this circum- stance, constantly acts upon it in practice, making it a rule never to perform any serious operation until he has put his patient in a proper condition for it by the rectification of his secretions and the improvement of his general health. Erysipelas has sometimes been regarded as consisting essentially in a bad form of capillary phlebitis, it being alleged that the smaller veins are gene- rally found to be involved in the disease, as is shown by the inflamed condi- tion of their coats, and the existence, in their interior, of various kinds of substances, as lymph, pus, and coagulated blood. Such changes undoubtedly occur, to a greater or less extent, in all severe cases of the malady ; but they occur, not as a cause, but as a consequence of the morbid action. Other 596 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. pathologists, again, consider erysipelas as being essentially an affection of the lymphatics; and, lastly, there is another class who look upon it as ori- ginating in both these vessels. All these views, however, amount to nothing but conjecture, their truth or falsity remaining to be established. Prognosis.—The prognosis in erysipelas is influenced by the character, extent, and seat of the morbid action, by the age and habits of the patient, and by the absence or presence of complications. Phlegmonous erysipelas, other things being equal, is generally more dangerous than the simple or oedematous, as it is more liable to end in extensive suppuration, gangrene, and metastatic abscesses. A simple erysipelas, however, if of great extent, is hardly less dangerous to life than a phlegmonous one, the shock to the nervous system being nearly as severe as in a superficial but extensive burn, which often kills on this account. When the disease attacks the head it is always more to be dreaded than when it makes its appearance upon other parts of the surface. Infants, young children, and old persons bear the dis- ease badly ; as do also the habitually intemperate. Erysipelas is particularly dangerous when it occurs during the progress of other maladies, as measles, scarlatina, and typhoid fever. Epidemic erysipelas is always a more destruc- tive disease than a sporadic one, the malady, under such circumstances, im- pressing itself with peculiar force upon the constitution. Traumatic erysipelas often kills in a surprisingly short time. In the summer of 1856, I attended a young butcher, who died in less than three days from a violent attack of this disease of the hand and arm, brought on by a punctured wound inflicted by a hook used for hanging meat upon in the market-house. TREATMENT. Erysipelas being capable of being developed by such a variety of circum- stances necessarily demands a corresponding variety of treatment. Experi- ence long ago showed that remedies which afford relief in one case are pro- ductive of no benefit in another, and hence it is all important, in every instance, that our curative measures should be based, if possible, upon a correct appreciation of the nature of the exciting causes. If the practitioner should attempt to combat it upon any other principle, he will find himself sadly mistaken. The treatment of this disease may conveniently be divided into constitu- tional and local, and it is hardly necessary to add that each head embraces a great variety of means, which it will be necessary to pass briefly in review. The constitutional remedies upon which our reliance is mainly to be placed are, bloodletting, emetics, purgatives, diaphoretics, mercurials, and anodynes. Bloodletting is not applicable in all cases of erysipelas ; on the contrary, there are some in which it inevitably proves mischievous, if not fatal, by augmenting the debility of the system, already, perhaps, greatly depressed by the violence of the morbid action. The circumstances which, in my judg- ment, render a resort to the lancet proper in this complaint are; first, a strong, full, and frequent pulse ; secondly, a robust and vigorous state of the system; thirdly, excessive pain and tension of the parts; and, lastly, the involvement, threatened or actual, of important internal organs, as the brain, lungs, and throat. The amount of blood to be abstracted must depend upon the effects which the operation exerts upon the system. One moderately copious bleed- ing, performed early in the disease, will usually be sufficient, and will answer a much better purpose than two or three small ones. It should be borne in mind that venesection should never be carried as far in epidemic as in sporadic erysipelas, and in old, sickly, or intemperate persons, as in the young, robust, and plethoric. In the epidemic erysipelas which prevailed so extensively a few years ago in various sections of the United States, the abstraction of ERYSIPELAS — TREATMENT. 591 blood was generally borne very badly, and many lives were lost by its inju- dicious employment. In the Louisville Hospital not a single patient reco- vered that was bled for this disease. In erysipelas supervening upon capital operations and severe accidents, as compound fractures and dislocations, wounds, and contusions, proper allowance must be made by the practitioner for the effects of shock and loss of blood, and the resulting suppurative dis- charges. Children affected with erysipelas rarely, if ever, require bleeding in any form. Great contrariety of opinion has prevailed among writers respecting the employment of emetics in this disorder, some having pointedly condemned them, while others have expressed themselves most warmly in their favor. In the hands of Desault and his disciples the greatest benefit seems to have at- tended their exhibition. The probability is that here, as elsewhere, in simi- lar cases, the truth lies between the two extremes; for it can hardly be sup- posed that a class of remedies of such acknowledged potency in many cuta- neous affections should be altogether useless in erysipelas. The cases in which, according to my observation, emetics are mainly indicated are those in which there is marked biliary derangement, along with nausea, loathing of food, headache, pain in the back and limbs, great restlessness, and dryness of the surface. These symptoms, so distressing to the poor sufferer, are often promptly relieved by full emesis, excited by ipecacuanha and tartrate of an- timony and potassa, ipecacuanha alone, or salt and mustard, and encouraged by the free use of tepid drinks. In protracted cases, and in the erratic form of the malady, attended with derangement of the digestive organs, gentle emetics often operate like a charm in breaking up the chain of morbid action. When it is remembered that this disease is often directly dependent upon an overloaded state of the bowels, the presence of irritating ingesta, and the suppression of the secretions of the digestive organs, it is not difficult to dis- cover a reason for the high estimate which has always been placed upon the administration of purgatives. Indeed, it would be hard to find a case in which it would be altogether improper to dispense with them. In my own practice I have always derived from them the most signal benefit, especially in the earlier stages of the complaint, although there is no period in which they can perhaps be entirely omitted with safety. The articles upon which I mainly rely are calomel, rhubarb, and compound extract of colocynth, variously combined, and given in sufficient quantity to produce two or three free and consistent mo- tions. Sometimes the addition of a little tartar emetic or ipecacuanha proves beneficial, especially when there is an arid state of the skin and mouth; while occasionally they may be advantageously replaced by others, as castor oil and spirits of turpentine, oil alone, senna, or Epsom salts. When there are nausea and headache, with a highly coated tongue, the best cathartic, in general, is calomel and ipecacuanha, in the proportion of about fifteen grains of the former to two grains of the latter, followed, if necessary, in six or eight hours, by a stimulating enema, or a dose of sulphate of magnesia. When the bowels have been once thoroughly evacuated, a moderate passage should daily be induced by some mild laxative, as blue mass and rhubarb, Seidlitz powder, or colocynth and hyoscyamus. Diaphoretics constitute a valuable class of remedial agents in the treatment of this affection, and can seldom be entirely dispensed with, as there are few cases in which the cutaneous function is not more or less interrupted, per- verted, or suspended. After proper depletion by the lancet and purgatives, or, at all events, thorough evacuation of the bowels, and the restoration of the secretions of the digestive organs, the administration of medicines calcu- lated to act upon the skin often proves eminently serviceable. Among the best of this group of articles are Dover's powder and the salts of antimony and morphia, aided by tepid sponging, or, when the patient's strength 598 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. admits of it, the warm bath. In children and debilitated persons, the spirit of Mindererus and wine of ipecacuanha may be advantageously resorted to. Aconite, in doses of three drops of the tincture, every two, three, or four hours, generally answers an excellent purpose, especially when there is a hot and arid condition of the surface, and inordinate excitement of the heart. The same is true of veratrum. There are few cases of erysipelas, even of the milder grades, in which the use of anodynes is not indicated, either for the purpose of allaying pain, or of inducing sleep. When the malady occupies, as it not unfrequently does, an unusual extent of surface, the system is very apt to suffer in the same manner as in severe burns and scalds, and requires, at a very early stage of the complaint, the employment of soothing measures. The remedy, which is commonly one of the salts of morphia, is administered upon the same princi- ples as in other inflammatory affections, either by itself, or in union with other articles, especially diaphoretics, in quantities proportioned to the exigencies of each particular case. As a general rule, the object is best attained by a full dose, repeated once or twice in the twenty-four hours. To an adult, laboring under great pain and restlessness, provided there is no cephalic trouble, not less than half a grain of morphia should be given at a time. Thus administered, the effects of the remedy are much more decided and beneficial than when it is exhibited in smaller doses, as is too often the case with practitioners, not only in this, but in other inflammatory maladies. Delirium, or cerebral disorder, does not necessarily contra-indicate the use of anodynes; on the contrary, persons so affected are often immensely benefited in a short time by their judicious exhibition. To no class of patients is this remark more applicable than to habitual inebriates, and individuals worn out by previous disease, loss of blood, protracted drainage of the system, or con- stitutional irritation. Such persons absolutely require, at an early period, and in every stage of the malady, the use of anodynes in large doses, in order to prevent exhaustion, and afford time and opportunity for the more efficient action of other remedies. Mercurials are sometimes usefully exhibited in this disease. They are par- ticularly valuable in the erratic form of erysipelas, and when there is a tend- ency in the malady to linger in the system, after its principal force has been exploded, but when it is still disposed, as it were, to dispute with the practi- tioner every inch of its possessions. In such cases, they occasionally act like a charm, even when they are not carried to the extent of ptyalism, which, however, is often necessary, before the disorder will relinquish its grasp. During the epidemic erysipelas which prevailed in Louisville and its vicinity in 1844, '5 and '6, 1 treated quite a number of cases upon this plan, with the most happy results, although now and then a patient was lost, even after the establishment of slight salivation. Mercurials should be most scrupulously avoided in erysipelas attended with a low, typhoid state of the system in old, worn-out subjects, and in persons exhausted by intemperance and dissipation. The best form of exhibition, when the remedy is indicated, is calomel with a small quantity of opium and ipecacuanha, or Dover's powder, to restrain its action on the bowels and allay nervous irritation. In urgent cases two grains of the metal may be given to an adult every four or six hours, combined with half a grain of the anodyne. When a less rapid impression is desired, blue mass, iodide of mercury, or the gray powder may be used. In whatever form or manner the remedy be given, its effects should be most carefully watched, and they should never be carried beyond the limits of the slightest possible ptyalism. The late Professor John K. Mitchell informed me that he had, for years past, derived more benefit, in this disease, frora the use of iodide of potas- sium than from any other remedy. His plan was, after gentle alvine evacua- ERYSIPELAS—TREATMENT. 599 tion, to begin at once with the article, giving it, largely diluted with water, every two or three hours, in doses of from five to ten grains, until the attack was arrested, which, it would seem, usually happened in a few days. In the few trials which I have made of this remedy, I have witnessed no material benefit, and in several cases I was obliged to suspend it at an early period, on account of its disagreeing with the stomach. Stimulants and tonics are required when there is, as occasionally happens even in the early stage of the disease, a tendency to excessive prostration. A hard, dry, and brownish tongue, sordes on the teeth, a small, feeble, and frequent pulse, twitching of the muscles, coolness of the surface, and copious sweats, with or without delirium, clearly indicate the necessity of the employ- ment of this class of remedies, which are sometimes alone capable of arrest- ing the disease and of establishing convalescence. The articles ordinarily resorted to for this purpose are ammonia, wine, brandy, porter, or ale, along with quinine, or some of the mineral acids, and nourishing broths. Of all these substances, the best by far is brandy, in the form of milk punch, julep, or toddy. Quinine may also generally be used with great benefit, and there is no internal remedy which I so frequently employ in the latter stages of erysipelas, or in cases demanding a decided tonic. The proper dose is from three to five grains every four, six, or eight hours. Lately, the tincture of the chloride of iron has been much employed by practitioners of this city, and apparently with very gratifying results, in doses varying from fifteen to thirty drops, from three to six times in the twenty-four hours. It is particularly serviceable where a tonic effect is indicated, and is, therefore, best adapted to feeble, delicate subjects, laboring under a deficiency of heraatosin, or the coloring matter of the blood. Like iodide of potassium, however, and some other articles, it is apt to disagree with the stomach, and should, therefore, be given with some degree of caution, the best plan being to suspend it in some pretty thick demulcent fluid. Throughout the whole treatment, the greatest attention should be paid to the ventilation and temperature of the patient's apartment; the body and bedclothes should be daily changed, and the cutaneous surface should be frequently sponged with tepid salt water, or some slightly alkaline solution. As disinfectants, free use is made of the chlorides. As soon as his strength admits of it, the patient should take gentle exercise in the open air, and, if possible, sleep in another apartment. All topical remedies in the treatment of this disease are to be regarded rather as auxiliary than as curative agents. Looking upon the cutaneous eruption merely as a local manifestation of a constitutional disorder, the philosophical practitioner will place his reliance mainly upon internal means, and consider all external ones as of secondary moment. Nevertheless, it would be wrong, even in many of the milder cases, wholly to neglect these, since experience has abundantly attested their utility. A vast variety of applications, many of them of the most opposite character, have been re- commended with this object, as warm and cold, dry and moist, astringent and relaxing, stimulating, vesicant, and anodyne. It would seem, indeed, as if almost every article of the materia medica had been called into requisition, as if to show what little confidence, as a general rule, is to be placed in their efficacy. At the head of the list of local remedies may be placed leeching, concern- ing the efficacy of which, however, practitioners are still divided in opinion. My own belief is that it may often be employed with great advantage, though, in general, it is, I think, entirely unnecessary. The fact that the operation is occasionally followed by erysipelas does not, in my judgment, prove that it may not at times be beneficial. It is only in rare cases, and under peculiar circumstances, as when the patient is of a very irritable habit, or the leeches 600 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. are sickly, that such a result is at all likely to occur. A gainst such a con- tingency the judicious practitioner will, of course, always guard. The use of the remedy is particularly indicated in erysipelas of the throat and larynx, the scalp, eyelids, vulva, toes, and fingers. The number of leeches must vary according to circumstances, as the intensity of the morbid action and the vigor of the patient; and the flow of blood should always be encouraged by warm fomentations until the desired quantity is obtained. One of the great topical remedies at the present day for the cure of erysi- pelas is iodine, either in the form of tincture or solution. I generally give the preference to the former, diluted with an equal quantity of alcohol, and laid on by means of a large camel-hair pencil, the end of a stiff feather, or a soft cloth mop, until the surface is of a yellowish, brownish, or mahogany color. The application should embrace a small portion of the sound skin, and should be repeated at least twice, if not thrice, in the twenty-four hours. In the milder grades of erysipelas a single application will occasionally suffice for a cure; while in the more aggravated a considerable number may be required before the disease is finally discussed. The remedy is sometimes productive of severe pain, especially in nervous, irritable, and thin-skinned persons, which may persist for several hours, and which hardly anything, save time, will allay. To obviate this occurrence, the first application should always be very light; if no inconvenience arise, the medicine may afterwards be used more freely, and may even, in some instances, be advantageously carried to the extent of vesication. If, notwithstanding this precaution, the pain be very severe, the part should be freely sponged with a weak solution of iodide of potassium, and covered with a starch poultice. I have employed the tincture of iodine in the form and manner here indi- cated for many years, both in the sporadic and the epidemic varieties of the disorder, and can confidently assert that I have derived more benefit from it than from any other article of which I have any knowledge. Kesorted to in the early stage of the disease, it rarely fails promptly to relieve the pain and tension, which form such prominent features in the symptomatology of the affection, and which add so greatly to the patient's suffering. The beneficial effects of the remedy appear to be due to its stimulant and sorbefacient pro- perties, which rapidly promote the removal of effused fluids, and assist in checking morbid action. When applied very freely it occasionally vesicates, and is thus instrumental in unloading the cutaneous capillaries. Doubtless, it also acts advantageously upon the blood and its vessels, indisposing them to further effusion. Another highly valuable agent for the cure of this disease is the nitrate of silver, employed either in substance, or in strong solution. It is applied either directly to the affected surface, or a belt is drawn around it upon the healthy skin, to prevent its further spread, which constitutes such a distin- guishing trait in its symptomatology. I commonly prefer the former method, using the solid nitrate instead of the solution, so strongly recommended by Mr. Higginbottom. In order to apply this substance properly, it is neces- sary, as a preliminary step, that the surface should be divested of all greasy and perspirable matter, otherwise it will refuse to unite with the epidermis, and so prove, in great measure, inert. The part should then be gently moistened with cistern water, when the caustic is passed firmly and efficiently over it until the whole has been thoroughly touched. Thus employed, the application speedily blackens the epidermis and coagulates its albuminous matter, thereby forming an excellent defence to the delicate tissues beneath. When used more freely it generally vesicates, elevating the scarf-skin into tolerably large blisters. Mr. Higginbottom applies a strong solution of the nitrate of silver, consisting of three drachms of the salt to the ounce of water, with the addition of a small quantity of nitric acid. I have no ex- ERYSIPELAS — TREATMENT. 601 perience with the remedy in this form. The probability is that nitrate of silver produces its beneficial effects very much in the same manner as the tincture of iodine, changing the tone of the capillary vessels and promoting the absorption of effused fluids, besides serving as a direct defence to the cu- taneous surface by its union with the albuminous matter of the superficial layer of the skin. Professor Gilbert, of this city, has been in the habit of using, for a long time past, pure creasote as a remedy in erysipelas. He applies it lightly, once a day, to the affected surface with a camel-hair pencil, and has found it more effectual in arresting the disease than any other article he has ever tried. It destroys the cuticle, converting it into a whitish substance, which thus defends the inflamed surface from the contact of the air. Solutions of acetate of lead and opium, Goulard's extract, alcohol, chloride of sodium, carbonate of potassa, sulphate of copper, and quinine, often prove beneficial in this disease. They are employed of varying strength, and are generally most grateful when used tepid, upon flannel cloths, frequently re- newed. In warm weather, and in strong, plethoric subjects, they may be applied cold, but when this is done their effects should be sedulously watched, lest they repel the disease, or force it upon some internal organ. Dr. Pitcher, of Detroit, strongly recommends, as an external application, the bichloride of mercury, in the proportion of twenty grains of the salt to the ounce of alcohol. During the prevalence of the epidemic already so frequently alluded to, I had occasion to try this treatment in quite a number of instances, and came to the conclusion that it possessed no advantage whatever over iodine and nitrate of silver. In nearly all the cases, upwards of twenty, the application was promptly followed by vesication and excessive pain, and, in a few, by pretty profuse ptyalism; effects which greatly aggra- vated the local and constitutional suffering, and rendered a speedy discon- tinuance of the remedy necessary. I have since tried the medicine in weaker solution, but without any encouraging results. Velpeau has great confidence in the use of sulphate of iron as a local re- medy in erysipelas. The praises, however, which he has lavished upon it have not been realized by practitioners generally, and the probability, there- fore, is that they are undeserved. In the trials which I have made with it, I have been sadly disappointed. It may be employed in solution, in the pro- portion of half an ounce to two-thirds of a quart of water ; or as an oint- ment, prepared by mixing one drachm of the impalpable powder with an ounce of lard. The former is applied by means of compresses, frequently moistened; while the latter is rubbed on freely several times in the twenty- four hours. Professor Holston, of Washington City, has recently strongly recommended the local use of chloroform in the treatment of erysipelas, washed over the affected surface for a few minutes with a large camel-hair brush, the parts being immediately afterwards covered with wadding, and the application re- peated, if necessary, at intervals of from three to four hours. Prompt relief, it is asserted, usually follows, the disease, even if extensive, often yielding in a very short time. In the milder varieties of erysipelas I have occasionally witnessed excellent results from a liniment of equal parts of laudanum, ammonia, and olive oil, applied with a soft, thin compress. When the skin is very delicate, the pro- portion of ammonia may be diminished. The common soap liniment, with the addition of a small quantity of tincture of iodine, is also a valuable re- medy in simple erysipelas. Various greasy substances, cerates, and unguents have been recommended by practitioners, and employed by the vulgar, in the treatment of this affec- tion ; but there are few surgeons who place much reliance in any of them. 602 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. Perhaps the best is the mercurial ointment, first advised in this complaint by Dean and Little, of Pennsylvania. A thick layer of this is spread upon cloth, and secured to the part by means of a bandage ; or, what is preferable, rubbed gently but efficiently upon the surface. The article has been highly lauded by Rayer and others, but my own experience has not supplied me with any facts in its favor. The opinion at the present time appears to be that the mercurial ointment of the shops does not possess any particular ad- vantage over common lard, or simple cerate, and, from all that I can learn, the remedy would seem to have become nearly obsolete. I should certainly place no special confidence in it in the more severe forms of the malady, while in the more simple I should not deem it necessary to resort to it. In infantile erysipelas, I have sometimes derived good effects from the applica- tion of calamine cerate, diluted with two parts of lard. Professor Gibson has sometimes used, with marked benefit, the preparation known under the name of British oil; and Dr. Coates, of this city, has successfully employed tar ointment. Dusting the affected surface with starch, flour, arrowroot, prepared chalk, carbonate of zinc, pearl powder, and similar substances, is a popular remedy, which is sometimes useful in the more simple varieties of erysipelas, but en- tirely unavailing when the disease is deep-seated, or of a phlegmonous character. In the former, they sometimes prove beneficial by relieving the disagreeable itching, smarting, or burning sensation of the skin. In super- ficial erysipelas, I have occasionally obtained advantage from painting the inflamed surface with collodion ; the application appears to impart a health- ful stimulus to the cutaneous capillaries, to incite the absorbents, and to con- tract the skin and subjacent cellular tissue. The treatment of erysipelas by blisters, formerly so much in vogue in this country, has of late fallen into undeserved neglect. In my own practice I have frequently resorted to it, and in hardly any case has it disappointed my expectations. The remedy is peculiarly valuable in the phlegmonous form of sporadic erysipelas, and in erysipelas supervening upon wounds, ulcers, chancres, buboes, and abrasions. My practice is to apply the blister directly to the inflamed surface, with a small margin for the sound skin, and to retain it until it has produced thorough vesication. The serum is then discharged with a needle, and the part dressed with a light starch, elm, or some other emollient poultice. In children, and old or sickly persons, the blister must be removed at an earlier period, otherwise serious mischief may ensue from its overaction. Much has been said, of late years, respecting the importance of punctures and incisions as means of relief in this complaint. Of the propriety of this mode of treatment, no one acquainted with its character can entertain the slightest doubt in any case, accompanied by suppuration, great tension, and impending gangrene. Under such circumstances, indeed', all other means must be regarded as of secondary moment; the knife alone is to be trusted, and the sooner it is resorted to the better. A few incisions, or a number of large punctures, will obviate an immense amount of mischief, by affording vent to effused fluids, as serum, lymph, pus, and even blood, relieving capil- lary strangulation, and removing pain and tension. The period for putting this practice in force is the moment there is the slightest perceptible fluctua- tion, and, in violent cases, even as soon as pain and throbbing show them- selves. By thus anticipating the suppurative process, the patient escapes much suffering, as well as loss of texture ; for, if the matter be retained in the parts, its inevitable tendency is to burrow among the surrounding structures, and, by being absorbed into the system, to contaminate the constitution. From neglect of this practice, many patients perish that might otherwise be saved, and many limbs are lost, or rendered useless for life. FURUNCLE, OR BOIL. 603 In practising incisions for the relief of erysipelas, it is not necessary that they should be made three, four, or five inches in length, as recommended by Mr. Lawrence and other British surgeons. Such a procedure is eminently cruel and reprehensible, and it is difficult to conceive how it should ever have received the sanction of enlightened practitioners. Independently of the pain which attends it, it is liable to be followed by copious hemorrhage, which, occurring at a time when the patient is perhaps ill able to bear it, is well calculated, in many cases, to hurry him on to a fatal issue. I must, therefore, enter my solemn protest against such a barbarous practice. In- cisions, I repeat it, are often eminently serviceable, if, indeed, not indispens- able both to the part and system ; but let them be made in a proper manner, and of proper dimensions. A cut from half an inch to an inch aud a half in length, and deep enough to liberate the pent-up fluids, ought to be sufficient in any case, unless there has been great mismanagement on the part of the patient, or his professional attendant. In such an event, the incisions may be multiple, being placed at suitable intervals from each other. It is hardly necessary to add that, in performing the operation, the knife should not be carried in the direction of any important structures, as large vessels, nerves, or joints. If hemorrhage be unavoidable, it is to be arrested by the usual means, as compression, styptics, or ligation. The best application after the bleeding has ceased is an emollient poultice, or the warm water-dressing, either simple or medicated. The loss of a small quantity of blood is often of essential benefit in relieving the disease. Punctures are more particularly useful in the cedematous forms of the dis- ease, to evacuate the serous fluid upon which the distension depends, and which often forms a source of so much mischief. When suppuration or gan- grene is threatening, punctures, as already stated, give way to incisions. The number of punctures, the depth to which they should be carried, and their proximity to each other, must depend upon circumstances. The best instrument for making them is a very narrow, sharp-pointed bistoury, intro- duced perpendicularly to the surface, with the necessary care to avoid im- portant structures. Finally, valuable aid may be derived, in almost every case of erysipelas of the extremities, from the application of the bandage. It is particularly effica- cious in the early stages of the disease, being well calculated, if judiciously employed, to afford support to the affected structures, and to prevent vesica- tion and suppuration. The application should be made as equably as pos- sible, and with a certain degree of firmness, its effects being carefully watched, and aided by simple or medicated lotions. SECT. II.—FURUNCLE, OR BOIL. A furuncle, vulgarly called a boil, is a peculiar inflammation of the skin and cellular substance. Liable to occur upon any portion of the body, ex- cepting, perhaps, the palm of the hand and sole of the foot, it is most com- mon upon the face, nape of the neck, buttocks, and fingers, often forming in considerable numbers, either simultaneously or successively, although gene- rally there is only one. Both sexes, and all periods of life are subject to it; the young, however, suffer more frequently than the old and middle-aged. Some persons are habitually affected with boils, being seldom entirely free from them at any time for years. Now and then they disappear for a while, and then suddenly break out again. Attacks of boils are a very common sequel of eruptive affections, as smallpox, measles, scarlatina, and typhoid fever. Children during dentition, and during chronic attacks of cholera, 1 occasionally suffer enormously from this cause. I have often, in these com- 604 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. plaints, seen the whole surface literally covered with boils, the patient ex- periencing great torment and bodily weakness. The causes of furuncle are generally inappreciable. Occasionally we can trace their formation to external violence, as a contusion, or the concussion sustained by the skin and cellular substance in riding on horseback. In the majority of cases, if not in all, it is obviously connected with a disordered state of the digestive organs, or with some derangement of the secretions. Thus, persons who labor habitually under disease of the liver, and females who are troubled with irregularity or suppression of the menses, are very prone to suffer from its attacks. A boil consists essentially in a circumscribed inflammation of the skin and subcutaneous cellular tissue, eventuating in suppuration and sloughing. It usually begins as a small, hard, red pimple, which, as it proceeds, gradually assumes a conical figure, the apex being formed by the skin, and the base by the cellular substance, its volume varying from that of a current to that of a pigeon's egg. The pain which accompanies it is, at first, of a burning, smarting character, but afterwards, especially when matter is about to be deposited, it becomes throbbing and exceedingly severe. A sense of tension is also commonly present. The skin is of a dusky, reddish aspect, and ex- quisitely sensitive to the slightest touch. As the tumor increases, a little vesicle forms at its apex, containing a drop of serum, and indicating the point where the boil will discharge itself. If the furuncle be large, or mul- tiple, there will usually be more or less constitutional disturbance, as mani- fested by the want of appetite, a bad taste in the mouth, headache, chil- liness, and a feeling of great uneasiness. Finally, if the disease occur in the lower extremity or upon the buttock, there will often be sympathetic enlargement of the glands of the groin, and in the upper extremity of the glands of the axilla. The period required for a boil to reach its height varies from three to eight days. If a section be made of a boil, with a view to the examination of its structure, it will be observed to consist of a mass of dead cellular substance, ordinarily called a core, immersed in thick yellowish pus, the parts around being very hard, matted together with lymph, aud preternaturally vascular. The skin is also indurated, and abnormally tense, red, and injected. Occasionally the contents of the swelling are almost wholly made up of blood, or of a mixture of blood, pus, and slough. This form of boil, to which the term hematoid may be applied, is most common in elderly persons of a broken constitution, and is generally attended with a great deal of local and general distress. It is seldom, under any circumstances, that a furuncle can be made to abort, or to terminate in resolution, its invariable tendency being to suppurate and slough. In its very incipiency, I have occasionally, though very rarely suc- ceeded in arresting its course by a brisk purge, and the application of iodine, but if it have already made some progress, such an attempt will prove alto- gether futile. The best plan generally is at once to poultice the part, and make an early and free incision to let out its contents. The relief experienced from the operation is always prompt and decided. If the sore is slow in healing, either from the retention of dead cellular tissue, or want of healthy action from other causes, its surface should be well touched with nitrate of silver; the same article, iodine, or a small blister being applied to the sur- rounding surface. In most cases the patient will be benefited by purgative medicine and light diet. When there is a decided furuncular diathesis, as when a great number of boils exist simultaneously, or form in pretty rapid succession, benefit may be expected frora an emetic, and from mercurial purgatives, with the internal use of iodide of potassium and Donovan's solution. Sometimes Fowler's solution of arsenic answers a good purpose, or, what I prefer, arsenic iu sub- ANTHRAX, OR CARBUNCLE. 605 stance, from the twentieth to the thirtieth of a grain three times a day. In very obstinate cases slight ptyalism may be required before the disease finally yields. When boils are developed as a consequence of exhausting diseases, tonics, mineral acids, a nutritious diet, and country air are indicated. Alka- lies should be used when there is evidence of acidity of the stomach and bowels. Daily bathing with salt water, or water impregnated with potassa, will occasionally be serviceable, especially when there is unusual torpor of the skin. SECT. III.—ANTHRAX, OR CARBUNCLE. The most accurate definition that can be given of a carbuncle is that it is a boil on a large scale, it being, like that affection, a peculiar inflammation of the cutaneous and cellular tissues, but, instead of being circumscribed, as in that disorder, it manifests a disposition to spread. Its most common seat is the posterior part of the trunk, particularly the nape of the neck, near its junction with the occiput. The gluteal and sacral regions are also liable to the disease, but it is very seldom that it occurs in the extremities. A bad form of carbuncle occasionally exists upon the chin and lower lip. Elderly persons are most prone to carbuncle, and it is generally believed that such as are fat and indolent, or addicted to the pleasures of the table, are more frequently attacked than the lean and active. In my own practice, however, this has not been the case. On the contrary, the greatest number of instances has occurred in thin subjects, after the age of fifty, whose con- stitution had been broken down by long-continued intemperance, impoverished diet, deficient clothing, and mental anxiety. In London carbuncle is said to be remarkably common among the lower orders, in consequence of the enormous quantities of ale and porter which they habitually consume. The disease is more frequent in winter than in summer, and in men than in women ; occasionally it displays an epidemic tendency. Carbuncle is one of the symp- toms of plague. The extent of the inflammation varies from that of a dollar up to that of a large saucer, its average being about that of the palm of a small adult hand. Of the exciting causes of carbuncle nothing whatever is known. Most commonly the outbreak of the disease is ascribed to the effects of cold, to disorder of the stomach, over-eating, constipation of the bowels, loss of sleep, excessive venery, and other debilitating influences ; but how far, or in what degree, these circumstances tend to favor its development it is impossible to say. I have myself long regarded the malady as essentially of a constitutional nature, resembling, in this respect, erysipelas and some other affections ; and a careful study of the history of the disease certainly warrants such an infer- ence. A long course of debauch, or indulgence in the pleasures of the table, attended with a vitiated state of the secretions, is, as is well known, eminently conducive to the development of carbuncle in its worst forms. When a per- son has been for years in this condition, eating and drinking luxuriously, and taking hardly any exercise, the slightest exposure to cold, suddenly checking the cutaneous perspiration, would, it may easily be imagined, tend to produce the disease in a part habitually congested and enfeebled in its action. But there is then not merely a bad state of the solids; the blood also comes in for a share in the proceeding, surcharged, as it must be, with irritating materials which the solids have long been unable to throw off as recrementitious substance. Whether, however, this conjecture be correct or not, the fact is indisputable that carbuncle is rarely, if ever, of traumatic origin, or found in persons of a vigorous and healthy circulation. The first symptom of carbuncle is generally an itching, burning, or smart- ing, with a sense of numbness, in a particular part of the skin, which, on 606 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. examination, is found to be of a dusky, reddish color, slightly tumid, and somewhat tender on pressure. As the disease progresses, the local distress sensibly increases; the pain soon becomes throbbing and exceedingly violent, the part feeling as if it were in contact with melted lead; the surface assumes a livid hue; the swelling spreads both in circumference and in depth ; and the slightest touch of the finger is intolerable. Along with these phenomena, the patient usually experiences a sense of weight and tension, which greatly adds to his suffering. The part is hard, and circumscribed, feeling like the rind of bacon, and occupying a space from the size of a dollar to that of the palm of the hand. Presently vesicles begin to form at the focus of the inflam- mation, containing a dirty turbid, yellowish, or sanguinolent fluid, and gene- rally not exceeding the diameter of a pea, though occasionally they are quite large. Upon bursting, these vesicles expose a corresponding number of openings in the true skin, giving the surface a cribriform appearance, and leading down into the cellular substance, which is already in a state of mor- tification. The ulcers, for so they may be called, have an irregular, ragged appearance, and are the seat of a foul, irritating discharge, which is often very abundant and exhausting. Upon dividing the affected structures, the skin is found to be remarkably dense and firm, cutting very much like the rind of bacon. The cellular sub- stance beneath is converted into a slough, having the appearance of a mass of wet tow, being bathed with ill-looking matter, and intermixed with flakes of lymph, or matter like putty, thick pus, or curds. When the disease is of unusual extent, there may be considerable involvement of the aponeuroses and muscles, but in general these structures are excluded from the morbid action, the skin and subjacent cellular tissue alone suffering. At the peri- phery of the disease the parts are always uncommonly dense, the boundary between it and the healthy structures being established by a deposit of plastic matter, less organizable, however, than in furuncle, the morbid anatomy of Fig. 184. Fig. 185. Carbuncle in its forming stage. Ulcerated carbuncle. which that of a carbuncle so closely resembles. The subjoined sketches, figs. 184 and 185, represent this disease in its earlier and more advanced stages. The constitution always, at an early period of the disease, strongly sympa- thizes with the part affected. Hence, fever is generally present soon after its ANTHRAX, OR CARBUNCLE. 601 commencement, and sometimes, indeed, almost before there is any marked evidence of the local affection, the first symptom being often a severe rigor, followed by high vascular excitement. However this may be, the case soon assumes an asthenic type, indicative of the depraved condition of the solids and fluids so intimately concerned in the production of the disease. The tongue speedily becomes dry, hard, and brown, sordes collect upon the gums and teeth, the appetite fails, gastric derangement exists, the bowels are con- stipated, the urine is scanty and high-colored, the skin is hot and arid, the mind is disposed to wander, and the pulse is frequent, soft, and without force. Vomiting is often present to a considerable extent, and the alvine evacuations are generally excessively fetid. There is no disease with which carbuncle can be confounded. Its large size, the severity of the attendant pain, and the great constitutional disturb- ance will always readily distinguish it from furuncle at its commencement, and afterwards the diagnosis will be still further aided by the vesicated and cribriform condition of the skin, so characteristic of carbuncle. The only affection which it at all resembles is a bedsore, but the history of the case, and the situation of the swelling, will always serve as means of discrimination. Malignant pustule begins as a little circumscribed pimple, not as a diffused swelling, as in anthrax, and soon forms a large vesicle, raised above the sur- rounding level, and resting upon a hard, solid base, which rarely acquires much extent, at least not until the affection has made considerable progress. A carbuncle is generally a dangerous disease, especially so when it is mul- tiple, or when it occurs in old, fat subjects, addicted to indolence and over- feeding. The site of the disease will also exert a marked influence upon the issue of the case. Thus, a carbuncle situated on the back part of the head and neck will, other things being equal, be more likely to produce death than when it occupies the back, nates, or extremity, inasmuch as it is extremely apt to involve the brain and arachnoid membrane, causing effusion of serum and lymph. Young and comparatively healthy persons will often recover, though generally not without great suffering, whatever may be the site of the malady. Treatment.—The treatment of carbuncle must be conducted with special reference to the improvement of the secretions and the support of the system. Few patients will be found to bear bleeding, or anything like active purga- tion. It is only when there is extraordinary plethora, combined with great vigor of constitution, that these means should be carried into effect. In all other cases, their inevitable tendency will be to do harm, by bringing on premature exhaustion. Efficient purging, however, may be regarded as an indispensable remedy in almost every instance, the object being not only to get rid of irritating fecal matter, but to produce a change in the secretions. For this purpose the medicine should be given early in the disease, and a mercurial cathartic should always be preferred to any other. When marked gastric derangement exists, as indicated by nausea, headache, and pain in the limbs, no time should be lost in administering an efficient emetic, or an'eraeto- cathartic, as ten grains of calomel and from ten to twenty of ipecacuanha, followed by large draughts of chamomile tea, or infusion of valerian. Clear- ance having been effected, and function improved or restored, stimulants and tonics will come into play, exhibited warily, especially if cerebral trouble is threatened, yet efficiently if evidence of exhaustion is present, the raost suitable articles being ammonia, quinine, chloride of iron, and brandy, with nourishing broths. Anodynes will generally be required, in large doses, to allay pain and procure sleep. After the first few days a mild laxative, as blue mass or castor oil, is occasionally given. Determination to the brain must be promptly met by a large blister applied as near as possible to the occiput. The best topical application, in the early stage of carbuncle, is the warm 608 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. water-dressing, medicated with acetate of lead and opium. Pencilling the surface well with tincture of iodine, and then covering it with a mixture of equal parts of olive oil, laudanum, and spirits of turpentine, sometimes pro- duces a very soothing effect. In many cases, there is nothing so promptly beneficial as a blister, large enough to include a considerable portion of the healthy skin, and retained until it has caused thorough vesication; it drains the vessels of serum, allays pain, and makes a salutary impression upon the general system. Leeches are commonly inadmissible, as they cause severe pain, and undue depletion. But the great remedy for carbuncle, as for fur- uncle, is free incision, the knife being carried into the healthy substance beneath, not at one point, but at a number. The operation, which should be practised as soon as possible at the focus of the disease, and afterwards towards the periphery, should there be any necessity for it, at once relieves the horrible pain and tension of the part, affords nature an opportunity of casting off the sloughs, and puts an effectual barrier to the further extension of the morbid action. I cannot see any reason why practitioners should still continue to apply caustics in these cases when the knife is so much more prompt and effectual in its action. If the dead tissues are slow in coming away, their extrusion may be expedited with the scissors, the surface of the ulcer being well touched immediately afterwards with the dilute acid nitrate of mercury, or nitrate of silver, to promote the formation of healthy granu- lations. As soon as this has been brought about, the part is dressed with some mild unguent, as the opiate cerate, elemi ointment, or ointment of the balsam of Peru. After recovery, the tendency to a recurrence of carbuncle, which is some- times very strong, should be counteracted by a change of air, attention to diet, a proper regulation of the secretions, and the avoidance of exposure to cold and fatigue, aided by an alterative course of iodide of potassium, the dose of which should not exceed two grains and a half thrice in the twenty- four hours. If there has been much disorder of the secretions, a very minute quantity of bichloride of mercury may be advantageously conjoined with the potassium. When there is marked derangement of the digestive functions, attended with acidity and flatulence, recourse may be had to the chlorate of potassa, given three times a day, in doses of from five to ten grains, until there is manifest improvement in the tone of the stomach and of the general health. A change of air is often indispensable to complete convalescence. SECT. IV.—GANGRENE AND BEDSORES. The skin is liable to gangrene, both idiopathic and traumatic, simple and specific, acute, and chronic; but as these several varieties have already re- ceived a sufficient share of attention, nothing need be said respecting them here. There is one species, however, which may be briefly described in this place, inasmuch as no special mention has been made of it elsewhere. I allude to what is called white gangrene of the skin ; an affection whose true character is still involved in obscurity, nothing that has yet transpired hav- ing thrown any light either upon its pathology or treatment. White gangrene usually comes on without any appreciable cause, or pre- monitory symptoms, in patches of irregular shape, from one to three inches in diameter. The sloughs are of a dead, milky color, and of a hard, dryish consistence, yielding little, if any, moisture on pressure. Any portion of the body may be the seat of this affection ; but observation has shown that the arms, back, and chest are the regions most frequently implicated. The dis- ease has hitherto been observed chiefly in old persons of a broken, anemic constitution. The treatment is to be conducted upon general principles, GANGRENE AND BEDSORES. 609 special reference being had to the improvement of the health by tonics, brandy, and nutritious diet. Bedsores.—There is another variety of gangrene of the integuments which, frora the frequency of its occurrence, and the severity of the attendant suffer- in"', merits special attention here. The immediate cause under whose influ- ence it is developed is steady and protracted pressure, impeding, and generally arresting, the circulation; hence it is exceedingly liable to arise on the sacro- lumbar region, the iliac projections, on the nates, and over the great tro- chanter, in consequence of long-continued confinement to one particular posture, as happens in typhoid fever, in severe fractures and wounds, and after surgical operations. Persons who have received violent injuries upon the back, eventuating in paralysis of the lower extremities, are more than commonly prone to this variety of gangrene, or bedsore, as it is usually called. I have at this moment under my charge a tall young man, affected for the last six months with paraplegia, who has a large and excessively painful ulcer upon the left buttock, merely from the pressure sustained in sitting on a chair. The disease is always necessarily preceded by inflammation, but in conse- quence of the absence of the usual symptoms, the want of proper care in examining these parts and keeping them clean, or the impossibility which the patient experiences in communicating a knowledge of his suffering, as when he is exhausted by typhoid fever, or other causes, it does not always attract attention until great mischief has been done, eventuating in extensive slough- ing, and the establishment of painful, irritable ulcers, which it is often ex- tremely difficult to heal. In some instances the first intimation which the patient has of the approaching mortification is a sense of prickling in the affected parts, as if he were lying upon some rough substance, as sawdust, or coarse salt. At other times, he feels severe pain, of a stinging, burning, or biting character, within a few days after he has been exposed to the pressure, and which is often so constant and distressing as to deprive him both of appetite and sleep. Upon examining the parts to which the suffering is referred, the surgeon finds that they are red, or marked by an erythematous patch, slightly swollen, with a dense base, congested, and excessively tender on pressure. Ulceration, if it have not already taken place, will be sure to begin in a short time, unless suitable measures are adopted for the patient's relief, and will be speedily followed by mortification, or mortification may take place without being preceded by ulceration. The extent to which the gangrene may proceed is variable ; we occasion- ally see it occupying an immense surface, perhaps as large as the crown of a hat, and reaching down to the very bones; at other times it is more limited both in diameter and depth, laying bare merely the muscles, or being even in great degree confined to the skin. In rare cases, the ravages are not limited to the soft structures, but involve also the osseous tissue. Bedsores, unless of very trivial extent, are among the most formidable complications liable to arise during the progress of fevers and other diseases, as well as after accidents and operations. As they seldom occur until the vital powers have been materially depressed, the excessive pain and drainage occasioned by them are often so severe as to destroy the patient, or, at all events, greatly retard his convalescence. The treatment of bedsores, or gangrene from pressure, is prophylactic and curative. In the first place, whenever there is any probability from the nature of the case that the confinement is destined to be a tedious one, and attended with constant decubitus, or a helpless state of the patient, means should be promptly adopted for hardening those parts of the surface which long experience has taught us as being most likely to suffer under such cir- cumstances. For this purpose they should be brushed once or twice a day vol. i.—39 610 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. with tincture of iodine, at first diluted, and then pure, or washed repeatedly with a saturated solution of alum and tannin. The greatest possible atten- tion should be paid to cleanliness, and to the arrangement of the sheets and clothes, that they may not be rolled up under the body, and thus become a source of suffering and disease, as too often happens in the hands of careless and thoughtless practitioners. As to the use of plasters, I have very little patience with them, for, unless they adhere well, they are extremely apt to become rumpled, much to the detriment both of the part and system. Change of posture should receive early attention, though this is not always practica- ble, from the inability of the patient to maintain himself in any other situation than that on the back. When the patient can afford it, he should use an air bed. The moment any decided suffering is experienced, or the parts become red and inflamed, a ring-shaped air-cushion should be provided for the purpose of equalizing the pressure, or, in the absence of this, an ordinary cushion, with a suitable central hole, the edges being broad and well padded with wool or horse hair. Such a contrivance, however, is a very imperfect sub- stitute for the air or water cushion, which should therefore always have the preference. When gangrene is threatened, the best application is the tincture of iodine, aided, if there be much pain aud tension, by one or two moderately free incisions, and followed^ by a yeast or port-wine poultice, sprinkled with laudanum, morphia, or powdered opium. Cleanliness is promoted by the liberal use of the chlorides and by the early removal of the sloughs. When granulations begin to spring up, the best dressing will be opiate cerate, balsam of Peru ointment, or a mixture of equal parts of castor oil and balsam of copaiba. The constitutional treatment of bedsores must be conducted according to the general rules followed in typhoid states of the system from whatever cause proceeding. Nutritious food, wine, brandy, milk punch, quinine, and ano- dynes are the means chiefly to be relied upon for upholding the flagging powers of nature. This treatment can hardly be commenced too soon when- ever there is any tendency to the formation of bedsores, for the very fact that such a tendency exists is a sufficient reason for redoubling our efforts to sup- port the patient's system. SECT. V.—BURNS AND SCALDS. There are few accidents which are of more comraon occurrence than burns and scalds, or which entail a greater amount of suffering and deformity. The progress of civilization, and the improvements in the arts and sciences, have greatly multiplied their frequency and severity, and call for correspond- ing attention on the part of the surgeon. From what I have seen of these lesions, I am satisfied that few practitioners understand their character, or treat them with the success of which they are capable. One reason, perhaps, of this is that every one has a remedy for them, and that hardly any two agree as to the kind of treatment best adapted to their relief. Burns and scalds differ from each other simply in this, that the one is the result of dry heat, and the other of moist. They both present themselves in various degrees, from the slightest erythematous blush of the skin to the total destruction of all the structures of a limb. Their extent also is ex- ceedingly variable, both as it regards their depth and their superficial area. Thus, while in one case they may involve only a little patch of skin hardly the size of half a dime, in another they may occupy an immense extent of surface; or, instead of being diffused over a large space, the iujury may be BURNS AND SCALDS. 611 concentrated upon a small spot, but penetrate to a considerable depth. These differences are of great practical importance, on account of the influence which they exert upon the issue of the case. The division of Dupuytren of burns and scalds, so generally adopted at the present day, seems to me to be most complex and unscientific, and therefore well calculated to embarrass the progress of the inquirer. No one can doubt that the more simple the arrangement of a subject is, the more easily, in general, it is understood. In accordance with this idea, I shall describe burns and scalds as consisting of two classes, the simple and complicated; comprehending under the former term those lesions which, however extensive, produce only inflammation, and under the latter those which cause the death of the parts, either on the instant, or within a short time after their infliction. Burns are most common in winter, among the poorer classes, who are very " liable to have their clothes set on fire in consequence of the manner in which they crowd around the hearth and grate to keep themselves warm. Women, on account of the peculiarity of their occupation, are more subject to them than men, and children than grown persons. Blacksmiths, plumbers, glass- blowers, and foundry men are particularly exposed in this way. The intro- duction of gas and camphene has been a fruitful source of these accidents. Scalds, on the other hand, are most common in kitchens, breweries, in differ- ent kinds of factories, especially soap and candle, and in all places where steam is employed, whether for domestic or public purposes. On our western waters, where steamboat explosions are of frequent occurrence, many persons are annually destroyed by the effects of hot water. Those parts of the body which are habitually exposed, as the hands and face, are most liable to suffer both frora burns and scalds, especially the latter, steam often penetrating the clothes in every direction. Dry and moist flame, hot water, and steam often enter the mouth and throat, producing violent, if not fatal, effects. A heated iron has been known to be thrust up the rectum for the purpose of homicide, as in the famous case of Edward II. It is well known that different agents possess different degrees of capacity for caloric, and that, consequently, they are capable of producing different effects when brought in contact with the living tissues. Thus, experience has shown that boiling metal will cause a more severe impression than boiling oil, and boiling oil than boiling water. The intensity of the injury, however, is not always in proportion to the relative capacity of the substance for heat; for it is well ascertained that copper will, other things being equal, occasion a more violent effect than iron, although the latter possesses a greater capa- city for caloric. This fact can be explained only on the assumption that some articles are not only better conductors of heat than others, but that they adhere more firmly to the surface, thus favoring its protracted extrication. Alcohol and ether, from their great volatility, usually produce only superfi- cial burns. In the milder forms of these accidents there is merely an erythematous appearauce of the skin, such as may readily be produced by exposing the back of the hand for a few moments to a stove, or by applying hot water to it. The discoloration is usually very temporary, but at times it is more per- manent, lasting for a number of hours, and being perhaps soon followed by slight vesication. The pain is of a smarting, pungent character, but compa- ratively trifling, and soon goes off. The constitution remains unaffected. The application of heat, whether dry or moist, unless sufficient instantly to destroy the vitality of the part, or so slight as to make only the most super- ficial and transient impression, is always speedily followed by an evolution of vesicles, containing a thin, watery fluid, identical with the serum of the blood, from which it is derived. When the vesicles are more slow in forming, as when they are the product of the resulting inflammation rather than of the 612 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. immediate effect of the caloric, their contents are, in general, partly fluid and partly solid, the latter consisting either of lymph or of fibro-albuminous matter. Their volume varies from that of a pin-head up to that of a fist, their number being usually in an inverse ratio to their dimensions. Cases are occasionally met with where the epidermis nearly of a whole limb, or the greater portion of the trunk, is elevated into one enormous blister, establish- ing a most frightful drainage upon the blood. The surface around the vesicles is of a scarlet color, more or less tumefied, and exquisitely tender on pressure, or on exposure to the atmosphere. The pain is of a burning, scalding character, and so severe as to cause the most intense agony. The part rapidly swells, feeling stiff and tense, and the pain assumes a throbbing character. Well-marked constitutional symptoms are always present, especially if the lesion is at all extensive, and the patient may be delirious, excessively restless, and intensely thirsty. These injuries are said to be complicated when they are attended with the destruction of the vitality of the part, or sorae other serious lesion, as a wound, fracture, or dislocation. The loss of life may be limited to the skin and subjacent cellular tissue, or it may extend much deeper, involving muscle, aponeurosis, vessel, nerve, and bone all in one common eschar. Such acci- dents are never produced in any other way than by burns, as when a person falls into the fire, or gets his limb in a stove, grate, or furnace. Dreadful scalds, however, sometimes occur from the protracted application of boiling fluids, as happens now and then in breweries and soap factories. Under such circumstances, the loss of vitality, although not as extensive as we sometimes find it from the operation of dry caloric, is yet sufficient to be productive of the most terrible ravages. The epidermis comes off in large sheets, no vesi- cles exist, or only around the border of the injured surface, and the skin is of a dirty grayish, cineritious, or yellowish color, sodden, insensible, and marked, here and there, by a purplish line, indicating the course of a subcu- taneous vein. Besides the pain which invariably attends all burns and scalds, no matter how slight, or wheresoever situated, there is apt to be more or less constitu- tional disturbance, coming on at a variable period after the accident; some- times immediately, and at other times not for several hours, days, or weeks. When the injury is at all extensive, the patient will have all the symptoms of one laboring under a severe shock. He will feel exceedingly cold, or, per- haps, have violent rigors; the pulse will be small, frequent, and feeble ; the respiration will be oppressed; and there will be extreme restlessness, along with great thirst and sickness at the stomach. The patient, in fact, lies in great torture, pale, prostrated, agonized. Reaction taking place, he will have violent fever, a flushed countenance, and a quick, frequent pulse, with a tendency to delirium ; pain, of a pungent, burning character, forming all the while a prominent symptom. If the excitement run high, there will be danger of over-action in the part, and of inflammation of some of the internal viscera, of the arachnoid membrane, and of the mucous lining of the bowel. Nume- rous cases have been published within the last fifteen years going to show that ulceration of the duodenum is one of the most frequent lesions which super- vene upon scalds and burns of the cutaneous surface; and, in the more chronic forms of these accidents, the same disease is sometimes widely diffused over the colon, thus accounting for the profuse and obstinate diarrhoea which is so often present under these circumstances. Among the more common local consequences of burns and scalds are, the formation of vicious scars, the adhesion of contiguous surfaces to each other, the retraction of the affected parts, anchylosis of the joints, and various transformations of the cicatricial structures, especially the keloid. The scars, which are often of frightful extent, and horribly disfiguring, possess an ex- BURNS AND SCALDS. 613 traordinary contractile power, which does not cease for a long time, which it is almost impossible to counteract, and which frequently draws out of place every tissue that is brought under its influence, bone not Fig. 186. excepted. Owing to this cir- cumstance, the chin is occa- sionally drawn down against the sternum, as seen in fig. 186, and the lower maxilla singularly changed in shape. The fingers may be retracted like claws, or literally buried in the palm, the hand thrown back at a right angle with the wrist, or the forearm drawn up against the arm, which is itself, perhaps, firmly pinioned to the side. Similar effects occur in the inferior extrem- ity. Thus, the foot is some- times tied to the forepart of the leg, and the leg to the pos- terior surface of the thigh. In neglected burns of the hand, the fingers are often united tO eaCll Otlier, SO as TO give Vicious cicatrices of the face and neck, caused by a burn. them a webbed appearance. Burns and scalds are among the most dangerous of accidents. If at all extensive, they often terminate fatally from mere shock of the system, without, perhaps, even the slightest attempt at reaction ; or, if reaction should occur, life may afterwards be assailed by inflammation of some internal organ ; or death may take place at a more remote period, in consequence of the second- ary effects of the lesion. A superficial injury of this kind is generally danger- ous in proportion to its extent. Thus, a scald involving an entire limb or the greater portion of the trunk, although merely affecting the external layer of the true skin, is always a most serious accident, liable to be followed by the worst results. On the other hand, the danger is hardly less when the ' lesion is very deep, although it may not be more than a few inches in diameter. When depth and great extent of surface are combined, the chances are that death will occur without reaction, or, at all events, soon after reaction has taken place, from constitutional irritation. A prognosis, therefore, should not be given without due regard to these circumstances. These injuries, moreover, are more dangerous in infants and children than in adults, on account of the greater susceptibility of their nervous system. Old persons, too, are very intolerant of them, and are liable to suffer severely, both primarily and secondarily. Pregnant females occasionally abort from their effects; and in the intemperate they often lead to the development of delirium tremens and other distressing symptoms. A burn on the neck and scalp is liable to cause arachnitis; of the chest, inflammation of the lung and pleura: of the abdomen, peritonitis and enteritis. Finally, a patient,N after having manfully struggled against ebb and tide, as it were, for weeks and months, may finally be worn out by profuse discharge and hectic irrita- tion. Treatment.—The indications in the treatment of these lesions are, first, to produce reaction and calm the system ; secondly, to limit the resulting inflam- 614 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. mation; thirdly, to promote the sloughing process, when death "has taken place, and to favor the development of granulations; fourthly, to moderate contraction, and prevent anchylosis ; and, lastly, to sustain the strength dur- ing the wasting effects consequent upon the protracted suffering which so often occurs when the patient has escaped from the primary effects of these ^injuries. To raise the system from the depression or collapse into which it so fre- quently sinks, even in comparatively slight burns and scalds, immediate re- course should be had to the exhibition of a full anodyne, along with hot toddy, ammonia, sinapisms to the extremities, and artificial warmth. The quantity of morphia, or whatever form of opium may be used, should be at least double what it is in ordinary accidents, the system being always, under these circumstances, uncommonly tolerant of the medicine. A large dose will not only be conducive to speedy reaction, but will greatly assist in allay- ing pain and calming the system. If the shock has been unusually severe, it may be necessary, iu addition to these means, to use stimulating injections and to rub the spine with some irritating lotion. In the child and old man, care is taken not to urge on the reaction too rapidly, or to give opium with- out a certain degree of caution, lest the subsequent excitement should over- tax the enfeebled brain and heart, thereby leading to visceral effusion. As the circulation comes up, the stronger stimulants are gradually withdrawn, the more simple alone being now trusted to for relief. The second indication is to moderate the resulting inflammation. With this view various remedies raay be employed ; but what these remedies ought to be is a point respecting which there is still much contrariety of sentiment; nor is it at all probable that the question will soon be settled one way or another. In the milder forms of these accidents the practitioner can hardly go amiss if he employs almost any of the numerous articles that have been recommended by the profession and the people. He will find that, at one time, the part and system are most comforted by cold applications, and, at another, by warm ; that to-day the one is borne best, and the other to-mor- row ; that one patient is benefited by an ointment, and another by a lotion; that in one case he may use moist applications with most advantage, and in another dry; in short, that the utmost diversity obtains in regard to the tolerance of this remedy or that. I am sure that the force of these remarks must often have been felt by every one at all extensively engaged in the practice of surgery. It is not surprising, therefore, as was stated at the opening of this section, that there should still be such a diversity of sentiment in relation to the proper management of these accidents. Cold applications are chiefly adapted to very young, robust subjects, during the heat of summer, but even then they should" not be resorted to without great care, for fear of internal congestion and effusion. The proper plan is to use them only so long as they are grateful and soothing to the system, and to discontinue them the moment they are found to be disagreeable. They may consist simply of cold water, spirits and water, or weak solutions of acetate of lead ; and the same articles may be applied warm, care being taken, when the one class follows the other, that the transition is gradual and gentle, not sudden and violent. If the lesion be very slight, the surface may be covered with poultices of scraped potato, apple, turnip, starch, arrowroot, or slippery elm; carded cotton ; saturnine unguents; or cloths wet with soap liniment, or a liniment made of lime-water and linseed oil. The latter constitutes the famous application so much used at the Carron Iron Works in Scotland ; it is, how- ever, exceedingly filthy and disgusting, and should therefore be discarded from genteel practice. Carded cotton, an American remedy, has always stood high in the estimation of the public, and there are few articles that are more constantly or more advantageously employed in the treatment of burns BURNS AND SCALDS. 615 and scalds. A remedy from which I have often derived signal benefit in the milder varieties of these affections is the dilute tincture of iodine, in the pro- portion of one part to two of alcohol. It is only applicable, however, when the skin is unbroken. In my own practice, I have experienced the most signal benefit in the treatment of burns and scalds from carbonate of lead, in the form of white paint; and in 1845 I called the attention of the profession to the subject in a short article inserted in Dr. Bell's Bulletin of Medical Science. Numerous observations made since that time have only served to confirm the views then expressed. From its great efficacy, and the readiness with which it can usually be employed, this mode of treatment deserves to come into more general use. It is not applicable merely to the milder forms of burns and scalds, but it may often be advantageously used, no matter what may be the extent or depth of the injury. As the lead of the shops is very stiff, and, consequently, unfit for use, my invariable plan is to incorporate with it a sufficient quantity of linseed oil to make it of the consistence of thick cream. Thus prepared, the affected sur- face is thickly and thoroughly coated with it by means of a large camel-hair pencil, a soft mop, or a small paint-brush. If vesicles exist, their contents are evacuated with a fine needle, and the parts are well dried; otherwise, the lead will not adhere. The dressing is completed by covering the painted surface with a layer of carded cotton, or a piece of old muslin or linen, sup- ported by a moderately firm roller. In mild cases, one application of this kind, allowed to remain on four or five days, will usually suffice to effect a cure. In the more severe forms of the lesion, on the contrary, a considerable number may be required. Whenever the dressings become stiff or saturated with secretions, they should be removed, others being immediately substituted. I have never witnessed any bad effects frora white lead paint, applied as here stated, although I have used it very freely in quite a number of cases. In one instance, that of a negro girl, sixteen years of age, who had a most severe and extensive burn of the neck, chest, and abdomen, I maintained the application upwards of five weeks, consuming more than a quart of the lead, without observing the slightest injury. In short, ray experience induces me to believe that the treatraent is perfectly safe in all cases, whatever may be the extent or depth of the lesion, or the age of the patient. Where a coun- ter-poison, however, is deemed necessary, it will be readily found in the occa- sional exhibition of a dose of sulphate of magnesia, which, while it keeps the bowels in a soluble state, combines with the lead, forming an inert sulphate. White lead paint probably produces its good effects in two ways : first, by forming a varnish to the affected surface; and, secondly, by directly obtunding its nervous sensibility. In many cases, it acts literally like a charm ; the patient, in a few moments, becoming perfectly calm, and passing, as it were, from torment into Elysium. Professor T. G. Richardson, of New Orleans, has recently employed with excellent effect the subnitrate of bismuth in the treatment of burns and scalds, his experience inducing him to give it a decided preference over white lead. His mode of using it is to rub the bismuth in a mortar with a sufficiency of glycerin to convert it into a thick paint, which is then freely spread upon the affected surface with a suitable brush, the parts being afterwards covered with carded cotton, retained by a roller. In the milder forms of the accident a single application often effects a cure. In Boston, a plan of treating burns and scalds is used with much advan- tage, consisting of the application of a thick coating of mucilage of gum Arabic, which is immediately after well dusted with dry powder, the whole forming a complete defence to the raw surface beneath. Mr. Meadows, of London, has recently recommended, for a similar purpose, a mixture of col- 616 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. lodion and castor oil, in the proportion of two parts of the former to one of the latter. The preparation, which may be kept ready for use for any length of time in an air-tight bottle, is applied by means of a camel-hair brush, and is speedily converted into a firm, adherent covering, the thickness of which may afterwards be increased if deemed proper. In the more simple forms of scalds and burns, the application of glycerin is occasionally very beneficial. Where a stimulant effect is required, as when the parts are in a condition verging upon gangrene, the most eligible dressing, perhaps, is Kentish's ointment, composed of one ounce of basilicon ointment and one drachm of spirits of turpentine, and spread upon strips of old muslin, bound on lightly by a roller; or, instead of this, the surface may be carefully pencilled with a weak solution of nitrate of silver, nitric acid, or acid nitrate of mercury, and then covered with a yeast, port wine, or tannin poultice. Along with these means, proper attention is paid to the state of the con- stitution, the bowels are maintained in a soluble state, diaphoretics are given to restore the functions of the skin, and the diet is carefully adapted to the emergencies of the particular case. The internal organs, particularly the brain and lungs, are sedulously watched, the avenues to disease being guarded by leeches and other suitable remedies for preventing inflammation. If, despite the utmost care and attention, the injury terminates in mortifi- cation, or if the vitality of the parts was destroyed in the first instance, an effort should be made to check its further progress, and to promote the sepa- ration of the sloughs. The most suitable remedies for this object are such as are in use for ordinary gangrene. Fetor is corrected with the chlorides. If the sloughs are very firm, the knife may be used, but not without the greatest caution, lest pain and hemorrhage be induced. As soon as the sloughs have dropped off, the indication is to promote the development of granulations; a circumstance which often requires much judg- ment and practical skill. The best remedies are the warm water-dressing, with the use of a very weak solution—not more than two drops to the ounce of water—of nitric acid. Sometimes the calamine cerate is very soothing, and seems to do good when almost everything else fails. If the granulations manifest a tendency to become exuberant, as they are very apt to do, they must be repressed with the scissors, nitrate of silver, and systematic compres- sion, tonics being given to support the system. Cases occur in which these bodies are rendered exquisitely sensitive, the slightest touch being followed by the most lively pain. We usually find that this condition is attended with an irritable state of the constitution, and that, consequently, it requires some- thing more than mere topical medication to get rid of it. A judicious course of anodynes and tonics, with the occasional application of nitrate of silver, and the constant use of an elm poultice, constitutes the proper treatment. Occasionally, no local remedy is so soothing as white lead paint. Whatever means may be employed, it will be found that they will require to be frequently varied; as one loses its effects another taking its place. To obviate deformity constitutes the fourth indication in the treatment of these injuries. The points to be attended to are threefold : first, to prevent adhesions between contiguous surfaces ; secondly, to counteract the tendency to vicious contraction ; and, thirdly, to obviate anchylosis. Allusion has already been made to the tendency which contiguous surfaces have to unite to each other during the progress of these accidents. This tendency is not confined to the fingers and toes, but is exhibited also in other parts of the body, as between the arm and trunk, the two labia, the thigh and scrotum, the ear and scalp. Whenever it appears, it must be carefully coun- teracted by the use of the bandage and the interposition of lint, aided, if need be, by splints. It does no credit to a surgeon to send forth his patient, after the completion of cicatrization, with webbed hands and feet, or with his arms BURNS AND SCALDS. 611 pinioned to the side of the chest, although such occurrences are not always entirely avoidable. The disposition to contraction in burns and scalds attended with loss of substance is always great, and is often productive of the most frightful de- formity. To counteract this disposition, recourse should be had, early in the treatment, to carved splints and tin cases, judiciously applied, and steadily used, not only until the parts are well, but for a long time afterwards; ex- perience having shown that the tendency to contraction continues for mouths, if not years, after the completion of the cicatrization. If, from neglect, mismanagement, or unavoidable circumstances, the con- traction has seriously impaired the usefulness of the part, or greatly marred the person's beauty, relief should be attempted by the division of the offend- ing cicatrice, or, perhaps, by its excision, the raw edges being afterwards united by suture, or adapted to a flap of integument from the neighborhood. This operation, constituting what is termed dermoplasty, should not, how- ever, be undertaken without due preparation of the system, for it will readily be observed that when the cicatrice is very large, two most extensive wounds will be made, thus inflicting a violent shock upon the constitution, extremely liable to be followed by erysipelas and a low form of fever, under which the patient might easily sink. At least a fortnight should be spent in this kind of preliminary treatment. The operation should be performed while the patient is under the influence of chloroform, and great care should be taken to dissect out every particle of the inodular tissue. To accomplish this, the surgeon is sometimes obliged to pass deeply among important vessels and nerves, which must, of course, not be interfered with. In conducting such an operation about the neck, the precaution must be used of preventing the entrance of air into the veins. The bleeding which attends the excision of the cicatrice is generally trifling, and is easily arrested by torsion : when the ligature is unavoidable, it should be brought out at the nearest point of the wound, or through a small open- ing in the transplanted integument. The skin for filling up the gap left by the removal of the inodular tissue, should always be taken from the immediate vicinity of the part. Thus, in the neck, it is usually obtained from the shoulder or top of the chest, and, when the wound is very large, two flaps are generally made, one on each side, the object being to guard against sloughing from inadequate nutrition. Due allowance must always be made for shrinkage. Hence, the flap should inva- riably be at least from one-fourth to one-third larger than the wound, have a good broad pedicle, and be well stitched in its new position, although care must be taken not to place the sutures too near each other for fear of embar- rassing the circulation. The central portions of the flap must be loosely confined with adhesive strips, and the edges covered with charpie, soaked in oil. The wound made by the transplantation of the integument is immedi- ately closed in the usual manner. The parts are kept perfectly at rest, being immovably fixed by suitable apparatus, and the case is afterwards managed according to the general principles of plastic surgery. The results of this operation have been much lauded; I have not, however, I must confess, much confidence in its ultimate efficacy, experience having taught rae that, sooner or later, the deformity is sure to return, though not always in its original extent. I have seen enough of these procedures, both in my own practice and in that of others, to convince me that they ought not to be classed among the triumphs of surgery. It is only when the cicatrice is very soft and superficial that they hold out any prospect of a very favorable result. When the contraction affects the muscles, tendons, fibrous membranes, and bones, forcing them out of their natural shape and position, the art of surgery can be of no avail. 618 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. Joints often become involved during the progress of burns and scalds, either from direct inflammation, or in consequence of the contraction of neigh- boring muscles, tendons, and aponeuroses. The parts are carefully watched, being moved from time to time, and constantly retained in splints, until all tendency to anchylosis has ceased. Finally, the secondary constitutional irritation and drainage, so common, and so hazardous in the more severe forms of these accidents, must be met by stimulants, tonics, and anodynes, along with a nutritious diet, and exercise in the open air. The wasting diarrhoea, which is so often present, must be checked with opium and astringents, of which acetate of lead and sulphate of zinc deserve particular mention, the former being given in two, and the latter in one grain doses, with half a grain of opium, three times in the twenty-four hours. Night-sweats are controlled with quinine and elixir of vitriol. Secondary amputation may be rendered necessary, when, an attempt having been made to save the part, death is likely to happen frora the excessive dis- charge and hectic irritation; or when the part is found not ouly to be useless but to be greatly in the way of the patient's comfort and convenience. SECT. VI.—FROST-BITE AND CHILBLAIN. Man, as is well known, possesses in an eminent degree the faculty of resist- ing the influence of physical agents. His constitution is able to bear almost any amount of heat and cold, provided the transition from the one to the other is not too great or sudden, and that he himself is at the time in the full enjoyment of his bodily powers. The experiments of Fordyce, Blagden, and others, show what an amount of artificial heat may be endured without entail- ing any serious effects, and the experience of travellers, as Banks, Solander, and Kane, is equally decisive in regard to his capacity of withstanding the effects of low degrees of temperature. It is only, or chiefly, when the alter- nation from heat to cold is very rapid, or when the application of cold is made in a very concentrated form, upon a part of the body whose circulation is naturally very languid, that severe consequences are apt to ensue. Baron Larrey, who enjoyed extraordinary opportunities of studying the effects of cold, during Bonaparte's celebrated retreat frora Russia, was forcibly struck with the little suffering which the soldiers experienced when exposed even for several successive days to the influence of a very low, dry, uniform tempera- ture. Thus, after the battle of Eylau, although the mercury had fallen fifteen degrees below zero of Reaumur's thermometer, none of the French troops complained of frost-bite, notwithstanding many of them had remained in the snow, in an almost inactive state, for upwards of twenty-four hours. Pre- sently, however, a fall of sleet coming on, during which the temperature rose suddenly from eighteen to twenty degrees, immense numbers of those who had been exposed began to suffer from the effects of cold, consisting principally in sharp, pricking pains in the remote parts of the body, especially in the feet, and in a disagreeable sense of numbness and weight. Severe swelling soon followed; the skin assumed a dusky, reddish appearance; the joints became stiff and insensible; feeling and warmth rapidly diminished; and black spots formed on the roots of the toes and on the back of the foot, announcing the occurrence of gangrene, the extremity looking dry and shri- velled, as in chronic mortification. It was observed that those who had warmed themselves at fires suffered more severely than those who had been more discreet in this respect. Frost-bite was very prevalent among the English troops during their first winter in the Crimea, and the French suffered in still larger numbers, as well FROST-BITE AND CHILBLAIN. 619 as more severely. The habit which the men had of sleeping in their wet boots, at one time almost universal, contributed greatly to its production, wet and cold corabined dirainishing the circulation and vitality of the feet and toes. On the 21st of January, 1855, when, according to Dr. Macleod, the thermometer stood at 5°, no less than 2500 cases of frost-bite were admitted into the French ambulances, and of these 800 died, death in many having no doubt been expedited by the effects of erysipelas, pyemia, and hospital gan- grene. The first effect of dry, cold air is a sense of numbness and weight with a peculiar prickling or tingling, and an afflux of blood to the surface, giving it a lively reddish appearance. If the impression be maintained for any length of time, the parts become stiff and perfectly insensible; and the blood, re- treating from the surface, leaves it of a pale, whitish aspect, contrasting strikingly with the previous discoloration. When the cold is intense, and suddenly applied, so as speedily to overwhelm the parts, the surface occa- sionally exhibits a mottled appearance, depending upon the presence of coagulated blood in the subcutaneous veins. The effects of moist cold are very similar to those of dry cold. Upon immersing the hand, for instance, in iced water, there is generally an imme- diate rush of blood to the surface, and a decided augmentation of its color, soon succeeded by an unpleasant tingling sensation and a marked degree of numbness. By and by, however, the surface becomes white, the skin con- tracts, exquisite pain arises, and the whole limb sensibly shrinks. There is thus, in fact, no essential difference in regard to the effects of these two varieties of cold; and the reader cannot fail to observe how closely the first impressions of both resemble those produced by the application of artificial heat, especially in its dry form. All parts of the body are liable to suffer from the effects of cold; excepting, however, those rare cases, where the impression has been maintained for an unusual length of time, the toes, feet, heels, fingers, hands, nose, and ears, together with the lips and cheeks, will be found to be more frequently affected than any other parts. Accidents of this description are most comraon among the poorer classes, those wretched beings whose system is broken down by starvation, intemperance, and every kind of exposure and hardship, calculated to depress the vital powers, and predispose to the development of disease. Sailors and the boatmen on our lakes and rivers are particularly prone to frost- bite, and there are few seasons that do not furnish a large supply of such cases. The primary effects of cold upon the general system are those of an agree- able stimulant; the circulation is increased in force and frequency, a slight glow pervades the surface, and the individual is universally exhilarated. By and by, this agreeable feeling is changed into one of pain and torpor; the brain is oppressed as if under the influence of a powerful narcotic; the whole body is cold and benumbed ; and the person, overwhelmed by drowsiness, is obliged to make the most powerful efforts to keep awake. If, in an unlucky moment, he should yield to his inclinations, away from friends and assistants, he sleeps to wake no more ; the blood rapidly settles in the internal organs ; the nervous fluid ceases to be generated ; the respiration becomes heavy and stertorous, and death takes place very much as in ordinary apoplexy. Should the individual, after long and severe exposure, be suddenly brought into a hot room, or placed near a fire, he will run the risk of speedily perishing frora asphyxia, brought on by the repulsion of the blood to the brain and lungs; or, should he survive a short time, the frost-bitten parts will be seized with gangrene, the spread of wdiich, as observed by Larrey, is often so rapid and striking as to be perceptible by the eye. Such are some of the more important local and constitutional effects of 620 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. cold, when applied in its more severe and protracted forms. As just seen, it may prove destructive both to the part and system, or, reaction taking place, the patient may recover, although he will be likely afterwards to suffer more or less in various parts of the body, especially the feet, cars, nose, and fingers, from the secondary effects of his accidents, which are often as dis- tressing to him as they are perplexing to the practitioner. The treatment of frost-bite requires no little judgment and adroitness to conduct it to a successful issue. The great indication is to recall the affected parts gradually to their pristine condition by restoring circulation and sensi- bility, in the raost gentle and cautious manner, not suddenly, or by severe measures. The first thing to be done is to immerse the part in iced-water, or to rub it with snow, the friction being made as carefully and as lightly as possible, lest over-action be produced in a part necessarily greatly weakened. If no ice or snow be at hand, the coldest well water that can be procured must be used; and if immersion be inconvenient, wet cloths are applied, with the precaution of maintaining the supply of cold and moisture by con- stant irrigation. Moderate reaction is aimed at and fostered. All warm applications, whether dry or moist, are scrupulously refrained from; the patient must not approach the fire, immerse his limbs in hot water, or be even in a warm room. Attention to these precepts is of paramount import- ance, and should on no account be disregarded, since its neglect would be almost certainly followed by mortification or other disastrous consequences. As soon as the natural temperature has been in some degree restored, slightly stimulating lotions will be found serviceable, such as weak solutions of camphor, soap liniment, or tincture of arnica with the addition of a few drops of ammonia to each ounce of fluid. The parts are placed at rest, in an easy and rather elevated position, and lightly covered with a blanket, or, what is better, exposed to the warm air of the apartment, there being now no longer any necessity of keeping the patient in a cool room, as there was in the earlier stages of the treatment. Some mild cordial may now also be given in small quantity, and the patient raay eat a little warm gruel or panado. If the local reaction threaten to be severe, it must be checked by astringent and cooling lotions, by attention to position, a properly regulated diet, and the exhibition of a purgative. For incipient mortification, conse- quent upon cold, the best remedy is dilute tincture of iodine. Dr. Hayes, the companion of Dr. Kane in his last Arctic voyage, gives an account of a mode of treatment of frost-bite pursued by the Esquimaux, which deserves brief mention, although it does not differ essentially from that just laid down. A native, says the writer, who had his leg frozen above the knee, to such an extent that it was stiff, colorless, and apparently lifeless, was placed in a snow-house at a temperature of 20° below zero. The parts were now bathed with ice-cold water for about two hours, and then enveloped in furs for about twice that period. At the end of this time frictions were commenced, first with the feathery side of a bird skin, and then with snow, alternately wrapping the limb in furs, and continuing the rubbing for nearly twenty-four hours. The limb was now carefully covered, and the tempera- ture of the room elevated by lamps above zero. On the third day the man was removed to his own house, and in seventy hours he was able to walk about, with only a slight frost-bite on one of his toes. When a person has been overpowered by cold, or is nearly frozen to death, the attempts at restoration must be conducted upon the same general princi- ples as when he is suffering merely from the local effects of cold; that is, he should be put in a cool room, and be gently but efficiently rubbed with flan. nel, wet with brandy, spirits of camphor, or ammoniated liniments, gradually followed by dry frictions and warm covering. If he can swallow, brandy should be given by the mouth, or this or some similar article should be throw n FROST-BITE AND CHILBLAIN. 621 into the rectum ; stimulants should be cautiously applied to the nose, espe- cially snuff, and sinapisms to the precordial region, the stomach, and spine. As the circulation and respiration improve, the temperature of the apartment may be gently elevated, and warm broths, or wine-whey, or, what is better, warm toddy, administered. The-efforts at resuscitation should not be discon- tinued too soon, since they have occasionally been crowned with success long after all reasonable expectation of recovery had ceased. The practice for- merly recommended of immersing the whole body in cold water, under these circumstances, cannot be too much deprecated, as it cannot fail to prove ex- ceedingly injurious. Pernio or chilblain.—The secondary effects of cold are usually described under the name of pernio or chilblain, and there are several varieties of form in which they may present themselves, as the erythematous, ulcerated, and gangrenous. These effects may supervene upon slight exposure, and hence they are occasionally met with among our better class of citizens, the parts most liable to suffer being the toes, heel, instep, ears, nose, and fingers. They are usually preceded by slight vesication, and by burning, tingling sensa- tions, as if the surface had been held near the fire. These effects may soon subside, or they may prove a source of annoyance for many months ; in general, however, they are of a transient nature, but the parts, instead of getting completely well, remain weak and congested, and are liable to new attacks of suffering from the slightest causes. Any sudden change in the weather is extremely prone to bring on a paroxysm; the affected structures become red, or of a dusky purplish hue, swollen, painful, and cedematous; the epidermis is often raised into little blisters, distended with yellowish, or sanguinolent fluid ; and there are few cases in which itching, sometimes almost insupportable, is not a prominent symptom, the patient feeling as if he could tear the parts to pieces. Ulcers not unfrequently form, as an effect of frost-bite ; generally preceded by slight vesication, they are superficial, irritable, and indisposed to heal, the discharge being of a thin, ichorous character ; the parts around are red, inflamed, and congested, and the erosive action often spreads over a con- siderable surface. In some cases it extends very much in depth, and may thus ultimately invade a neighboring joint, bone, tendon, or muscle. Gangrene is more frequently a primary than a secondary effect of frost-bite ; the affected part is of a dark brownish, or blackish color, cold, insensible, and exquisitely fetid ; in some cases the slough is dry and shrivelled, like a rotten pear, in others, it is moist and expanded. In persons of weak constitution, and in the more remote parts of the body, where the.circulation is naturally very feeble and languid, it often spreads to a considerable extent; but in general its tendency is to limit itself to a small space. When considerable, it may invade all the component tissues of a limb, the soft parts as well as the bones and joints. Pernio may,' as already stated, last for many years, alternately disappear- ing and recurring under the slightest local and constitutional changes. At- mospheric vicissitudes generally exercise a marked influence upon these attacks, the patient being often a complete barometer ; a combination of cold and moisture is particularly prejudicial. During the dry weather of summer the disease not unfrequently goes off spontaneously, but is sure to return on the approach of winter. In this manner life may be rendered perfectly mis- erable, especially when the chilblain is seated in the feet, the patient being hardly ever able to walk about with any degree of comfort or satisfaction. The treatment of pernio is generally too little regarded by the practitioner, who, knowing that it never endangers life, is too apt to overlook its just claims to his syrapathy. Of the various remedies that have been, from time to time, recommended for its relief, those that are of a slightly stimulating 622 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. character are most entitled to confidence. The milder forms of the disease may often be promptly relieved by immersion of the part in cold, or ice water, followed by a pretty strong solution of acetate of lead and opium, or, what is preferable, the dilute tincture of iodine, which, on the whole, I have found to be more beneficial than any other article. Sometimes prompt relief follows the application of carded cotton, soap liniment, spirits of camphor, or some other stimulating embrocation. When blisters form they should immediately be opened, and the affected surface freely touched with solid nitrate of silver, or painted with tincture of iodine. Not unfrequently excellent effects follow the use of the dilute citrine ointment, or ointment of the oxide of zinc. In obstinate cases I have derived great advantage from a blister, retained until thorough vesication was produced. The gangrenous form of pernio must be treated upon general principles. Fetor is allayed by the chlorides, and sloughs are removed as they become detached. Amputation is refrained from until there is a well-marked line of demarcation. In all cases proper attention must be paid to the general health; the diet must be regulated, the bowels evacuated, and the secretions improved and restored. There is reason to believe that great temporary suffering is often induced by neglect of these precautions. SECT. VII.—MORBID GROWTHS. The skin is subject to a variety of morbid growths, some of a benign, others of a malignant character. Among the more simple formations belonging to the former class are warts, corns, horny excrescences, and the so-called seba- ceous tumor, which, as its name implies, has its seat in the sebaceous follicles, so common in different regions of the cutaneous surface. Fibrous, fibro- cellular, or fibro-plastic growths are also sometimes met with, although they are infrequent; they are never malignant, but are extremely apt to return after extirpation. The most common and interesting development of this description is what is termed the keloid turaor, incidentally referred to in the chapter on the general history of morbid growths. Finally, the skin is occa- sionally remarkably hypertrophied, either congenitally, or as a result of inter- stitial deposits. The number of malignant growths of the cutaneous tissues is quite con- siderable, and, as they are of frequent occurrence, and often followed by disastrous consequences, it becomes necessary to study them with more than ordinary care and attention. The principal affections, recognized by patho- logists, as appertaining to this class of diseases, are scirrhus, melanosis, eiloid, lupus, epithelioma, and the peculiar bark-like formation first de- scribed by Dr. Warren under the name of lepoid. 1. WARTS OR VERRUCOUS GROWTHS. Warts are those peculiar excrescences, or prominences, so often seen upon the hands and face of young persons, although the old are by no means exempt from them. They consist essentially of a hypertrophous condition of Jhe papillary structure of the skin, and sometimes occur in such numbers as to constitute a genuine verrucous diathesis. When this is the case, they are not only developed with remarkable rapidity, but are apt to attain an extraordinary size. Of the exciting causes of warts, nothing is known ; they often occur in several members of the same family, and instances are observed in which they betray a hereditary tendency. r SEBACEOUS TUMORS. 623 A wart is a hard, insensible excrescence, generally of a conical shape, more or less movable, and attached by a broad base, although sometimes the re- verse is the case, the union being effected by a very narrow pedicle; its sur- face is rough, fissured or tuberculated, and usually a few shades darker than the adjacent skin ; its size seldom exceeds that of a common pea. When cut, it is painful, and bleeds somewhat. Its structure is essentially cellulo- fibrous. The fluid which follows a section of a body of this kind, has been supposed, but erroneously, to be contagious, or inoculable. A wart on the face, arm, or shoulder soraetimes becomes the seat of carcinoma, especially when it is constantly rubbed or irritated The treatment of warts is very simple. In young persons, in fact, they often disappear spontaneously. The best local remedy is chromic acid, with equal parts of water, applied with a glass brush. It instantly turns the skin black, and forms an eschar, which drops off in six or eight days, leaving a healthy, granulating sore, which soon heals. Tincture of iodine, acetic acid, bichloride of mercury, and sulphate of copper, also, answer an excellent pur- pose. When a verrucous diathesis exists, recourse must be had to the exhi- bition of arsenic, or Donovan's solution. Excision is necessary when a wart displays a tendency to malignancy. 2. SEBACEOUS TUMORS. The sebaceous tumor, essentially consisting of an enlargement of a seba- ceous gland with a retention of its secretions, has been described under va- rious names, founded either upon the character of its walls, the fancied nature of its contents, or the kind of structure in which it originates; as encysted, atheromatous, meliceric, steatomatous, and follicular. Wen was the familiar appellation by which it was known by the older surgeons. The term seba- ceous, being expressive of the true situation of this variety of tumor, seems to me to be preferable to any other, and I shall therefore retain it on the present occasion. The manner in which the sebaceous tumor is formed is easily explained. The first link in the morbid chain is the obstruction of a sebaceous gland, or cutaneous follicle, either in consequence of adhesive inflammation, or the inspissated condition of its own secretion, thereby offering a mechanical im- pediment to its escape. Being thus for- cibly retained, the matter gradually in- Fig. 187. creases in quantity, and. as it does so it necessarily presses everywhere upon the walls of the gland, which, in time, ex- pands into a strong sac, fig. 181, varying in size from that of a pea up to that of a small orange. Essentially, then, the tu- mor is an encysted tumor, consisting of an enlarged or hypertrophied condition of the sebaceous gland, and of an altered state of its own secretion, both the direct and inevitable result of the closure of the natural outlet preventing the evacuation of the affected structure. The contents of the sebaceous tumor are extremely variable, both in color and con- sistence ; in general, they are thick and whitish, looking and feeling very much like a mass of lard or tallow; occasion- ally they present the appearance and con- Sebaceoustumorsof thescalp; oneatabeing sistence of honey; and cases are met with laid opeil t0 show its cyst and contents. b. 624 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. in which they bear a very close resemblance to putty, or a thick mixture of flour and water. Sometimes the contents of a tumor of this kind are thin, almost watery, and exceedingly offensive. At other times, again, short hairs, very soft, and having well-formed roots, are found in them, as represented in fig. 188. Pilous matter is most commonly found in seba- ceous tumors about the forehead and eyelids. I have repeatedly seen it in these situations, and in several instances in very young subjects. It is not likely that the hairs that are found here are develop- ed in the morbid growth ; on the contrary, the pro- bability is that they are intercepted during the cyst of a sebaceous tumor, process of occlusion of the cutaneous follicle, and with hairs in its interior. that, after they have fallen into the cavity of the cyst, they are capable of attaining a certain deve- lopment, but ultimately cease to grow, and so become effete matter. The sebaceous tumor sometimes contains calculous matter, either in part or in whole ; consisting of phosphate and carbonate of lime, cemented toge- ther by a minute quantity of animal substance. A case has been recorded where the integuments of the buttocks were completely studded with small collections of this description ; they occurred in a young lad, and evidently had their seat in the skin-follicles. Similar formations have been observed on the forehead, scalp, nose, shoulders, trunk, and scrotum. The cyst of this variety of tumor, at first very thin, soft, and delicate, becomes, in time, quite thick and dense, often resembling a fibrous mem- brane ; and instances are occasionally met with, although they are rare, in which it is transformed into fibro-cartilage, cartilage, and even bone. In cases of long standing, its thickness is sometimes very remarkable. Exter- nally the cyst is rough, and more or less intimately connected with the sur- rounding parts by cellular tissue, which is not unfrequently considerably con- densed ; internally, on the contrary, it is generally smooth and glistening, very much, for example, like the inner surface of the dura mater. Small sacs are soraetimes observed in its interior, and I have several times seen indis- tinct partitions thrown across it, the result, apparently, of plastic, organized deposits. The sebaceous tumor has but few vessels, and even these are always very small; hence its progress is invariably tardy, and its removal is never at- tended with any hemorrhage. Little or no pain accompanies its develop- ment, and it never manifests any malignant tendency. Sometimes, however, it ulcerates, and becomes the seat of a good deal of local irritation and of a highly disagreeable, offensive discharge. WThen seated on the scalp, the steady, persistent pressure of such a turaor may occasionally partially indent the osseous tissue, as I have seen in several instances that have fallen under my observation. Although the diseased follicle is originally situated in the substance of the skin, the cyst, as it increases in size, gradually pushes itself beneath it, so that the connection between them is ultimately completely de- stroyed. Meanwhile, the skin itself becomes attenuated, and often, in great measure, deprived of hair, especially when seated on the scalp, where, par- ticularly in cases of long standing, the surface is often quite bald. The degree of mobility of the morbid growth is extremely variable, depend- ing upon its age and volume, but, above all, upon the amount and laxity of the cellular tissue in the structures in which it is developed. Its shape is for the most part globular; but when it is subjected to considerable pressure, it is not uncommon for it to have a compressed, flattened appearance. The most common sites of the sebaceous tumor are the face, forehead, and scalp. It is also met with on the neck, eyelid, shoulder, back, buttock, and MOLLUSCOUS TUMORS. 625 scrotum. On two occasions I have seen it on the prepuce, the patients being small boys who had been circumcised at the usual period at which that ope- ration is performed according to the rites of the Jewish Church. It is very seldom that the sebaceous tumor is found on the extremities. The number of sebaceous tumors, although usually small, is extremely variable. Sometimes there is only one, but it is not at all uncommon to see as many as five or six on the same person. In one instance, that of a raan aged forty, I counted upwards of two hundred, most of them being situated upon the head, face, and neck. Nearly all began when he was quite young, soon after bathing in cold water. They were of the meliceric kind, the con- tents of many being visible at the enlarged and partially obstructed follicle, where they had concreted, and presented a yellowish, dirty, wax-like appear- ance. They were of a globular or ovoidal shape, and varied in volume from that of a pea up to that of a hen's egg. Occasionally these tumors occur in several members of the same family; and now and then they display an evident hereditary tendency, as in a case which fell under my observation in 1844, in which the disease existed upon the scalp of a young woman of twenty-seven, and also upon that of her father, a paternal aunt, and her paternal grandmother. The tumors were, respect- ively, from four to seven in number, and varied in volume frora that of a marble to that of a walnut. More recently two other instances of a nearly similar character have corae under my notice. The diagnosis of the sebaceous tumor is sufficiently easy. Its chronic march, indolent character, soft, doughy consistence, mobility, and subcutane- ous situation, together with the absence of enlargement of the subcutaneous veins, and the normal appearance of the skin, always serve to distinguish it from other morbid growths. The only remedy for this variety of tumor is thorough excision, care being taken that not a particle of the cyst or wall be left behind, otherwise repud- iation, to a greater or less extent, will be inevitable. If the tumor be situated upon the scalp, a single longitudinal incision may be made across it, the flaps being dissected off from each side, and the morbid mass lifted out bodily, without exposing its contents. In most other regions, however, the best plan is to lay the tumor open from within outwards, turn out its contents, and then tear away the cyst. When the integuments are diseased, it may be proper to include the altered structures in an elliptical incision. However performed, the operation should never be undertaken without some prepara- tion of the system, as I have repeatedly known it to be followed by erysipelas. 3. MOLLUSCOUS TUMORS. There is a form of cutaneous tumor, to which, from its fancied resemblance to the knots on the bark of the maple, the term molluscous has been applied. When fully developed, it is about the size of a ripe currant, which it further resembles by having a central depression upon its surface, caused by the peculiar arrangement of its contents. Their form is variable; some are round or oval, some elongated, and as if compressed, some pedunculated, and some wallet-shaped. In color, they are usually red, reddish-brown, or dusky yellowish ; in consistence, soft and spongy. Molluscous tumors occur upon various parts of the body, as the face, neck, back, shoulders, nates, and extremities, and often exist in such immense num- bers as to constitute a genuine molluscous diathesis. What is singular is, that they are sometimes met with in several members of the same family ; a circumstance which, together with their rapid and consentaneous develop- ment, has led to the idea of their being occasionally contagious, or communi- VOL. i.—40 626 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. cable from one person to another by contact. Whether this, however, is really so or not remains to be proved. The disease, although it has been noticed at a very early period, as in children under five years of age, is raost common in adult and elderly sub- jects. Its progress is frequently very rapid, a large portion of the surface becoming studded with tumors in a few weeks. How the disease is excited we are uninformed, nor is anything known of its predisposing causes. The immediate influence under which it is developed is inflamraation of the seba- ceous glands, giving rise to a rapid secretion of sebaceous matter, which, becoming too thick to escape at the natural outlets, accumulates in the inte- rior of these reservoirs, pressing asunder their walls, and giving them a lobulated appearance, as is rendered evident on a section of them. The contents of these little tumors consist mainly of epidermic scales, in union with ovoid, oblong, or cuboid cells, heaped together like a pile of eggs, and occupied either by granular matter, oil globules, or a peculiar homoge- neous substance, of whose nature we are ignorant. Left to themselves, molluscous tumors nearly always pass into ulceration, generally beginning at their summits, and gradually progressing until their contents are completely discharged, when the parts usually readily heal; or they are invaded by gangrene, which occasionally extends deeply iuto the subjacent tissues, and thus leads, in the event of recovery, to disfiguring scars. Finally, cases occur in which the tumors become atrophied, or transformed into little pendulous wart-like excrescences. The treatment of these molluscous formations is best conducted by the topi- cal use of stimulants, of which the most efficacious are tincture of iodine, acid nitrate of mercury, sulphate of copper, chloride of zinc, and chromic acid, all more or less diluted to adapt them to the exigencies of each particular case, or the tolerance of the parts, the object being rather to produce a sorbefacient than an escharotic effect. In general, it will be found that brushing the sur- face of the tumor over freely once a day with the tincture of iodine will not only promptly arrest its development, but rapidly promote its removal. Lay- ing open the morbid growth, and touching the raw surface slightly with the solid nitrate of silver, is a plan highly recommended by some practitioners. The most expeditious method of all, however, is to cut it away with the knife, or to effect its strangulation with the ligature ; but it is obvious that such a procedure can only be adopted with any degree of propriety when the num- ber of tumors is very small. Constitutional treatment is not to be neglected in this disease. Occa- sionally the molluscous tumor in great degree, if not entirely, disappears, simply under the influence of a change of air, a judiciously regulated diet, and attention to the bowels and secretions. When the general health is much disordered, the first object should be to amend it by the interposition of suitable remedies, medicinal and hygienic. Cleanliness is of great importance, and must not be overlooked. If there be a scorbutic state of the blood, iron and quinine, with sub-acid drinks and vegetables, will be indicated. 4. MOLES. Moles are congenital spots, occurring upon various portions of the external surface of the body, usually of a dark, grayish, blackish, tawny, or brownish color, and closely covered with short, thick, almost bristly hairs. They oc- casionally project somewhat above the surrounding level, but in general this is not the case; they are usually a little harder than the natural skin, and they present themselves in various forms, of which the round and oval are the most common. Some persons seem to be remarkably prone to the formation of moles, and when this is the case it is not uncommon to see a number of ELEPHANTIASIS. 621 them scattered over different parts of the body. When single, or existing in small numbers, they generally occur on the face, shoulder, neck, or arm. Their size varies from that of a three-cent-piece to that of a dinner-plate. The color of these spots is due to a redundant deposit of the natural pig- ment of the mucous network of the skin, with an altered condition of the proper substance of the dermis, and probably also of the cuticle and of the hair follicles. Long-continued local irritation, such as is caused by friction, pressure, or the want of cleanliness, may occasionally awaken ulceration in these bodies, but in general they remain perfectly stationary and innocuous. A few years ago, I excised a mole from the back part of the arm of an old gentleman, of upwards of eighty, which had been a source of annoyance to him, more or less, for thirty years. It had latterly become ulcerated, had often bled, and was the seat of a very fetid, nasty discharge. It was included in an elliptical incision, the parts healing kindly, and there being no return of the disease. It is not often that moles become the subjects of surgical interference ; it is only, in fact, when they cause serious disfigurement, or when they fall into ulceration, that professional aid is sought. It has been proposed to get rid of them by mild caustic applications, as solutions of ammonia or caustic po- tassa; but as such a procedure might be followed by the development of keloid, the best plan always is to remove them with the knife, the morbid structures being included in an elliptical incision, the edges of which are afterwards healed, if possible, by the first intention. 5. HYPERTROPHY OF THE SKIN. Hypertrophy of the skin is now and then observed, chiefly, if not exclu- sively, as a congenital affection. It is characterized by a soft, pendulous condition of the skin, which hangs off in loose folds from the surface to which it is naturally attached, as if it had been stuck on without any special object. In all other respects, the integument is apparently perfectly normal, there being not the slightest alteration of color, consistence, or structure, at least so far as we are enabled to judge from inspection. The most comraon sites of hypertrophy of the skin are the nates, scrotum, prepuce, and vulva. The most remarkable example that I have met with occurred on the back of the neck in a female child, upwards of a year old, as the result of a congenital vice; the integument formed a large pendulous mass, of a doughy, inelastic feel, extending from ear to ear, aud causing a very unseemly deformity. The child was in other respects well formed, and, with this exception, remarkably beautiful. When the hypertrophied integument forms an unsightly mass, or when it proves inconvenient by its bulk, the surgeon will be appealed to for advice, and under such circumstances it may become necessary to remove the offend- ing structures. For this purpose, the parts should, if possible, be included in an elliptical incision, care being taken not to cut away so much of the skin as to interfere with reunion. If the tumor be very large, and the patient of tender age, recourse to the knife should be postponed until the constitutional stamina are sufficiently developed to enable the child to bear the shock at- tendant upon so severe an operation. Special pains should be taken to guard against hemorrhage. 6. ELEPHANTIASIS, OR HYPERTROPHY OF THE SKIN AND CELLULAR TISSUE. Arabian elephantiasis, Egyptian sarcocele, or the glandular disease of Barbadoes, as it is variously denominated, although uncommon in this country, deserves passing notice not less on account of the hideous deformity which it 628 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. induces than its obstinate and intractable character. The favorite seat of this singular disease is the leg, which often acquires an enormous volume and a most grotesque appearance, causing a striking resemblance to the leg of the elephant, whence its name. It is not, however, confined to this part of the body; on the contrary.it is liable to occur in various organs, particularly the scrotum, prepuce, and puden- Fig. 189. dum, which, in consequence, some- times acquire an enormous bulk. A tumor of this kind, presented to me by Dr. Bozeman, and re- moved by him from the genital organs of a negro, weighed forty pounds ; and Clot-Bey extirpated one, occupying a similar situation, which weighed one hundred and ten pounds. The adjoining cut, fig. 189, affords an illustration of this disease as it manifests itself in the foot and leg. The disease is met with in both sexes, but much oftener in men than in women ; it occurs in va- rious races of men, and frequently Elephantiasis of the leg and foot. begins at an early age, although it is most common in young adults. In this country and in Europe the affection is very rare, but in certain parts of Asia, Africa, Syria, Arabia, Egypt, and the West Indies, it is extremely prevalent and sometimes observes an endemic tendency. Of the causes of elephantiasis nothing satisfactory is known. The disease is evidently of an inflammatory character, but how this is brought about we are entirely ignorant. It has been supposed that it is owing to an obstruc- tion of the principal veins of the affected parts, impeding the return of blood, and thus creating congestion and irritation, followed by plastic exudation in the interstices of the cutaneous and cellular tissues. From the fact that attacks of erysipelas are not uncommon in the earlier stages of the disease, or, rather, that this affection not unfrequently precedes the outbreak of ele- phantiasis, it has been imagined that it is essentially dependent upon the disturbance which it occasions in the nutritive and secretory functions of the parts. Others, again, have been led to conclude that the malady essentially consists in an inflammation of the lymphatic vessels, attended with plastic deposits within and around these vessels, whereby their caliber is choked up, and, as a necessary consequence, their contents are prevented from dis- charging themselves into the thoracic duct. This view is, on the whole, extremely plausible, for it really comprises all the cardinal elements of a con- sistent theory, which the others certainly do not. That there is, in this dis- ease, serious mechanical obstruction of some kind or other, is unquestionable, and I know of none that would be more likely to produce such a result than compression of the lymphatic vessels. If, then, it is allowable, in the exist- ing state of the science, to frame a doctrine in respect to the origin of an affection so obscure as elephantiasis is acknowledged to be, we may conclude that it is an inflammation of the absorbents, attended with obstruction of their caliber, and deposits of plastic matter, which, becoming gradually or- ganized, is ultimately converted into an analogous fibrous tissue, thereby completely changing the character of the primitive structures, especially the cutaneous and cellular. If the affected structures be carefully examined by dissection, the following ELEPHANTIASIS. 629 appearances will be observed : The epidermis is very much thickened, rugose, and so firmly adherent as to come off with difficulty. The true skin is of a whitish color, striated in its texture, and very hard and dense, cutting almost like the rind of bacon. In many cases it is from a quarter of an inch to half an inch in thickness. The papillae are enormously hypertrophied, and of an elongated shape, forming large bodies which stand off prominently from the substance of the true skin. The cellular tissue is completely changed in its character; its areolae are obliterated, and their place is supplied by a dense, inelastic fibroid substance, exhibiting none of the properties of the original. In elephantiasis of the leg, the muscles, compressed by the new matter, and deprived of activity, are found to be wasted, pale, and in a state of fatty degeneration. The bloodvessels are generally very much enlarged, and hence, when an attempt is made to extirpate the morbid mass, as when it occupies the genital organs, tremendous hemorrhage is to be expected. In some cases, however, the larger veins are obliterated, especially in ele- phantiasis of the lower extremity. The principal nerves have a white, flat- tened appearance, and are apparently augmented in size. Elephantiasis often, if not, indeed, generally, comes on suddenly and un- expectedly, without any apparent local or constitutional cause. At times, however, its development is directly traceable to local injury, as a blow, sprain, or contusion ; and in quite a number of cases it has seemingly fol- lowed upon the protracted immersion of the parts in cold water, the occupa- tion of the individual compelling him to pursue such a habit. The symp- toms are at first of an inflammatory character; the affected surface, red and painful, pits on pressure, and imparts a nodulated, cord-like sensation to the finger; the subcutaneous cellular tissue is hard and infiltrated; and the movements of the diseased structures soon become stiff, awkward, and em- barrassed. Sometimes red lines or streaks extend along the course of the lymphatic vessels, as high up as the nearest ganglions, which are themselves more or less tender and swollen. Considerable febrile commotion is gene- rally present, but this soon subsides, and the disease gradually lapses into a chronic state, which often ceases only with the patient's life. The diagnosis of elephantiasis is unmistakable; there is no other affection which bears any resemblance to it. Once seen, it can never be forgotten. The part is not only enlarged, but enormously increased in weight and consist- ence ; it feels heavy and cumbersome, and is as hard, dense, unyielding, and rough as the leg of the animal from the resemblance to which it has derived its name. The surface of the skin, usually much darker than natural, is fissured, grooved, nodulated or tuberculated, and completely deprived of its normal sensibility. Sores occasionally form upon it, and, gradually spreading in diameter and depth, add greatly to the local distress. Sometimes small, hard, shining scabs exist, not unlike those of ichthyosis. The chronic march of the disease, the remarkable deformity of the affected parts, and the peculiar condition of the skin will always prevent it from being confounded with ana- sarca, the only lesion which bears any resemblance to it. The disease, once fully established, may remain completely stationary for years, or even during the remainder of life, or it may go on gradually in- creasing until the affected parts have acquired a volume and a weight many times beyond the natural state. Even under these circumstances, however, the suffering is chiefly of a mechanical character; the general health often continuing good to the last. It is only, in fact, when intractable ulcers form, and there is an abundant discharge of pus, that the constitution is likely to give way under the local drain and irritation. The prognosis is of course most unfavorable in those countries where the disease is endemic; in Europe and the United States, where it occurs only as a sporadic affection, very few die of it. 630 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. The treatment of elephantiasis is, at best, very unsatisfactory, however early it may be commenced, or however perseveringly and judiciously it may be conducted. Regarding it as essentially consisting in an inflammation of the lymphatic vessels, or of these vessels and the veins, the most rational plan of treatment that suggests itself is the antiphlogistic, of which leeching, blister- ing, and the application of tincture of iodine are among the more important and reliable means. The object, in the first instance, should be to reduce local action, and thereby prevent subversion of structure. Hence the sooner these remedies are applied the more likely shall we be to obtain resolution. As a sorbefacient, there is no article in the whole materia medica that holds out such strong hopes of relief as tincture of iodine, used either pure or variously diluted to suit the exigencies of each particular case. It not only promotes the removal of effused fluids, but produces a powerful revulsive and antiphlogistic action, and should be employed, steadily and persistently, for many months together. The effects of the treatment will be greatly aug- mented, if, superadded to it, the parts be occasionally scarified, to relieve engorgement, kept at rest in an elevated position, and well bandaged, strapped, or mechanically compressed. Inunction with mild mercurial oint- ment also sometimes proves beneficial; and, in the earlier stages of the complaint, lotions of acetate of lead, hydrochlorate of ammonia, and of recti- fied spirits, are worthy of trial, especially when there is much pain, with a tendency to rapid effusion and organization. Constitutional treatment is not to be disregarded in this disease. It will, in general, greatly assist the action of local remedies if the patient be put under proper restraint in respect to his diet, if he take occasionally a brisk cathartic, and if he be kept pretty constantly under the influence of the saline and antimonial mixture, with a few grains of calomel every night at bedtime, until slight ptyalism is produced. General bleeding might even be advan- tageously employed at the beginning of the treatment, if there be a robust and plethoric state of the system. When the malady has attained an extraordinary degree of development, or has gone on for many years progressively increasing, or has remained stationary for a long time, no treatment of which we have at present any knowledge, not even ligation of the principal arteries of the affected tissues, will be likely effectually to eradicate the disease, or, more properly speaking, enable the parts to resume their primitive condition. All topical and general means are, under such circumstances, absolutely unavailing; and the utmost that can reasonably be expected from cutting off the supply of blood to the part is a diminution of its size, not a complete restoration of it to health. Professor Carnochan deserves great credit for the laudable effort which he has made, in several cases of elephantiasis of the leg, to arrest the morbid growth, and ultimately cause its absorption by ligating the femoral artery; but, although his patients, three in number, were, from all accounts, much benefited, it is questionable whether, in any, a complete cure has been effected. In the summer of 1851,1 was present at the Philadelphia Hospital, when Dr. Campbell, then surgeon-in-chief, performed an operation of this kind upon a negro, aged about fifty, who had long been afflicted with this complaint iu one of his legs; but the result was not at all encouraging. I saw the man occasionally afterwards for many months, and during my last visit to him, more than a year after the operation, the limb had not undergone any mate- rial change, either in volume or consistence. Indeed, such a procedure could hardly be expected to eventuate favorably, when we take into consideration the excessive disorganization of the parts and the astonishing enlargement of the branches of the femoral artery. The operation might, if performed early in the disease, and if conjoined with the use of sorbefacients aud the bandage, KELOID TUMORS. 631 be worthy of further trial; but I should certainly not feel inclined to recom- mend its indiscriminate employment. When the diseased mass is very large, greatly incommoding by its weight and bulk, and entirely unamenable to treatment, the only resource is removal with the knife. If it occupy a limb, amputation will be both a safe and a facile procedure, but if it involve the scrotum, penis, or pudendum, excision may prove not only extremely difficult, but exceedingly perilous, life being endangered, in the first instance, by shock and hemorrhage, and afterwards by pyemia and exhausting suppuration. 1. KELOID TUMORS. The keloid tumor, so called from its fancied resemblance to a crab, is an affection of the skin, first accurately described by Alibert, in his treatise on cutaneous diseases, in 1810. It is characterized by the existence of hard, semi-elastic, prominent excrescences, of a cylindrical or rounded form, more or less discolored, and the seat of an unpleasant itching sensation. Pro- cesses, roots, or branches usually extend from it into the neighboring parts, the whole looking very much like the cicatrice of a burn. The disease is generally described as being extremely infrequent; but judging from my own experience I am far from thinking that this is the fact. I have notes of at least thirty cases, and many more have come under my observation of which I have neglected to keep a record. It occurs in all classes of society, in both sexes, in nearly all parts of the body, and at almost all periods of life. The youngest case of it that has been under my charge was that of a little girl three years and a half old; on the other hand, I have repeatedly seen it after the age of sixty. A number of my patients were negroes; but whether they are more subject to the disease than whites I am not prepared to affirm, although this is highly probable. The exciting causes of keloid are not always the same. In some cases, though these constitute a marked minority, it arises spontaneously, and is then very liable to show itself in various parts of the body, as if the indivi- dual was laboring under a real keloid diathesis. Of this form of the affec- tion I have seen two remarkable examples. In general, keloid succeeds to some local injury, sometimes of a severe, but more commonly of a trivial character, as, for instance, a scratch, puncture, or abrasion. In four of ray cases it supervened, respectively, upon the operation of cupping, the appli- cation of a blister, the contact of nitric acid, and the cicatrices left by small- pox. In another instance it broke out upon a vaccine scar. In a young lady of seventeen, it was produced by the application of caustic potassa, employed for destroying an enlarged lymphatic ganglion of the neck. In several cases I have known it to follow the use of the knife in the extirpation of tumors. Thus, in an elderly lady from whom I removed the right mammary gland, two years and a half ago, two well-marked keloid growths came on, soon after the operation, at the site of two small incisions made to ease one of the flaps with a view to more accurate approximation ; and the occurrence of the disease after the ablation of keloid tumors both at the line of union of the edges of the wound and at the parts transfixed by the pins used in introducing the twisted suture, is familiar to every one who has seen much of this affection. But the raost comraon causes of keloid, so far a_s my observation and reading extend, are burns and scalds; the great majority of the cases that have come under my notice having been produced in this way. The period which intervenes between the occurrence of the exciting cause and the actual development of the disease is altogether uncertain; in many cases it is quite short, not exceeding a few weeks, or, at farthest, a few months; on the other hand, however, the time is occasionally much longer. 632 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. In several of ray cases, the tumors had acquired a large bulk in the space of a single year. Once fairly commenced, the disease generally proceeds with marked rapidity, especially when it is the result of some traumatic cause; the same is also true, at least in some instances, when it arises sponta- neously. Thus, in an instance recently under my observation, an immense number of these excrescences appeared spontaneously upon different parts of the body within a few months after the first manifestation of the morbid action. The peculiar external characters of keloid will be readily understood from the annexed drawing, fig. 190, taken from a colored man upwards of fifty Fig. 190. Keloid tumors. years of age, whose body was literally covered with morbid growths of this kind. They were particularly numerous on the neck and trunk, both in front and behind, and also on the shoulders and arms, while the forearms, hands, and lower extremities were entirely exempt from them. In size they ranged from that of a small Lima bean up to that of a sausage, from six to eight inches in length. They were of all shapes ; some round or cylindrical, some elongated and flattened, some angular, some crucial, some crab-like or full of processes, roots, or prongs ; in short, nature seemed to have exhausted her ingenuity in devising figures for their representation. The surface of nearly all was rough, wrinkled, or puckered. Most of them projected from a line and a half to an inch and a quarter above the surrounding level; some were isolated, others ran into each other, thereby adding still farther to their grotesque appearance. Their consistence varied ; most of them were remarkably hard and firm, feeling very much like a mass of fibro-cartilage, with a slight degree of the elasticity inherent in that tissue. In regard to their color, some resembled the natural skin, but the great majority of them KELOID TUMORS. 633 were several shades lighter. The intervening integument was sound up to the very borders of the keloid tumors, which were all distinctly circumscribed, and slightly movable, allowing themselves to be raised up with the thumb and index finger; only a few seemed to be completely tied down. This remarkable case had commenced early in life, but had for years past been almost stationary. The raan was well conditioned when I saw him, and his general health had all along been excellent; the only annoyance which he experienced was an itching or stinging sensation in some of the tumors, which, although at times very severe, especially when he labored under constipation or accidental overheating of the body, left him sufficient comfort for sleep and other enjoyment. Through the kindness of Dr. Hazard, of this city, I had an opportunity, last summer, of seeing another very interesting case of spontaneous, universal keloid disease, in the person of a young gentleman, aged 18 years, a native of Cuba. Up to twelve months previously, when it first began to show itself, he had always enjoyed excellent health, and, so far as he knew, he was per- fectly free from hereditary taint of every description. The tumors were, for the most part, of a rounded or oval shape, not very hard to the touch, mov- able, vascular, and of a dusky reddish hue. In a few places they existed as distinct ridges, from a line to an inch in width, projecting prominently beyond the level of the surrounding surface. The hands and feet were covered with them, particularly the joints of the fingers and toes ; they were also found on the legs, knees, buttocks, right arm, and elbow. They were free from pain, and quite tolerant of manipulation. The general health was somewhat im- paired, the youth looking dyspeptic, and laboring under partial paralysis of the left superior extremity. In white persons the keloid tumor is generally a few shades redder than the adjoining skin ; occasionally, indeed, it has a very fiery appearance, and is pervaded by numerous, delicate, superficial vessels, in a state of habitual congestion. The site of the keloid tumor presents nothing of a definite character. When traumatic, it may occur in any part of the body, and the same thing, as we have already seen, may happen in the idiopathic form. It is generally supposed that it is particularly prone to appear on the chest, but, judging from my own observation, I should be inclined to doubt it. Pathologists have made a distinction between keloid tumors by separating them into two varieties, the true and the spurious. The former, it is alleged, arise spontaneously, whereas the latter are always caused by some local injury, such as that already referred to. From my knowledge, however, of this dis- ease, I am satisfied that such a division is altogether arbitrary, and, conse- quently, without any foundation in nature ; the structure in both of the so- called varieties being perfectly identical. Keloid, although a troublesome, is not a dangerous disease, inasmuch as it never degenerates into malignancy. Of all the cases that have come under my notice, not one has exhibited such a tendency. When excised, however, it nearly always returns, and that in a very short time, rising with increased activity, like a phoenix from its ashes; so that the second state is literally much worse than the first. In some cases, the tumors remain completely stationary for a long time ; in others, on the contrary, they gradually advance until they have acquired a considerable bulk, when they usually become pas- sive, and so continue for many years. Occasionally, in consequence appa- rently of prolonged pressure or local irritation, they take on ulcerative action, but such an occurrence is, according to my observation, very unusual. In regard to their structure, keloid formations belong to the class of fibro- plastic growths, described in the chapter on tumors. The fibres intersect each other in every possible direction, intercepting cells or spaces occupied 634 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. by plastic matter, of a softer nature. A section presents, to the naked eye, a whitish, homogeneous aspect, or, if the mass be very old, very much the appearance of an unripe pear or turnip. It creaks slightly under the knife, and is of a dense, firm consistence, with very little elasticity. Hardly any vessels are perceptible in its interior, but the surface of the growth is usually, as already stated, quite vascular, the vessels passing over it in distinct lines, more or less tortuous and varicose in their arrangement. The minute struc- ture of keloid is well seen in fig. 191, drawn from one of my specimens by Dr. DaCosta. Fig. 191. Microscopical characters of keloid. The treatment of keloid is altogether unsatisfactory. So far as I know, there is no remedy which exercises the slightest influence in arresting its pro- gress or promoting its removal. Sorbefacients and alterants of every de- scription, in every form of combination, and in every variety of dose, have been employed, and yet I am not aware of a solitary instance in which their exhibition, however protracted, has been followed by a cure, or even by a tendency towards such a result. The different preparations of iodine, arsenic, chloride of barium, hydrochlorate of ammonia, and other kindred articles, so serviceable in some other morbid growths, have all signally failed in effect- ing any beneficial changes in this. The excessive itching, burning, or sting- ing, which is a source of such annoyance when the tumors are large or nume- rous, is best relieved, according to my experience, by a proper regulation of the diet, an occasional active purgative, the exhibition of the antimonial and saline mixture with Fowler's solution of arsenic, and the frequent use of the tepid bath, either simple, or medicated with soda, potassa, comraon salt, or bran. Anointing the tumors occasionally with oil or mild pomatum will also prove serviceable. Everything like pressure or local irritation must be carefully guarded against. If ulceration arise, none but the raost soothing remedies should be employed. As to excision, my experience is decidedly opposed to it. In the many cases in which I have tried it, signal failure has been the result, the disease always returning at the site of the cicatrice within a short time after. It is only when the tumors act obstructingly, as when they impede the opening of EILOID—LEPOID. 635 a natural outlet, or become a source of great disfigurement, that interference should be considered as warrantable. In some cases relief might possibly be afforded by a plastic operation, but on this point I am not able to say any- thing from personal experience. 8. EILOID. The eiloid tumor is extremely uncommon, only a few cases having hitherto been met with. It was first described by Dr. John C. Warren, who gave it the present name in consideration of its peculiar coil-like disposition. In its earlier stages it presents the appearance of a small elevation, similar to that occasioned by a burn, which goes on gradually increasing, without pain, heat, redness, or ulceration, until it acquires a large bulk, and sensibly affects the general health. The rolls, in the case of the Boston surgeon, lay in close contact with each other, each being about four inches in length, the whole together looking very much like a triple coil of inflated intestine. The growth seemed to have begun on the right side of the neck by a narrow base. The patient was a negress, about fifteen years of age, whose health had not been good for some time past. The tumor, although removed along with a portion of sound skin, soon returned. When the girl was seen eighteen months after- wards, it occupied the same site, but was not as large as the original one. Being again extirpated, it rapidly reappeared, and soon proved fatal, the patient dying dropsical. Dissection of the body revealed important disease of the liver, water in the splanchnic cavities, and great enlargement of the lymphatic ganglions of the abdomen. Of the anatomy of eiloid nothing is known. It probably takes its rise in the substance of the dermis, but how, or in what particular part, has not been determined. It is to be regretted that Dr. Warren has failed to inform us whether the secondary growth had the same coil-like appearance as the pri- mary one. The only remedy, of course, for this disease, is early and efficient extirpation, with proper attention afterwards to the general health. 9. LEPOID. The lepoid formation is most generally observed upon the face, nose, and forehead of elderly persons, usually males, of a delicate florid complexion, with a habitual tendency to congestion of the capillary vessels, light eyes, and light, brown, or reddish hair. Although occasionally single, I have more commonly found it to be multiple. In some instances, indeed, quite a num- ber of lepoid spots are observed, scattered about in different directions, with intermediate healthy skin. It generally makes its appearance in the form of a small, circumscribed speck, not larger, perhaps, than a mustard seed, and of a dirty, grayish color, which becomes covered with a very rough, brownish crust or scale, resembling the bark of a tree, whence its name. This, falling off, is soon succeeded by another, of the same complexion, form, and con- sistence. Thus the disease is often kept up for many successive years. At last, however, ulceration sets in, and the dermis exhibits a red, glossy surface, spicular, pitted, or granular, and throwing out a thin, ill-elaborated pus. The skin, upon inspection, is found to be almost of a gristly hardness, its internal surface being studded with numerous little, whitish, rounded bodies, con- nected together by a dense, grayish substance. The progress of the disease is attended with hardly any pain; but the patient is generally very much an- noyed by itching, leading to an irresistible desire to scratch, which always aggravates it. The nature of lepoid is undetermined. Without being able to speak posi- tively, I am strongly inclined to believe that it is merely a variety of lupus 636 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. or epithelioma; a supposition deriving plausibility frora the circumstance that, although generally disposed to remain long stationary, or to make hut little progress, it often ultimately takes on malignant action ; pursuing then very much the same course as the milder forms of lupus. The best remedy for this disease is non-interference. The rough, bark-like scale may occasionally be softened with a little very dilute citrine ointment, or covered with a mixture of two parts of collodion and one of castor oil, to serve as a defence from the air. All irritating applications must be refrained from. If the disease is inclined to spread, the tissues may be destroyed with the Vienna paste, or removed with the knife; but in general it will be safest to eschew all operative interference, as likely to aggravate the case by an early recurrence of the formation, and its more rapid tendency to malig- nancy. 10. LUPUS. Under the term lupus are comprehended two varieties of disease, the chief peculiarity of which is a tendency to destructive ulceration of the skin and areolar tissue, or of these and the more deep-seated structures. In point of fact the two affections are identical, the only difference between them being that the one is milder than the other, more tardy in its progress, and less disposed to spread, its ravages being generally limited to the cutaneous tex- tures, or to the parts in which it is originally located. The former of these affections is called the non-exedent, stationary, or serpiginous ulcer; the latter the exedent, eating, or corroding ulcer. It is also known as the can- croid or voracious ulcer. The older surgeons described it under the appella- tion of noli me tangere, in reference to the exquisite sensibility by which it is so often characterized. The term lupus, signifying wolf, is suggestive of the destructive tendency of the affection. Of the causes of lupus, in both of its forms, we have no definite know- ledge. In general, it comes on spontaneously, or without any assignable reason, and soon exhibits its peculiar features. Occasionally its origin is apparently referable to some local injury, as a scratch, abrasion, or contu- sion, or to the irritation of some warty growth. It is commonly supposed that a scrofulous state of the constitution predisposes to its occurrence, and this is probably true, although in a much less degree than has been imagined. My own experience certainly does not warrant the conclusion that the origin of the disease has, in general, any such relation; in most of the cases that have come under my observation, the patients seemed to be peculiarly free from strumous taint, both as it respected the actual state of their own sys- tem, and everything like hereditary transmission. Persons of a delicate, ruddy complexion, with light hair, blue eyes, and an unusually active capil- lary circulation, are most prone to the disease, not only as it regards its fre- quency, but also the rapidity of its progress and the extent of its ravages. How far a syphilitic taint of the constitution may act as a predisposing cause of lupus is a point that has not been ascertained ; unfortunately, it is seldom in the power of the practitioner to obtain a sufficiently accurate account of his cases to enable him to trace, in a satisfactory manner, their various rela- tions. Lupus may occur in any part of the body, but it will most commonly be found to manifest a peculiar predilection for the nose, cheeks, and eyelids, especially the lower. It is observed in both sexes, and rarely shows itself until after the age of forty. When it attacks the face, it soraetimes breaks out simultaneously, or nearly so, at several points. The ulcers, in both varieties of the affection, are usually of an intractable nature, or if, as occa- sionally happens, they heal at one place, they are sure to spread at another. Their secretions are of an ichorous nature, and their surface is covered by a LUPUS. 631 brownish, characteristic scab. If reparation take place, the new skin is always very hard, white, irregular, and prone to take on disease from the slightest causes. 1. The non-exedent lupus, often described as the serpiginous ulcer of the face, generally begins either as a small, hard, white, shining tubercle, or as a fissure, crack, or excoriation, with indurated edges, and a thin, brownish incrustation. In either case, it soon exhibits its characteristic tendency to spread, not in depth, but circumferentially, for it rarely, at least in its earlier stages, penetrates beyond the substance of the true skin, or even far into it. In fact, it is essentially a superficial ulcer, passing generally from one point to another, but seldom involving the deeper structures, except, perhaps, when it appears on the ala of the nose, where it occasionally evinces a highly ero- sive disposition. When it affects the eyelids, it may, in time, extend to the fibres of the orbicular muscle, and even to the tarsal cartilage, but in gene- ral it remains limited for years to the skin, or skin and areolar tissue. The parts around the ulcer are hard, puckered, tender, and usually somewhat red- dish, although very often they retain their normal color. The ulcer is the seat of occasional, darting, stinging, or shooting pain, and of more or less itching, generally much more disagreeable than the pain itself. When the scab, which is usually very thin, and of a brownish, or blackish color, drops off, it is speedily succeeded by another of a similar kind. When the surface is thus exposed, it is occasionally found to be covered by very red, vascular, sensitive granulations, smeared over with thick, yellowish, viscid pus, and dis- posed to bleed on the slightest touch. The edges of the ulcer are usually steep, jagged, and slightly everted. As the sore spreads in one direction, it often heals in another, leaving a whitish, leucoid, or milky scar, strikingly contrasting with the surrounding parts. The non-exedent form of lupus is said to be most common in young scro- fulous females, but, if this be the fact, my experience has failed to afford me any evidence of it. In raost of the cases that have fallen under my observa- tion, and they have been very numerous, it appeared after middle life, in both sexes, with a complexion that was either very florid at the time, or had been so shortly before the attack. My opinion is that writers often confound this affection with the effects of a syphilitic taint of the system, exhibiting itself in the form of one or more superficial, foul, obstinate ulcers, which, when their nature is properly understood, may always be made to disappear promptly under the use of iodide of potassium and bichloride of mercury. In the treatment of this variety of lupus, none but the miidest and most soothing applications should be employed. The one from which I have de- rived most benefit is the dilute tincture of iodine, which, while it changes the action of the secernent vessels, promotes the removal of effused fluids, and serves as a protective against atmospheric and other injurious impressions. As long as the scab remains on the surface of the ulcer, it should not be dis- turbed ; otherwise it may be covered with a piece of lint, spread with a small quantity of the ointment of the nitrate of mercury, largely diluted with simple cerate. Occasionally a little powdered opium forms a valuable addi- tion. Brushing over the part once every three or four days with a mixture of collodion and glycerine often answers a good purpose. When the ulcer is foul, and has a disposition to spread, it should be touched once or twice, lightly but effectually, with the dilute acid nitrate of mercury. All severe applications must be avoided, as they generally do immense harm. Along with these topical remedies, special attention must be paid to the state of the general health, which is often not a little disordered. The diet should be light, simple, unirritant, and chiefly, if not exclusively, of a vege- table character, the drinks consisting of water, milk, or weak tea; the bowels and secretions should be regulated with blue mass and ipecacuanha, or blue 638 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. mass and colocynth ; and if signs of debility exist, as denoted by the state of the countenance, pulse, and strength, tonics should be resorted to, in com- bination with alterants, of which the best are quinine and iodide of iron, in combination with a minute quantity of bichloride of mercury and arsenious acid. Of late, very favorable mention has been made of the use of the chlo- ride of arsenic in the treatment of this affection, in doses varying from eight to fifteen drops thrice a day, and a number of cases illustrative of its bene- ficial effects have appeared in the medical journals. Of its efficacy, how- ever, I can say nothing from personal experience. When the vital forces are much impaired, cod-liver oil and milk punch must be pressed into the service. 2. The other variety of lupus, the exedent, corroding, or devouring lupus, of authors, belongs unmistakably to the class of affections described by modern pathologists under the name of epithelioma, or cancroid disease. It is a genuine cancerous development, generally beginning in the form of a hard tubercle, crack, or warty excrescence, and rapidly extending in different di- rections, both in circumference and depth, until it has occasioned the most frightful ravages, and the most dreadful and disgusting deformity. Thus, it often consumes the whole of the nose, one cheek, the entire lip, the chin, or perhaps the orbit of the eye, and the forehead, the ball of the eye being completely severed from its connections and dropping down into the frightful chasm below. To witness some of these cases is a truly pitiful and shocking sight. The progress of the disease is often remarkably rapid, great mischief being sometimes done in a few months; at other times its march is more slow, or the malady, after having evinced a most destructive tendency, may suddenly stop, with all the appearances of a complete cessation of hostilities. A case has been reported to me where the morbid action, after having destroyed the greater portion of one cheek with the corresponding antrum, has remained in a state of abeyance for the last eight years, although it had been steadily pursuing its course for upwards of fifteen. The ulcer in this variety of lupus has an excavated appearance, as if it had been punched out of the parts on which it rests; its edges, however, are generally somewhat everted, or everted at one place and slightly overhanging at another, ragged, and often as if worm-eaten ; the bottom is foul and covered with unhealthy granulations, or granulations and aplastic lymph; the discharge is ichorous and irritating; and the surface around is indurated, tender, and more or less discolored and cedematous. The pain is generally severe, being of a sharp, biting, darting, or shooting character, and liable to temporary exacerbations from exposure, irregularities of diet, and atmospheric vicissi- tudes. The general health, at first perhaps entirely sound, becomes seriously affected during the progress of the disease; the appetite and sleep are im- paired; the strength declines; marasmus gradually ensues; and the patient, worn out by suffering, finally dies completely exhausted. The great object in the treatment of the corroding form of lupus is to ar- rest the morbid action, either with the knife, or some suitable escharotic, as the acid nitrate of mercury, or the Vienna paste. In regard to the first of these measures, I must confess I have no great confidence in its efficacy as a means of preventing a recurrence of the disease, since it does not appear to be capable of exerting upon the capillaries in the neighborhood of the affected parts that alterant influence which is necessary to cause a perma- nent suspension of the specific action upon which the malady originally de- pended. In most of the cases in which I have employed the knife, the result has been anything but flattering, notwithstanding the most thorough excision and the most careful attention iu regard to the after treatment. Indeed, I have often been struck with the apparent avidity, so to speak, with which the disease returns. My opinion, therefore, is that excision, as a general MELANOSIS — SCIRRHUS. 639 rule, should give way to escharotics, either such as have been just alluded to, or, what I believe is preferable, in nearly all cases, the actual cautery. The hot iron not only effectually destroys the diseased tissues, but it seems to create a wide spread salutary influence among the surrounding parts, emi- nently unfavorable to repuUulation. Notwithstanding, however, all the care and precaution that can be employed both to get rid of the disease and to oppose its return, it must be confessed that our efforts are generally, in the end, unavailing, the malady usually coming back, and ultimately terminating fatally. As long as the disease is stationary, it will be best, as a general rule, not to interfere with it in any manner; the scab, if there be any, should be let alone, or, if the surface be exposed, it should be treated with the most sooth- ing and gentle means. The general health must, in this as in the more simple variety, receive, throughout, proper attention ; alterants and tonics will often afford essential service; and the strictest vigilance should be exercised in regard to the diet, bowels, and secretions. Arsenic, bichloride of mercury, and iodide of iron are particularly deserving of trial as constitutional remedies. 11. MELANOSIS. Melanosis of the skin, fig. 192, is very uncommon, and probably never occurs as a primary disease, being apparently always propagated from the subcutaneous cellular substance, or from some lymphatic ganglion. It Fig. 192. nearly always co-exists with melanosis in other parts of the body, and is, therefore, merely an evidence of a general taint of the system. In a case that was under my observation, some years ago, in a man, aged fifty- eight, it involved nearly all the princi- pal organs, and of course finally proved fatal. In another instance which occurred in this city, while I Was a pupil Of the late Dr. George Nodule of black cancer in the true skin. McClellan, an immense number of melanotic tumors existed in the skin and cellular tissue of the abdomen, varying from the volume of a small pea up to that of a mass the size of a large almond ; they were of a firm, fibrocartilaginous consistence, slightly movable, exquisitely painful, and of a bluish-black color. The remedy, in this case, was excision, a few of the larger tumors being removed at a time ; the operation was repeated every ten or twelve days, for several months, by which time, but little progress being made towards a cure, the patient became tired, and positively declined further interference. He finally died completely exhausted by his disease. When melanosis is confined to the integuments, and occurs as a circumscribed tumor, the proper remedy is early and free excision ; but under opposite cir- cumstances, or, when it co-exists in other parts, or is extensively diffused through the cutaneous and areolar tissues, all interference of the kind should be avoided, as likely to accelerate the fatal crisis. 12. SCIRRHUS. Scirrhus of the cutaneous tissue is also exceedingly uncommon ; it is, how- ever, occasionally met with in various parts of the body, particularly the face, 640 DISEASES OF SKIN AND CELLULO-ADIPOSE TISSUE. forearms, and hands. It generally begins in the form of a whitish, milky, or leucoid spot, commonly a little elevated above the surrounding level, but now and then apparently somewhat depressed, of a dense, firm consistence, more or less rough, and completely inlaid in the substance of the skin. Large vessels frequently extend across the affected parts, the redness contrasting strikingly with the whiteness of the intervening surface. Movable at first, the tumor gradually contracts adhesions, and, in time, involves the subcuta- neous cellular substance. If a section be made, it will be found to be tra- versed by white lines, and to yield, on pressure, a small quantity of lactescent fluid. Although the progress of this affection is usually slow, its tendency is ulti- mately to disintegration and decay, the resulting ulcer having an irregular, jagged appearance, with everted edges, and a foul bottom, the discharge being of a sanious or ichorous nature. More or less pain, of a sharp, lanci- nating character, generally attends. As the morbid action proceeds, new leucoid spots are often superadded to those already existing; the health gra- dually gives way, and the patient finally dies exhausted, though commonly not until carcinomatous disease has developed itself in some of the internal organs, particularly the lungs, pleura, and liver. Occasionally the affected parts assume a true encephaloid character, and in this way a tumor of con- siderable size may ultimately be formed, very tender, vascular, and subject to frequent hemorrhages. Finally, the scirrhous matter sometimes exists as an infiltration, although such an occurrence is very infrequent. Secondary scirrhus of the integuments is by no means uncommon ; it is raost frequently seen in carcinoma of the mammary gland and lymphatic ganglions, and generally presents itself in the form of small, hard, shot-like tubercles, firmly and immovably fixed in the substance of the skin. The number of these little bodies is sometimes very great; they are usually quite painful, seldom attain much bulk, and do not often ulcerate, the patient nearly always dying of the primary disease before this event has had time to take place. The ultimate character of these secondary formations is not well under- stood ; in most cases, especially when of long standing, and of large size, they contain encephaloid matter and true cancer juice. Melanotic substance is soraetimes interspersed through them. Scirrhus of the integuments presents the same unrelenting character as this disease in other parts of the body ; extirpation, the only resource in the early stage of the malady, holds out no prospect of permanent relief, and hence all that can generally be done is to palliate the patient's suffering. SECT. VIII.—INSECTS IN THE SKIN AND CELLULAR TISSUE. The skin and cellular tissue are liable to be infested by certain insects, which although not poisonous, are capable of inducing serious suffering, especially in persons of a nervous, irritable temperament. I refer more par- ticularly to the chigoe and the Guinea worm. The chigoe, which is very common both in this country, South America, and the West Indies, is a little insect, scarcely half the size of the smallest pin head, which penetrates the skin of the hands and feet, as well as of other exposed parts of the body, for the purpose of sustenance and hatching. It is a species of flea, with a rostrum as long as the body, of a pale-brownish, semi-transparent appearance, with legs of a light lead color, which often deposits its eggs in immense numbers. The first effect is an itching sensa- tion, which is soon followed by heat, redness, and swelling, and, ultimately, by an ugly, irritable, spreading ulcer. If the part, when it has attained this INSECTS IN THE SKIN AND CELLULAR TISSUE. 641 stage, be carefully examined, it will be found to contain a cyst, about the size of a pea, and of a bluish color, in which the ova live and multiply with astonishing rapidity. When a number of chigoes penetrate the skin together, the suffering produced by them may be so great as to cause violent constitu- tional disturbance and even death. The treatment consists in picking out the insect and its eggs with a fine needle, care being taken not to rupture the cyst, otherwise the young brood may produce further mischief. Clearance having been effected, the partis well washed with salt water, tobacco juice, or spirits of turpentine, and thoroughly painted with dilute tincture of iodine. The female slaves in the West Indies are said to extract these insects with great dexterity. The Guinea worm, or little dragon, technically called filaria medinensis, also buries itself in the body. It is chiefly met with in hot countries, parti- cularly in Egypt, Arabia, Persia, Abyssinia, and Guinea, the inhabitants of which are often sorely afflicted by it. Of a white color, and of a filiform shape, it has an orbicular mouth, and a slightly pointed tail, its usual length being from five to ten inches, and its thickness that of a small violin string. Its ordinary abode is the subcutaneous cellular tissue of the feet and legs, though it is also found in other parts of the body, as the face, neck, scrotum, hands and arms. It is commonly coiled up circularly, and is inclosed by a distinct cyst, which thus separates it from the surrounding parts. The ani- mal enters the skin when quite young, and gradually increases in size, excit- ing intolerable itching, inflammation, swelling and suppuration, often attended with fever, and sometimes followed by gangrene. The precise situation of the worm is generally indicated by a sort of boil, or a hard, ridge-like eleva- tion. When ulceration sets in, the head of the creature usually protrudes at the opening, thus confirming the diagnosis of the case. In the treatment of this affection, the proper plan is not to allow the patient to be tormented by the employment of inefficient remedies, but to cut down at once upon the part, and extract the intruder. It is worse than useless to waste time in the application of leeches, liniments, and embrocations, which, so long as the cause of irritation lies buried under the skin, can produce none but the most transient effect. If the tumor is already open, and the head of the animal is protruding, extrusion may be promoted by gentle tractions. vol. i___41 642 DISEASES OF THE MUSCLES AND THEIR APPENDAGES. CHAPTER II. DISEASES AND INJURIES OF THE MUSCLES, TENDONS, BURSES, AND APONEUROSES. SECT. I.—MUSCLES. The muscles are liable to wounds and lacerations, inflammation, atrophy, hypertrophy, and different kinds of transformations, especially the fatty form, which occasionally exists in a very high degree, and over a consider- able extent of the body. They are also subject to some of the carcinomatous formations, and to the development of hydatids and serous cysts. 1. Wounds.—When a muscle is divided by a sharp instrument, or acci- dentally ruptured, its fibres immediately retract so as to drag the edges of the wound more or less widely asunder. The extent to which this separa- tion may be carried varies, in general, according to the length and thickness of the muscle, from a few lines to as many inches. In transverse fractures of the patella, the action of the straight muscle of the thigh often draws the superior fragment from three and a half to four inches away from the inferior; and it is reasonable to conclude that fully as extensive a gap would be pro- duced between the ends of this muscle if it were cut in two, or torn asunder. In rupture of the straight muscle of the abdomen, the edges of the subcu- taneous wound have repeatedly been found to be separated from an inch and a half to two inches. In the operation for the cure of strabismus, the retrac- tion of the posterior extremity of the divided muscle is seldom less than from four to six lines, and often even considerably more. The above facts are highly interesting in a practical point of view, inasmuch as they point out the propriety of adopting prompt and energetic measures for effecting and maintaining apposition of the ends of the divided muscle; for observation has shown that the more accurate this is the more speedy and perfect will be the cure. If the edges are brought fully and intimately toge- ther, the union will necessarily require but a small quantity of plastic matter for its early and complete consolidation. If, on the other hand, the gap amounts to several inches, either no union will occur, or it will be effected through the intervention of a large quantity of cellulo-fibrous tissue, pos- sessing none of the properties of muscular fibre. Hence the affected struc- tures must always remain proportionably weak and disabled. But this is not the only inconvenience that follows such an accident; in wounds of the abdominal muscles, for example, the gap is sure to give rise to hernia, and it is easy to see that a deficiency of this kind elsewhere would hardly be pro- ductive of less serious effects. 2. Laceration.—Rupture of the muscles is often produced by very trifling causes, the raost common of which are leaping, or jumping across ditches or over fences, lifting heavy weights, or falls from a considerable height, in which the person makes a powerful effort to ward off injury. Cases are upon record of women having lacerated the abdominal muscles during parturition. In- juries of this kind are most likely to happen, other things being equal, when a muscle has undergone the fatty degeneration, which, by rendering its fibres MUSCLES. 643 soft and lacerable, acts as a powerful predisposing cause of rupture. Long continued inactivity of a muscle followed by sudden and violent contraction may be mentioned as another predisposing cause of the accident. The muscles which are most liable to rupture are the straight muscles of the abdomen, the psoas, deltoid, the two-headed flexor of the arm, the straight femoral, and gastrocnemius. The place where the rupture usually occurs is near the junction of the fleshy fibres with their tendons; but occasionally a muscle may give way at its middle, or, in fact, at almost any portion of its extent. In twenty-one cases of this affection analyzed by Sedillot, the rupture, in thirteen, took place at the insertion of the fleshy fibres into their tendons, while in the remainder the lesion was seated in the body of the muscle itself. The laceration is sometimes limited to a few fibres ; at other times it involves the entire thick- ness of a muscle, or of a muscle and its aponeurotic envelop. Finally, cases occur in which a number of muscles are ruptured. The symptoms attendant upon this lesion are not always well marked, especially when the affected muscle is deep seated. In general, it may be assumed that the accident has occurred, if, at the moment of some violent bodily exertion, as in leaping a ditch or fence, the individual has heard a distinct noise or snap, like the crack of a whip, feels severe pain in some particular spot, and either falls down, or has but an imperfect use of himself. Upon examining the suffering part, a vacuity will probably be noticed at one point, and an unusual prominence at another, followed by more or less dis- coloration and tenderness under manipulation. Occasionally the accident is attended with a rather copious hemorrhage, caused by the rupture of an artery of considerable size, as, for instance, the epigastric in laceration of the straight muscle of the abdomen. The pain which follows the injury is often very sharp, and rarely entirely disappears until after the primary effects of the lesion have measurably passed off. Temporary lameness and inability to move about for some time are, in general, the most serious consequences to be apprehended from this accident, provided it is properly managed immediately after its occurrence. In most cases, a considerable period must necessarily elapse before the reunion of the torn structures will be sufficiently firm to justify their accustomed use. Oc- casionally violent symptoms have supervened upon the accident; and an instance has been reported of a young man who died from rupture of the psoas muscle, death having been preceded by severe inflammation and infil- tration of pus. The treatment of this lesion cannot be the same in all cases, or under all circumstances. Whenever it is practicable, from the superficial situation of the affected muscle, its ends, whether they have been cut or ruptured, should be freely exposed, and then carefully approximated by a sufficient number of stitches to hold them in contact until firm union has been established. For this purpose the threads should be carried nearly through the entire thickness of the muscle, the object being thorough apposition both of the superficial and deep portions of the wound. In case the muscle has been ruptured, the edges of the wound may be so ragged as to require some retrenching before placing them in contact, just as in a lacerated wound of the integuments. If the precaution of stitching the parts be neglected, the results above adverted to will be inevitable, and it is, therefore, impossible to insist too strongly upon the importance of attention to this rule, wdiich is so much neglected by surgeons. The parts being properly approximated are next placed in an easy, ele- vated, and relaxed position, splints and bandages being employed for this purpose, if necessary; they are then treated upon general antiphlogistic prin- ciples. If the ruptured muscle be deep-seated, our chief reliance must be 644 DISEASES OF THE MUSCLES AND THEIR APPENDAGES. upon rest and relaxation, aided by soothing and astringent applications, along with suitable internal remedies, to moderate the resulting inflammation. In lacerations of the muscles of the extremities, important advantage may always be obtained from the use of two rollers, applied in opposite directions, as the ends of the wound may thus not only be more effectually approximated, but the contraction of the fleshy fibres more easily controlled, than in any other manner. 3. Inflammation.—Inflamraation of the muscles may present itself in two varieties of form, the acute and chronic ; both, however, are uncommon, and are chiefly observed as consequences of external injury, as blows, wounds, or contusions, such as we meet with in fractures and dislocations; or as effects of gout and rheumatism. The sheaths of the muscles very frequently, if not generally, participate in the morbid action. When the inflammation is at all severe, considerable effusion of serum and lymph may take place, but it is seldom that the disease runs into suppuration, much less mortification. The latter termination is chiefly met with in erysipelas and carbuncle, in old worn- out subjects, and in persons of different descriptions after violent external injury. It is easily recognized by the dark greenish color of the fleshy fibres, by their softness and lacerability, and by their excessively fetid odor. The parts are detached in ragged shreds, bathed in a thin, sanious, dirty, and offensive fluid. Acute inflammation of the muscles is characterized by excessive pain, of a sharp, darting character, or by dull, heavy, aching sensations, accompanied with a feeling of soreness, and aggravated by the slightest motion and pres- sure. In some cases, as when the disease supervenes upon fractures or the amputation of a limb, it is attended by a remarkable twitching or jerking, occasionally amounting to real spasm, which only yields to large doses of anodynes, and hot, soothing applications. Chronic myositis is not uncommon ; like the acute variety, to which it generally succeeds, it is more frequently met with, surgically considered, as a secondary than as a primary affection. When long continued, it is very prone to give rise to fatty degeneration, softening, ulceration, and other changes, which it is often impossible to cure. 4. Fatty Transformation—Fatty degeneration of the muscles is often, if not generally, a result of chronic inflammation, especially when conjoined for any considerable period with steady, persistent inactivity, or want of ex ercise. Whether inflammation, however, is always necessary to its forma- tion is still a mooted question, although it is highly probable that it is. When thus affected the fleshy fibres assume a pale yellowish, whitish, or slightly reddish color, at the same time that they are unctuous to the touch, and so much softened as to yield under the most trivial force. On pressure, a clear, oily fluid comes out, which greases the finger, is highly inflammable, and is composed of elain, adipocire, and ordinary fat, in variable propor- tions. These substances are not deposited, as some have conjectured, be- tween the fleshy fibres, but form actually a portion of their constituent principles; their proper tissue being found, when examined microscopically, to be tilled with granules, partly interposed between their striae, and partly replacing them. The fatty transformation is most common, as well as most marked, in the muscles of the loins, hip, thigh, and leg of old persons affected with para- lysis. It is likewise occasionally observed in the heart, and now and then in the muscles around unreduced luxations, large exostoses, and old, deep-seated ulcers. When the change is profound and extensive, it sometimes involves the corresponding tendons and aponeuroses, which, in consequence, lose their polished, satin-like lustre. So far as we know, this disease does not admit of cure. MUSCLES 645 5. Ulceration.—Ulceration of the muscles is an uncommon occurrence; it i i is chiefly noticed in phagedenic sores of the leg, extending successively I 1 through the integuments, cellular tissue, aponeuroses, and, finally, the mus- i i cles, which, however, generally resist its encroachments in a very remarkable i i degree. In some of these cases the fleshy fibres are in a complete state of fatty degeneration, of a whitish color, and so soft as to admit of being scraped away with the greatest facility. When the ulceration is slight, the restorative process usually proceeds kindly, and the breach is soon filled with healthy granulations. No special treatment is required in this disease, apart from the remedies ordinarily employed under such circumstances. 6. Contraction.—Another effect of inflamraation of the muscles, or of the muscles and their fibrous envelops, is contraction of their fleshy fibres, lead- ing to marked disorder of their functions, along, perhaps, with severe pain, and even to great deformity, as we so often see in wry neck, consequent upon inflammation of the sterno-cleido-mastoid and splenius muscles, and the mus- cles of the thigh from the effects of hip-joint disease. In many of these cases the disease is obviously of a gouty or rheumatic character, and, under these circumstances, it often occurs at a very early age, the immediate excit- ing cause being usually exposure to cold or cold and wet. In the treatment of myositis attended with contraction of the affected mus- cles, the first object should be to ascertain, if possible, the nature of the ex- citing cause; as to whether it is the result of rheumatism, gout, scrofula, or syphilis, or of external injury, as a sprain, twist, blow, wound, or contusion; for upon the knowledge thus derived must necessarily depend the character of our remedies, and the chance or otherwise of a cure. I have usually re- ceived marked benefit in these cases from the use of the wine of colchicum in combination with a full dose of morphine at bedtime ; aided by active pur- gatives and diaphoretics, especially the warm bath, a well-regulated diet, and the frequent application of Granville's lotion in union with laudanum and soap liniment, thoroughly rubbed upon the affected muscles. The muscular rigidity attendant upon a syphilitic state of the system is best treated with iodide of potassium, either alone, or conjoined with mercury. In the more subacute or chronic cases of muscular contraction, great bene- fit may be expected from the use of the hot and cold douche, employed twice a day, and followed, first, by dry friction, then by the application of stimu- lating liniments, and, finally, thorough shampooing. Frequent motion is also generally of great service; to break up adhesions, and to promote the ab- sorption of effused fluids, upon which the rigidity often mainly depends, as is observed in the shortened and rigid state of the limbs after severe fractures and dislocations. 1. Atrophy.—Atrophy of the muscles, of varying degrees, is occasionally observed; it may occur in any of the voluntary muscles, but is most common in those of the shoulder and hip, the deltoid suffering perhaps more fre- quently than any other individual member. It may depend upon different causes, but generally it is produced by inflammation, palsy, or defective cir- culation ; indeed, whatever has a tendency to impair the function of innerva- tion, retard or diminish the supply of blood, or induce permanent inactivity in a muscle, may be considered as so many causes of the affection. Hence it is found that the lesion is usually associated with paralysis, whether pro- ceeding indirectly from disease of the cerebro-spinal axis, or directly from injury of the nerves distributed to the suffering structures. The muscles around luxated joints, especially those of the hip and shoulder, are frequently i atrophied, either simply from the want of use, or, what is more probable, the conjoint influence of inflammation and inactivity. In coxalgia similar effects i generally occur, the wasting usually involving all the muscles of the lower 646 DISEASES OF THE MUSCLES AND THEIR APPENDAGES. extremity. The fact that gout and rheumatism are frequently productive of atrophy of the muscles is familiar to every practitioner. The extent to which the wasting of the muscles may proceed is variable. When it exists in a high degree, they may be reduced to mere membranous bands, pale, flaccid, and almost devoid of irritability; in some rare instances their fleshy fibres are completely absorbed, a dense cellular substance being all that is left in their place; or, instead of this, they are found to be soft- ened and transformed into fatty matter. In the treatment of atrophy of the muscles the first object should be to ascertain, if possible, the nature of the exciting cause, by removing which the lesion sometimes rapidly disappears of its own accord, or, at all events, under very simple management. Atrophy dependent upon imperfect supply of blood is often irremediable, and the same is frequently the case when it is caused by gout and rheumatism, or when it is conjoined with the fatty de- generation. The treatment of atrophy dependent upon loss of innervation, constituting what is called wasting palsy, will receive special attention in the chapter on the diseases and injuries of the nerves, where its consideration properly belongs. Whatever the cause of atrophy of the muscles may be, much may be done, after that cause has been removed, towards effecting restoration by the steady and persistent use of the hot and cold douche, stimulating embrocations, dry frictions, and regular, systematic exercise of the affected structures, educating them, so to speak, and thus gradually qualifying them for the resumption of their appropriate functions. 8. Tumors.—Various morbid growths occur in and among the muscles, the principal of which are the hydatic, cystic, melanotic, and encephaloid. a. It is uncommon to meet with hydatids in the muscles; I have myself seen but one case of it. It occurred in 1853, at the surgical clinic of the University of Louisville, in a laboring man, aged twenty-five years, who accidentally discovered a swelling in the substance of the right deltoid muscle six months previously, when it was hardly as large as a hazelnut. At the time of my examination, it was of the volume of an almond with its shell, of a rounded, elongated shape, somewhat movable, and of a firm, fibrous con- sistence, with a slight degree of elasticity. Within the last few weeks the turaor had become somewhat painful, especially after exercise, and the pres- sure made in examining it was productive of considerable uneasiness. The skin over it was perfectly healthy. The patient was not aware of anything that could have produced the disease. The diagnosis of the tumor could not, of course, be determined beforehand; what it resembled most, especially in point of consistence, was an enlarged lymphatic ganglion, but the rarity of such a disease in this situation invali- dated this conclusion, and left me in complete doubt as to the true nature of the case. It was too deep-seated for a sebaceous tumor, and it possessed none of the external characters of a fibrous, fibro-plastic, or fatty one. In performing excision, the knife was carried perpendicularly down over the tumor, in doing which, the point penetrated its interior, an occurrence which was instantly followed by the escape of a small quantity of thin pus, inducing me to think that the tumor, after all, was merely a dis- Fig. 193. eased lymphatic ganglion. On continuing the dissection, how- ever, I soon found that there was a distinct cyst, which, being collapsed, was separated with some difficulty from the fibres of the deltoid muscle, in which it was imbedded. The dissection being completed, a small body, fig. 193, was picked up on the Hydatid. floor, which, on inspection, proved to be a globular hydatid, not more than six lines in diameter, and furnished with a distinct sucker. The cyst was very soft and thin, smooth internally, and filamentous externally. TENDONS. 641 b. Tumors of a cystic character are sometimes met with in and among the muscles. In a case of this kind, which I had an opportunity of seeing in 1856, with Dr. Da Costa, the growth, occupying the upper and outer portion of the thigh, had acquired nearly the volume of an adult head. The patient was a female, aged fifty-eight, and the disease had apparently resulted from a fall down a flight of stairs, in which she struck the limb severely, causing deep ecchymosis and great difficulty in walking. At the end of two months a swelling formed in the situation adverted to, which, gradually increasing, in the course of ten months acquired the size above mentioned, being at the same time the seat of severe darting pains, with considerable discoloration of the integuments. The tumor fluctuated indistinctly, but a puncture with the exploring needle gave vent merely to a few drops of fatty fluid. When re- moved by Dr. Briuton, it was found to be composed of a very thick, dense, fibrous cyst, filled with a sero-oleaginous fluid. The patient gradually re- covered from the effects of the operation, but has been troubled ever since with pain in the limb and difficulty iu walking. c. Melanosis sometimes occurs in the muscles, either as an infiltration, or as a distinct tumor, with or without a cyst, of an irregularly spherical shape, firm in consistence, and from the volume of a pea up to that of a foetal head. The morbid product, which generally coexists with similar formations in other parts of the body, is occasionally directly chargeable to external injury ; but generally it takes place without any assignable cause. d. Encephaloid, scirrhus, and colloid of the muscles are very uncommon, so much so, that few practitioners ever meet with them. They obey the same law here as when they occur in other parts of the body. In the interesting case of colloid described by Professor J. C. Warren, an immense number of tumors of this kind, varying in size from a pea to that of a small granule, hardly visible without the aid of a microscope, existed in the voluntary muscles, in different regions, especially in those of the thigh and leg. The probability is that none of these heteroclite formations are developed in the muscular substance, properly so-called, but that they begin in the inter- fibrillar tissue, from which, as they increase in size, they gradually encroach upon the fleshy fibres, which they thus displace, alter, or destroy. SECT. II.—TENDONS. The tendons, like the muscles, are liable to wounds and lacerations, but, unlike them, they never suffer from malignant formations, excepting seconda- rily, and then only very rarely. Inflammation of these structures is also very infrequent. 1. Wounds___Tendons, when divided subcutaneously, readily unite through the intervention of plastic matter, without the occurrence of any considerable degree of inflammation. Indeed, the idea is very common at the present day that such wounds are always repaired without inflammation, it being alleged that this process, instead of being necessary for this purpose, is a positive detriment. I cannot subscribe to such a doctrine. If its advocates mean that the inflammation is very slight, or not characterized by the ordinary phenomena, I perfectly agree with them ; but if they wish to be understood as affirming that inflammation is entirely absent throughout, from the begin- ning to the close of the case, it is what I cannot believe, and what is certainly not true. When a tendon, such, for example, as that of the heel, is cut across sub- cutaneously, the first thing that is noticed is the retraction of the divided ends, so as to leave a distinct gap between them, often amounting to from an inch and a half to two inches, according to the size of the cord and its 648 DISEASES OF THE MUSCLES AND THEIR APPENDAGES. previous tension, or the degree of force employed in stretching the parts with which it is connected. Inflamraation, generally of a very slight form, next takes place, and, soon after this is set up, plastic matter is poured out, filling up the space between the two extremities of the tendon, which, at the same time, it serves to connect together. As the abnormal action subsides, nucleated cells form in the interior of the effused matter, and the process of organization thus begun steadily advancing, the new substance is gradually converted into cellulo-fibrous tissue, and this, in its turn, at length into tendi- nous, which, however, although well calculated to fulfil the purpose for which it is intended, is, like all new tissues, a very imperfect type of the original. The reproductive process generally advances very rapidly, so much so that the person soon acquires an excellent use of the affected parts. It is upon a knowledge of this property in tendon, when subcutaneously divided, to speedy reunion, that is founded the operation of tenotomy, one of the greatest improvements in modern surgery. When a tendon is divided in an open wound, the two ends rarely reunite at all, owing mainly to two circumstances; the first is, that the ends retract too far to enable us to bring them properly together, and the second, that the wound nearly always suppurates; an occurrence eminently inimical to adhesive action. All the earlier operations of tenotomy that were performed according to this principle, failed in consequence of the violence of the re- sulting inflammation. The treatment of a divided tendon, then, with an open wound, is very different from that where the wound is subcutaneous. In the latter, the application of a bit of adhesive plaster to the puncture to exclude the entrance of the air, and a little attention to rest and position, make up the whole sum of the surgeon's duty. In the former, on the contrary, the cut ends must be carefully approximated by the silver suture, the rest of the wound being firmly closed; or the limb with which the tendon is connected must be placed in the most thoroughly relaxed position possible, in order to approximate its extremities, and thus afford them an opportunity of reuniting, an occurrence, however, which, I am sure, will rarely take place under any circumstances, however propitious. The experiments of Dr. Levert, of Mobile, performed many years ago, prove that union between the divided ends of a tendon will be much more likely to proceed kindly and satisfactorily, when the parts are held in contact by a metallic suture than by an ordinary one. My opinion is that practitioners have not profited enough by the results of these researches. The recent introduction of silver wire, by Dr. Sims, into our surgical arma- mentarium, will; no doubt, tend to re-excite attention to them. The surgeon is sometimes consulted on account of an ununited tendon, with an intervening gap, perhaps, long after the external wound has healed. Under such circumstances, it has been proposed to puncture the retracted extremities subcutaneously, and it has been alleged that such a procedure is not only safe, but generally quite successful. Safe it undoubtedly is, but, as to its being successful, that is an utter impossibility, unless, what seldom happens, the two ends remain in close proximity with each other. The proper remedy is to expose the parts by a free incision, and, having pared - the retracted extremities, to uuite them with silver wire. 2. Rupture.—Tendons are soraetimes torn away from their sheaths along with the fleshy fibres into which they are inserted, hanging, perhaps, merely by one extremity; when this is the case, it would be useless to replace them, even if this were practicable, as there would be no likelihood whatever of reunion ; on the contrary, severe inflammation and sloughing would be inevitable. When a tendon is ruptured subcutaneously, a loud snap, like the crack of a whip, is generally heard at the moment of the accident, especially if the TENDONS. 649 cord be a large one; the part is instantly deprived of its functions, and a well-marked gap, interval, or hollow is perceptible at the site of the injury. More or less inflammation follows, and a long time usually elapses before the patient regains the use of the affected limb. The tendon which is most liable to suffer in this way is that of the heel, its rupture being generally caused by violent muscular exertion, either for some special effect, as in the case of persons on the stage, or for the purpose of saving the body from a fall, as when the individual makes a false step. The treatment of a subcutaneously ruptured tendon must be conducted by rest and complete relaxation of the affected structures, so as to enable us to bring the divided ends as closely together as possible. To effect this to the best advantage, special apparatus is generally required, as well as the greatest attention and vigilance on the part of the practitioner. The time necessary for obtaining satisfactory union varies, on an average, from six to eight weeks. 3. Dislocations.—The tendons are sometimes dislocated, or thrown out of the grooves in which they are naturally situated, in consequence of the lace- ration of the connecting ligaments, or retaining bands. The accident, which is most apt to befall the tendon of the two-headed flexor of the arm, as it runs along the bicipital groove of the humerus, is generally attended with severe pain at the site of the injury, inability to move the affected limb, and more or less discoloration of the integuments. Considerable swelling often follows, and, if the accident is overlooked, permanent lameness may result. Replacement should be effected as speedily as possible, and it is gratifying to know that this is usually quite easy, provided the true nature of the case is recognized soon after its occurrence. 4. Hypertrophy.—Finally, the tendons are occasionally the subjects of hypertrophy, exhibiting an irregular, knotty appearance, which is not only unseemly but sadly productive of discomfort. The affection is most common in gouty, rheumatic, and syphilitic persons, and is usually very readily detected hoth by touch and sight. The proper remedies are removal of the exciting cause, the exhibition of iodide of potassium, either alone or in union with mercury, and sorbefacient applications. 5. thecitis.—Inflammation of the sheaths of the tendons, technically called thecitis, may originate as an independent affection, or, as not unfrequently happens, it may begin consentaneously with inflammation of the parts which it surrounds and lubricates. In either event, the disease is often of a much more serious character than is generally imagined, nothing short, perhaps, of permanent lameness and deformity being the result. Various causes may give rise to thecitis; thus it is occasionally induced by gout, rheumatism, syphilis, and exposure to cold. On the other hand, it often supervenes upon external injury, as a sprain, blow, puncture, or contusion. In the hand and fingers it is frequently met with as a consequence of dislocation of the wrist- joint, or fracture of the lower extremity of the radius and ulna. In regard to its character, it may be acute or chronic ; more generally perhaps the latter than the former. Once fairly established, it is commonly removed with much difficulty, and is liable, as just stated, to be followed by the most disastrous consequences. The most common sites of thecitis are the sheaths of the tendons of the fingers, the wrist, elbow, feet, ankles, and knees; the disease may occur by itself, or in union with inflammation of the burses and the lining membrane of the neighboring joints. In thecitis of the hands and fingers it is seldom that the disease exists except in this association, especially when it has been caused by a sprain, dislocation, or fracture of the radio-carpal articulation. Under such circumstances, as I have had frequent occasion to notice, the in- flammation is extremely apt to extend to the sheaths of all the tendons, as 650 DISEASES OF THE MUSCLES AND THEIR APPENDAGES. well as the joints of the fingers, rendering them stiff, tumid, and exquisitely painful. If the case be neglected, misunderstood, or improperly treated, the whole hand becomes rigid, and the fingers wasted and attenuated, presenting more the appearance of the claws of some of the inferior animals than the organs which represent those parts in the human subject. The pain accom- panying this form of thecitis often reaches as high up as the axilla, and I have known it to be so distressing at night as to deprive the patient completely of sleep for days together. Thecitis, although apparently a trivial disease, assumes a most important character when it invades a number of thecae simultaneously, or successively, and the gravity of the case is greatly augmented if there is at the same time considerable involvement of the neighboring joints, as when the attack takes place in the hands and fingers. Hence no time should be lost, and no pains spared, to get rid of the inflammation before it has produced any serious structural changes, particularly firm and extensive adhesions of the thecae to their tendons. Leeches and tincture of iodine, either alone or in union with saturnine and anodyne fomentations, are the chief topical remedies upon which reliance is to be placed, while the patient is freely purged and restricted in his diet. Venesection and antimony will be necessary if the case prove ob- stinate. If the disease is found to be associated with a gouty or rheumatic state of the system, wine of colchicum will be of service. In thecitis de- pendent upon a syphilitic state of the constitution, recourse must be had to iodide of potassium. If the parts have become stiff in consequence of firm adhesions, the hot and cold douche, followed in immediate succession, along with frictions with sorbefacient liniments, embrocations, or unguents, steady, systematic passive motion twice a day, and the application of the bandage to support the affected structures, will gradually, though in general not under several months, effect restoration. In obstinate cases a mild mercurial course may become neces- sary, on the same principle that such a plan is occasionally adopted in inflam- mation of other tissues attended with plastic effusions and morbid adhesions. When the disease is located in the hand, I have generally found it expedient to bandage each finger separately, and to support the member upon a carved splint. In short, in many of these cases nothing but the most zealous and determined perseverance will enable us to effect a cure. 6. Ganglion.—A ganglion is a small circumscribed cyst, situated along the course of a tendon, to which it is intimately united. Composed of a single layer, which rarely exceeds the thick- ness of the dura mater, it is filled with a thin, yellowish fluid, more or less ropy in its cha- racter, and bearing a very strong resemblance, in its general features, to olive oil, the white of an egg, or a solution of gum Arabic. In cases of long standing, the contents of the sac are sometimes nearly entirely solid, con- sisting of a thick ropy substance, of a dark color, not unlike currant-jelly; of masses, apparently, of semi-organized lymph; or of small bodies, similar, in shape and size, to cucumber seed. In a ganglion of the hand upon which I operated two years ago, I ob- served the singular looking bodies sketched in the accompanying cut, fig. 194. They appeared to be in different stages of development, and were evidently merely so many masses of lymph, which had been originally attached to the inner surface of the sac, but had become Fig. 194. Fibroid bodies of a ganglion. r SYNOVIAL BURSES. 651 separated in consequence of the continual friction of the tendon to which the sac was connected. The volume of the cyst varies from that of a pea to that of a pigeon's e<*g • it is of a globular or ovoidal shape, somewhat elastic, perfectly movable, free from pain, and unaccompanied by any discoloration of the skin. A sense of stiffness and of uneasiness, felt chiefly along the course of the tendon on which it is situated, sometimes attends its formation, and induces the patient to apply for advice. I have never known a ganglion to suppurate. The tumor is most common in the female, and is met with chiefly along the extensor tendons on the back of the hand, wrist, and lower extremity of the forearm. I recollect seeing, some years ago, a case where it was situated over the radial artery, the pulsations of which were so thoroughly imparted to it as to induce the belief, on the part of several physicians who examined it, that it was an aneurism of that vessel. In 1854, I operated before the medical class of the University of Louisville, upon a young woman who had two tumors of this kind, each of the size of a small bird's egg, upon the dor- sal surface of the foot. How this cyst is formed is still a mooted point. From what I have seen of it, I am inclined to regard it merely as a sacculated expansion of the sheath of the tendons, and not, as some pathologists do, as a new formation. From the fact that it is most common in hard working people, it, doubtless, owes its origin to inflammation, although it is seldom directly chargeable to external violence. The affection soraetimes appears at an early age. Not long ago I met with a case in a little girl only eight years old. The most simple and certain method of treatment consists in rupturing the ganglion, and scattering its contents into the surrounding cellular substance, where they are in general speedily absorbed. I usually perform the operation with the thumb, but, if the cyst is old and very firm, it will be necessary to strike it with a book, or to pierce it previously by a subcutaneous puncture. Evacuation having been effected, a compress inclosing a piece of coin is tied upon the part, to promote the adhesion and obliteration of its cavity, the limb being maintained at rest until the resulting inflammation has subsided. When the ganglion is quite young, a cure may sometimes be procured by the application of iodine and systematic compression ; but ordinarily such means are quite futile. Iodine is sometimes employed as an injection, in the same manner as in hydrocele; experience, however, offers nothing in favor of the treatment. When the ordinary means fail, the sac should be cut up as minutely as possible with a delicate bistoury, inserted subcutaneously, the operation being followed up by compression. Both excision and direct in- cision must be avoided, as likely to endanger the functions of the part. SECT. III.—SYNOVIAL BURSES. The synovial burses, bursae mucosae, or mucous pouches, exist in consider- able numbers in various regions of the body, especially about the joints of the extremities, being small, semi-transparent sacs, occupied by a thin, unc- tuous fluid. They are for the most part interposed between bone and tendon, tendon and tendon, bone and skin, or tendon and skin, their object being to facilitate motion and ward off pressure. Hence, they are always most con- spicuous in those situations which are habitually subjected to friction; and for the same reason they are occasionally developed to meet special contin- gencies arising from accidental causes, as the pressure of a shoe, crutch, or artificial leg. In club-foot synovial pouches are constantly found upon those parts of the foot which, being partially displaced, are compelled to sustain 652 DISEASES OF THE MUSCLES AND THEIR APPENDAGES. the weight of the body. Altogether there are about one hundred and fifty of these sacs in the natural state. The largest and raost important synovial pouches, surgically considered, are situated on the acromion process of the scapula, the space between the hyoid bone and thyroid cartilage, the condyles of the humerus, the olecranon process, the styloid projections of the ulna and radius, the tuberosity of the ischium, the great trochanter, the anterior superior spine of the ilium, the front of the patella, the condyles of the femur, the tuberosity of the tibia, the ankle, the calcaneum, and the heads of the first and fifth metatarsal bones, at their palmar aspect. The principal diseases of the burses are inflammation, suppuration, indura- tion and thickening, dropsical accumulations, and the development of fibro- cartilaginous concretions in their interior. It does not seem probable that they are ever the seat of any of the heteroclite formations; at all events, I have never met with any examples of them. Inflammation of these sacs may occur either in an acute or a chronic form, the latter being, however, by far the more frequent. The usual cause is in- ordinate and long-continued friction conjoined with pressure. The disease may also be produced by blows, contusions, wounds, and punctures, and, in persons predisposed to gout, rheumatism, scrofula, and syphilis, by exposure to cold, or the sudden repulsion of the cutaneous perspiration. The house- maid's knee, and the collier's elbow, are examples of inflamed and enlarged burses produced under the influence of concentrated and protracted pressure; another instance, not less striking, is afforded by the bunion which so fre- quently forms over the inner surface of the metatarso-phalangeal articulation of the big toe. 1. Acute inflammation of the burses is generally productive of very severe suffering; the pain is tensive, throbbing, persistent, and greatly aggravated by motion, pressure, and dependency; the swelling, which is often consider- able, is usually due partly to exterior deposits, partly to an accumulation of synovial fluid, the quantity of which is commonly very much increased; the skin is of a dusky reddish color, and deeply congested; and the functions of the affected structures are greatly impaired, if not completely arrested. Not unfrequently the swelling is of an cedematous or erysipelatous character, pit- ting readily under pressure, and being the seat of a dull, heavy, prickling sensation. In the more severe forms of acute bursitis, there is usually con- siderable constitutional involvement, the patient being feverish, thirsty, rest- less, and troubled with headache, loss of appetite, and other disagreeable symptoms. Upon cutting into the affected sac, its inner surface is found to be deeply congested, and roughened with lymph, while its cavity is filled with a bloody, serous, or sero-oleaginous fluid, often in considerable quantity, especially if the disease has been of some standing. Bursitis occasionally passes into suppuration, the symptoms, when this is about to occur, suddenly assuming a more severe form, just as when matter is about to be deposited in any other part of the body. The pus, which is usually of a thin, oleaginous character, intermixed with flakes of lymph, may find its way to the surface by ulcerative action, or it may discharge itself into a neighboring joint, although such an event is extremely rare, and is not likely to occur unless the joint has freely participated in the inflammation. The treatment of this disease must be actively antiphlogistic ; the part and system are kept perfectly at rest; leeches are applied to the affected surface, followed by anodyne and saturnine fomentations; the bowels, diet, and secre- tions are duly attended to; and the pain, which is generally severe, is con- trolled by morphine, or morphine, antimony, and aconite. If matter form, as denoted by an increase of pain and other symptoms, a free and early incision is SYNOVIAL BURSES. 653 made, the edges of the opening being kept asunder by a small tent to prevent reaccumulation. The milder forms of bursitis are generally easily combated by rest, cooling laxatives, and the application of the tincture of iodine, or, what is frequently preferable, a blister, large enough to extend over the affected surface, and retained sufficiently long to produce thorough vesication. 2. Chronic inflammation of the burses occasionally gives rise to remark- able structural changes, the most common of which is an indurated and hyper- trophied condition, the result either of long-continued interstitial deposits, or of the formation of adventitious membranes. However this may be, the walls of the affected sac are sometimes found to be upwards of a quarter of an inch in thickness, and of a dense fibro-cellular consistence, without the slightest trace of its primitive characters. Under these circumstances, the cavity of the pouch is generally very small, filled with altered synovial fluid, and roughened upon its surface, so as to exhibit an appearance not unlike that of a honeycomb. Now and then shreds of lymph are stretched across its in- terior, dividing it into different compartments. In cases of very long stand- ing, partial ossification of the cyst has been noticed, but such an occurrence is extremely uncommon. These chronic enlargements of the burses are often very obstinate and troublesome, resisting not unfrequently the best directed efforts of the surgeon for their removal. The remedies upon which our chief reliance is to be placed are sorbefacient applications, as iodine and hydrochlorate of ammonia, blis- ters, mercurial inunctions, and systematic compression. Wrhen, these means failing, the tumor is productive of pain and other inconvenience, our only resource is thorough excision, care being taken, especially if a large joint be close by, not to cut too widely away from the morbid mass, lest the synovial membrane of the articulation be inadvertently pierced, or so much injured as to excite violent inflammation. 3. Another result of chronic inflammation of these bodies is an accumula- tion of their natural secretions, giving rise to what is called dropsy, of which one of the best examples is afforded in the so-termed housemaid's knee. The fluid, which varies in quantity from a few drachms to six or eight ounces, ac- cording to the size and situation of the affected burse, and the duration of the disease, is generally of a pale straw color, of a slightly unctuous consist- ence, and of a notably saline taste; now and then it is reddish, or brownish, and remarkably thick and viscid. It is readily coagulable by heat, alcohol, and acids, showing that it is essentially composed of albumen. The presence of the fluid is easily detected by the elastic and fluctuating character of the swelling, and very frequently a distinct friction sound and sensation can be perceived upon handling the tumor; if necessary, an exploring needle is used. The integuments are free from discoloration, there is no enlargement of the subcutaneous veins, and the principal inconvenience experienced by the patient is of a mechanical nature. Now and then there is a good deal oi pain, but more generally simply a sense of soreness and stiffness. The size and shape of the tumor formed by these dropsical collections are subject to great diversity; in general, it does not exceed the volume of an orange, or a goose's egg, but there are cases in which it reaches the bulk of a foetal head, although this is very uncommon. Its shape is generally ir- regularly rounded or ovoidal, with a compressed, flattened appearance. Dropsy of the synovial pouches may often be relieved, in its earlier stages, by the diligent application of iodine, astringent and sorbefacient lotions, and, above all, by blisters; conjoined with rest, attention to the bowels, and the use of the bandage. In cases of long standing, however, such treatment is seldom of any permanent advantage, nothing short of a complete and ra the coagulum projecllng and cylindrical, except its cardiac extremity, from the orifice of the sheath. 692 DISEASES AND INJURIES OF THE ARTERIES. which is nearly always conical, as in fig. 202. The longer the internal co- agulum is the less danger is there generally of its premature detachment. The changes above mentioned as occurring in the two clots are generally the work of time; the gluing process is usually effected rapidly, since its in- tention is to protect the patient against hemorrhage ; but the removal of the serum and coloring matter of the blood, and the conversion of this fluid into solid matter, take place more slowly, and are often not completed under several months. Finally, if the parts be examined at a still later period, it will be found that both clots have entirely disappeared, and Fig. 203. that the injured vessel, as high up as the first large collateral branch, has been transformed into a dense, strong, fibrous cord, fig. 203, similar to that observed in the umbilical arteries of the infant. Such, then, is the process which nature employs for the purpose of arresting the flow of blood from a divided artery. Taking advantage of the exhausted condition of the system consequent upon the injury and loss of blood, she instinct- ively forms the two clots, having, first of all, drawn away the vessel from the main wound, as well as caused it to diminish its caliber, and then she goes deliberately to work to fasten these clots just precisely where they are most needed for the purpose. The vessel being thus hermeti- cally sealed, she afterwards busies herself still further in getting rid of these plugs, seeing that they are no longer required, and, finally, completes the labor by converting the now obsolete extremity of the artery into an analogous change in the shape tissue. These changes, which are both profoundly curious and structure of an and interesting, bear, it will be perceived, a very close re- artery after ligation, semblance to those which take place in the callus of a broken bone. After the ligation of an artery, the supply of blood in the parts beyond the seat of the obstruction is maintained by what is called the collateral circulation, the vessel above communicating freely with that below, as in fig. 204, by its anastomosing branches. Fig. 204. Diagram of collateral circulation. When an artery is divided only partially, whether transversely, obliquely, or longitudinally, an external clot forms, but this is generally so imperfect as to render it altogether incompetent to offer anything like an effectual barrier to the flow of blood. What adds to the difficulty of the case is that the edges of the wound have a constant disposition to gape; and hence, although plastic matter may perhaps be deposited in great abundance, yet it is impos- sible for the parts to contract permanent and satisfactory adhesions to each WOUNDS AND HEMORRHAGE. 693 other. Whenever the circulation is conducted with any degree of vigor, the blood as it sweeps along washes off the clot, and appears upon the exterior of the wound; and thus the hemorrhage usually continues, paroxysm after paroxysm recurring in more or less rapid succession, until it proves fatal. Although such is the course which the case usually pursues when an artery is divided only in a part of its diameter, yet it must not be thence inferred that a very small lesion of this kind may not occasionally be susceptible of spontaneous cure. Such an event, which must, however, at best, be extremely rare, may be supposed to be most likely to occur when the wound is oblique or longitudinal; when the opening in the overlying parts is a mere fissure or canal, offering an imperfect outlet to the contents of the vessel; when the system remains for a long time in a prostrate condition ; and when, finally, there is a rapid and abundant deposit of plastic matter in the various struc- tures involved in the injury. I have several times seen small shot wounds of the larger arteries, as the subclavian and femoral, healed in this manner; and there is reason to believe that punctures made accidentally in the brachial, in bleeding at the bend of the arm, are occasionally repaired either by the direct adhesion of their edges, or through the intervention of an external clot. In general, however, all such injuries are followed either by hemorrhage, or aneurism, according to the opportunity, or otherwise, which the blood may have to find its way to the surface. It is well known that contused and lacerated wounds of the arteries bleed much less freely than incised. The reason of this has already been explained in the chapter on wounds, and need not, therefore, be reproduced here. But, although nature may, and, indeed, sometimes does, arrest the hemor- rhage from a divided artery, yet no sensible surgeon would intrust her with such an office, when it is in his power to get at the seat of the wound; for it is hardly possible to conceive of a case involving one of the larger trunks where her efforts would be likely to be successful, or where, if ultimately triumphant, the patient would not be brought repeatedly to death's door before she could attain her end. It is only in wounds of the internal arteries, as those of the chest and abdomen, and in the aorta and its larger branches, that we must refrain from direct interference, and limit ourselves to the use of general means calculated to keep down vascular action, especially the liberal use of anodynes and sedatives, as opium, aconite, and acetate of lead, the application of ice over the seat of the injury, exposure of the body to cold air, and perfect quietude, both of mind and body. All active exertion must for a long time be avoided, in order that, if a cure should take place, the wound may not be suddenly reopened by the giving way of its edges, in consequence of the imperfect organization of the clots and plasma. The means employed by art for suppressing hemorrhage are quite nume- rous, as well as quite diversified in their nature, and will therefore require to be considered somewhat in detail. The most important of these means are : first, the ligature; secondly, compression; thirdly, styptics; and fourthly, torsion. Besides these there are several others of a subordinate character, and upon which, consequently, we shall bestow merely a passing notice. 1. Ligature.—Ligatures are composed of various materials, as silk, linen, and soft leather. Of these, the first is the most unexceptionable, and almost the only one now employed by experienced surgeons. It should be round, smooth, well twisted, colorless, and so strong as not to break without con- siderable effort. For the smaller arteries, as the radial, tibial, and temporal, common sewing silk is well adapted ; but for the larger trunks, as the femoral, iliac, and carotid, stay silk, which is a much stouter article, is required. Some practitioners are in the habit of using what is called dentist's silk, no matter what may be the size of the vessel, on the ground that it is much stronger in proportion to its thickness than any other similar substance, and, therefore, 694 DISEASES AND INJURIES OF THE ARTERIES. less liable to excite undue irritation. This thread, which is employed in making fishing lines, is rendered very hard and stiff by means of gum, which, however, is easily removed by boiling it for a few minutes in a slightly alka- line solution. Treated in this way, a piece long enough to tie the iliac artery will hardly weigh the twenty-fifth of a grain. I have not had occasion to use this form of silk, having always had reason to be satisfied with the com- mon article. Linen thread makes an excellent ligature; and in case of emerg- ency, a sensible surgeon will not hesitate to take anything that may happen to come in his way. Whatever substance be employed, it is very important that it should be thoroughly waxed, otherwise it will be difficult, if not im- practicable, to draw and tie it with the requisite degree of firmness, to say nothing of the greater tendency of the knot to slip. From eight to ten inches is a good average length for a ligature. Animal ligatures were first introduced to the notice of the profession by Dr. Physick, early in the present century, and they have ever since been occasionally employed by different practitioners, chiefly American. The late Dr. Jameson, of Baltimore, used them nearly altogether for many years, under the belief, founded upon numerous experiments and clinical observations, that they were decidedly superior to all others, their presence never causing any of the irritation which sometimes follows the use of the ordinary sub- stances. The article to which he gave the preference was soft buckskin leather, which he cut into thin, narrow strings, care being taken not to tie them too firmly, lest they should break, and be prematurely detached. Other practi- tioners have recommended the fibres of the sinew of the deer. The advan- tage of the animal ligature is that, besides approaching more nearly to the living tissues than any other material, the ends may be cut off close to the knot; its disadvantage, that it soon becomes disintegrated, from the imbibi- tion of the fluids, thereby rendering it liable to separation before it has ac- complished the object for which it was applied. This reason is, I conceive, quite sufficient to induce its rejection from practice; for no conscientious surgeon, it seems to me, would ever subject his patient to such a contingency, especially when he has always at hand so reliable a substance as silk. The wounded artery may be very conveniently drawn out with a pair of spring forceps, seen in fig. 205, an instrument which, indeed, I generally Fig. 205. The spring artery-forceps. prefer, or with a tenaculum, represented in fig. 206. If the vessel be small, it should be seized in its longitudinal axis, but in the horizontal if it be large, Fig. 206. Tenaculum. since in this way we can more effectually occlude its orifice, and thus prevent the loss of blood. It is for this reason, also, that the forceps are generally to be preferred to the tenaculum; the latter instrument, however, possesses WOUNDS AND HEMORRHAGE. 695 an advantage over the former when the artery is cut off very closely, or when it is desired to include some of the surrounding tissues. Care must be taken not to transfix the coats of the vessel, and then tie the ligature below the Sliding-forceps. point of perforation, as this might lead to secondary hemorrhage. When no good assistant is at hand, the artery forceps, represented in fig. 207, an Fig. 208. Fig. 209. Mode of drawing out and isolating an artery. instrument with broad, serrated extremities, and a movable slide or catch, to close the blades, will be found convenient. The vessel being pulled gently out, as in fig. 208, is carefully isolated from its connec- tions, either with another pair of forceps, the finger, or the knife, or all three together, as may be most expedient. The propriety of excluding from the ligature the smallest nervous filament, as well as the most insignificant vein, and every particle of muscular tissue, must be obvious to the merest tyro, and need not therefore be expatiated upon here. Such a procedure would not only be produc- tive of pain, but would be liable to be followed by sup- purative action, and perhaps materially impede the sepa- ration of the thread. The ligature is placed immediately above the point of the instrument, whether this be the forceps or tenaculum, and being tied in a single knot, is drawn with sufficient firmness to divide the inner and middle tunics, as in fig. 209, if the artery be one of large size, or even of medium caliber; while in the smaller branches, mere apposition of the opposite surfaces will suffice. In executing this part of the operation, the ex- tremities of the ligature are to be drawn round the fore and middle fingers of each hand, while the thumb is ex- 4. , •, ,, , „ ., . . . Effects of ligation upon tended upon them nearly as far over as the vessel, in order the inner coats of the that the force may be exerted in as gentle and equable a artery. 696 DISEASES AND INJURIES OF THE ARTERIES. manner as possible. Nothing is more unseemly, or more truly abominable, than to see a surgeon or his assistant pull a ligature by fits and Jerks, or so violently as to break it in pieces, or, perhaps, lacerate and tear off the artery itself. With a little care and gentleness, a comparatively weak ligature may be thrown round a vessel so as to answer the intention most fully. I deem it my duty to dwell upon this point with some degree of emphasis, because it has happened to me to witness quite an unusual number of Fig. 210. these Herculean feats with the ligature, the men often pulling as if they had hold of a rope and piece of wood, instead of a delicate thread and artery. Fig. 210 shows the indented ap- pearance of the artery after ligation. The ligation is completed by making a double knot, when one end is cut off close, and the other is afterwards brought out at the nearest angle of the wound. The knot which is thus made is the reef-knot, fig. 211, in which the ends of the Fig. 211. Fig. 212. Reef-knot. Surgeon's knot. Exterior of an thread lie across the artery, in the same manner as in the artery after nga- lips of the wound in the ordinary interrupted suture. The non. surgeon's knot, fig. 212, is no longer used for the purpose, as, from the manner of making it, it is very irregular, and, consequently, ill adapted to the object. In tying very small vessels, we sometiraes use only one knot. The practice of cutting off both ends of the ligature, and of closing the wound over the injured vessel, first suggested towards the latter part of the last century, by Mr. Haire, of England, and afterwards so warmly lauded by Mr. Lawrence and Mr. Hennen, is now, I believe, universally abandoned, and very justly so, on the ground that the noose, after having performed its duty, creates irritation among the parts with which it lies in contact, leading thus to the development of abscesses, which continue to discharge as long as the foreign substance remains. When the animal ligature is used, this objec- tion does not obtain, as the noose is soon removed by absorption ; but then, as was previously observed, this material ought not to be employed, because of its liability to give way before the vessel is completely occluded. When the arteries are diseased, or abnormally brittle, in consequence of the fibrous, cartilaginous, earthy, or fatty degeneration of their tunics, the ordinary ligature must be dispensed with, and a flat one used in its stead. It raay consist of two or more silk threads, carefully waxed, and arranged side by side, or of a piece of soft, narrow braid, and should be drawn so gently around the artery as merely to approximate its serous surfaces. In using the round ligature the object is to divide the inner and middle tunics, as this is most favorable to adhesion ; but in this case we aim to preserve their integrity, well knowing that if this be not done the ligature will fall off prematurely, and thus lead to secondary hemorrhage. Cases occur in which the fragility of the arteries is so great as to render them incapable of bearing even this degree of pressure ; under such circumstances our only resource is WOUNDS AND HEMORRHAGE. 697 to surround the vessel with a portion of muscular or aponeurotic substance, and to include the mass in a flat ligature. Such a procedure is much more scientific than the practice, formerly recommended, of tying the artery over a roll of adhesive plaster, an operation which cannot fail to be followed by mischief. In regard to the propriety of drawing the ligature so firmly as to divide the inner and middle tunics, no doubt is any longer entertained by enlight- ened practitioners. In the time of Scarpa much disputation prevailed re- specting this point in the ligation of arteries, it having been alleged by this distinguished surgeon, on the strength of numerous experiments, that a cure could be effected quite as rapidly, and, in the end, more safely, simply by placing the serous surfaces gently in contact with each other. It was sup- posed that the part, treated in this way, would unite by direct adhesion, and that, consequently, when the ligature finally became detached, there would be much less risk of hemorrhage than when the vessel is lacerated and contused by the ruder method of procedure above described. Plausible as this theory may, at first sight, appear, it is found to be wholly unreliable in practice, for the very reason which induced Scarpa and his followers to advocate its adop- tion, the ligature being not only a much longer time in separating, but the two ends of the artery being much less effectually occluded. When it is recollected that a certain degree of inflammation is necessary, after this ope- ration, in order to afford the requisite amount of plasma, for gluing the inner clot to the surface of the vessel, it is reasonable to suppose that it would be much more easily induced by a partial division of the inner and middle tunics than by the mere approximation of the opposite sides of the tube; and this is precisely what the general experience of the profession has at length estab- lished in relation to the subject. When a considerable portion of neighboring tissue is obliged to be included along with the artery, the best instrument for performing the operation is a Fig. 213. Tenaculum-needle, armed with a ligature. sharp tenaculum, with an eye near its point, as seen in fig. 213 ; a curved needle armed with a ligature; or Physick's artery-forceps, fig. 214. Fig. 214. Physick's artery forceps. An artery is sometimes rendered incapable of bearing the ligature in con- sequence of the softening of its tunics by inflammation. Such an event, which is often exceedingly perplexing, is most liable to happen in cases of second- ary hemorrhage after wounds and amputations. The remedy is to isolate the vessel a short distance beyond its diseased limits, and to ligate it there in the usual manner; or, this being impracticable, to tie the diseased part along 698 DISEASES AND INJURIES OF THE ARTERIES. with more or less of the surrounding tissues ; or, this also failing, to cut down upon and secure the main trunk of the artery. In tying an artery in its continuity, whether as a means of arresting hemor- rhage, or of curing disease, the ligature is passed around the vessel by means of an aneurism-needle, fig. 215, a kind of blunt tenaculum, with an eye at Fig. 215. Aneurism-needle, armed with a ligature. the free extremity. Special care must be taken, in performing the operation, to disturb the sheath of the artery as little as possible; this structure is inti- mately connected with the nutrient vessels, and hence the less it is interfered with the less likely will the artery be to soften, ulcerate, or mortify. There is another point of deep interest connected with this operation, and that is the application of two ligatures, with the section of the vessels between them. This operation, which dates as far back as the time of Aetius, was revived by Mr. Abernethy, through whose influence it became for a while quite popular. It was soon found, however, that it was liable to be followed by secondary hemorrhage, owing chiefly to the injury inflicted during its execution, aud it has therefore deservedly fallen into desuetude. It was also in the Aetian operation that some of the surgeons of the last century employed what was termed the reserve ligature, intended as a ready resource in sudden emergencies. The cord was placed loosely around the artery, to be tied instantly in the event of hemorrhage, from the premature detachment of the original ligature. Experience, however, which is the only true test in such cases, soon showed that the procedure, instead of answering the design for which it had been intended, had a direct tendency to bring about the mischief, from its liability to produce ulceration of the denuded and tortured vessel. Its evils, indeed, are so palpable that it is extremely probable that it will never be revived by any enlightened surgeon. When an artery is cut completely across in the continuity of a limb, as, for instance, in a sabre wound of the femoral, it is necessary to use two ligatures, one for the cardiac, and the other for the distal extremity of the vessel. The reason of this is that, however securely the cardiac end may be tied, there will inevitably be more or less hemorrhage from the lower end, unless this be tied also, iu consequence of the activity of the recurrent circulation. Every one who has ever had occasion to ligate the brachial artery at the bend of the arm, on account of injury inflicted upon the vessel in bleeding, must have seen that the hemorrhage was only partially controlled by ligating the upper extremity. The blood, under such circumstances, wells up from the lower part of the artery as water bubbles up from the bottom 'of a spring; it does not issue in jets, or in a saltatory manner, as when it proceeds from the upper orifice, but lazily, and of a dark color, the bleeding resembling that of a vein rather than that of an artery; and thus the hemorrhage goes on, with little or no interruption, until it is arrested by ligature, or until it proves fatal. The flow may, it is true, be temporarily stopped, during an attack of syncope; but even then seldom perfectly, for the reason, apparently, that the vessel here does not possess the same power of contraction and retraction that it does WOUNDS AND HEMORRHAGE. 699 above, and that, therefore, it is not capable of forming any efficient clot, either external or internal. The changes which occur in an artery after the application of the ligature are essentially similar to those which occur when the bleeding is arrested spontaneously. The first thing that happens, after such an operation, is the coagulation of the blood within the artery as high up, generally, as the first considerable collateral branch, thus forming what is named the internal clot. The external clot is of course wanting, and this circumstance constitutes the chief point of difference in the two cases. The injured tunics, becoming in- flamed, pour out plasma into their ow>n substance, and also upon the free surface of the serous membrane, by which the internal clot becomes firmly and permanently fixed in its situation ; the clot next becomes organized, and finally, after an indefinite period, it is completely removed by absorption, the corresponding portion of the artery being converted into a dense, fibro- ligamentous cord. The changes experienced by the arteries and the blood in their interior, after the application of the ligature, are admirably illustrated in the adjoin- ing sketches. Fig. 216 represents the carotid artery of a dog 48 hours after Fig. 216. Fig. 217. Fig. 218. deligation. At a the coats are cut across; lymph is effused around, and a clot is formed on each side of the ligature. Fig. 217 exhibits the artery 96 hours after the operation. The extremities of the vessel are surrounded by 700 DISEASES AND INJURIES OF THE ARTERIES. a mass of plasma, through which the ends of the ligature are seen protrud- ing. Fig. 218 represents the vessel on the twelfth day after the deligation. At a the artery is cut open, to show its interior; at b numerous vessels are seen coming from the exterior, and coursing onwards to enter the clot at c. The period at which the ligature is detached varies with many circum- stances, of which the principal are, the size of the cord and the manner in which it has been tied, the state of the artery, and the amount of the resulting inflammation. A small ligature will, other things being equal, be detached sooner than a large one, and a firm sooner than a loose one ; a sound artery will be longer in throwing it off than a diseased one, simply because it has more power of resistance. A ligature upon the brachial artery will gene- rally be detached in about ten days ; upon the femoral, in from twelve to fourteen ; upon the external iliac, in sixteen ; and upon the common iliac, in about twenty-one days. To this rule there are, of course, many exceptions. I recollect the case of a man in the Louisville Marine Hospital, in whom, after an amputation of the leg, the ligature was still firmly adherent to the anterior tibial artery at the end of the fourth month. Dr. Lopez, of Mobile, commu- nicated to me, some years ago, the particulars of a case where the separation was not effected before the end of the eleventh month; and Professor Eve met with one where it did not occur until after the thirteenth month. Such cases constitute, of course, exceptions to the general rule, and it raay be fairly assumed that they usually depend either upon the faulty manner in which the operation is performed, or upon the presence of an extraordinary quantity of organized plastic matter, interfering mechanically with the detachment of the thread. When the ligature is indisposed to come away, gentle traction may be made upon it, repeated once in the twenty-four hours; great care, however, must be exercised in performing the operation, otherwise we may not only inflict severe pain upon the patient, but subject him to the risk of secondary hemorrhage. The process by which the separation of the ligature is effected is worthy of inquiry. It is generally ascribed to ulcerative action, and this is undoubt- edly true ; but it is equally true that that portion of the artery immediately embraced by the ligature mortifies, and comes away in the form of a slough. When the cord is drawn very tight, the corresponding part of the artery is strangulated, either at once, or, at any rate, in a few hours; but, in general, the process takes place more tardily, and thus affords the two ends of the vessel time to prepare and fortify themselves for the approaching crisis. If we study the whole subject minutely, it will be found to embrace the follow- ing acts : first, the strangulation and death of the vessel at the site of the ligature ; secondly, ulceration and the consequent separation of a part of the artery, thus producing a gap in its continuity ; thirdly, the adhesion of the clot to the inner surface of the vessel, speedily followed by its organization; and lastly, the absorption of the clot and the transformation of each extremity of the tube into a dense fibrous cord. In addition to these changes, there is occasionally slight suppuration, the matter usually presenting itself in the form of a little abscess. The discovery of the use of the ligature is due to Ambrose Pare, in the sixteenth century, prior to whose time surgeons were in the habit of stanch- ing hemorrhage with the actual cautery, hot pitch, and all sorts of styptics, of the most cruel and barbarous nature. " For the good of mankind," says this great man, "and the improvement and honor of surgery, I was inspired by God with this good thought." Pare himself fully appreciated the utility of his invention, but his cotemporaries spared no pains to undervalue it, and to revile and persecute its author, subjecting him to the humiliating office of searching the writings of the ancient fathers of medicine for traces of the use WOUNDS AND HEMORRHAGE. 701 of the ligature as a justification of his practice. Gourmelen, the jealous and malignant President of the College of Physicians of Paris, made himself par- ticularly conspicuous on the occasion, and thus earned an infamous reputa- tion ; for the only act by which he is now remembered is his bitter and unre- lenting persecution of Pare, rendered immortal by his great achievements. 2. Acupressure.—The credit of devising acupressure, as a means of arrest- ing hemorrhage, is due to Professor Simpson, who published an account of it in the Edinburgh Medical Journal for January, 1860. Since that period the operation has attracted much attention, having b^|h performed by different surgeons both in Europe and this country with results generally of a highly gratifying character. What its ultimate fate raay be, however, time alone can determine. That it is destined entirely to supersede the use of the liga- ture is not at all likely; on the contrary, indeed, highly improbable, inasmuch as the instrument with which the pressure is made can be applied only in certain regions of the body. The advantages claimed for this operation over that of the ligature are, first, that it is more easy, simple, and expeditious of execution; secondly, that the acupressure needle does not, like the ligature, provoke irritation, much less suppuration, ulceration, or mortification at the seat of the constric- tion ; thirdly, that the instrument may generally be removed, even when a large sized artery, as, for example, the femoral, is concerned, at the end of the second or third day; fourthly, that the wound will, other things being equal, be more liable to unite by the first intention ; and, lastly, that there will be much less risk of the occurrence of erysipelas, pyemia, phlebitis, abscesses, traumatic fever, and secondary hemorrhage. The only instrument required for this operation is a steel pin, sharp at one end and provided at the other with a glass-head, of a rounded shape, suffi- ciently stiff to prevent it from bending, perfectly smooth, aud coated with silver, zinc, or gold, although this is not at all essential. The length of the pin should vary, according to the caliber of the vessel and the diameter of the limb in which it is situated, frora two and a half to six inches. In ordinary cases the lady's bonnet pin, or the pin worn by gentlemen in their shawls, will answer every purpose. In regard to the isolation of the artery from the surrounding structures, the same rules are applicable as in the use of the ligature. There is, however, less danger from the inclusion of the accompanying veins, and hence these vessels may with great propriety be embraced along with the artery in the event of their being disposed to bleed unduly, as they occasionally are in amputations, resections, and the extirpa- tion of large tumors. In performing the operation, the pin, previously oiled, is passed from with- out inwards through the skin and thence on through the muscles and other structures down to and underneath the artery, in such a manner as to oblite- rate completely its caliber by bringing together its opposite surfaces. The instrument is then pushed through the tissues on the other side frora within outwards, so that, when the transmission is effected, the extremities shall rest upon the skin, while the middle shall firmly embrace the artery. Should the constriction not be sufficient to arrest the flow of blood, a ligature may be thrown tightly around the pin as in the operation for hare-lip; but this will seldom be necessary, especially if the precaution be taken of insertiug the compressor close to the vessel, or at a rather acute angle. The point of compression for the larger vessels should be at least six lines frora the open orifice, and about half that distance for those of sraaller size. The pin should be left entirely free during the application of the dressings, and in withdraw- ing it the parts must be well supported in order to avoid the risk of hemor- rhage. The annexed sketches, from Erichsen, will serve to show, at a glance, the 702 DISEASES AND INJURIES OF THE ARTERIES. application of acupressure. Fig. 219 exhibits the extremities of the pin as they project through the skin, while fig. 220 displays the manner in which the instrument embraces and constricts the artery. A good idea of it may also be formed by the manner in which the stalk of a flower is fastened to the lapel of a coat by transfixing the cloth with a pin. 219. Acupressure, showing the manner in which the ends of the pin project across the skin. Position of the artery and pin in acupressure. Fig. 221. 3. Compression.—Although the ligature is the most certain means of ar- resting hemorrhage, yet cases occur to which it is either not at all adapted, or where, from the great depth and narrowness of the wound, it is impracti- cable to apply it. It is under such circumstances that compression becomes available ; an agent which is often hardly less valuable than ligation itself. It is particularly serviceable when the injured vessel lies upon a bone, as in wounds of the brachial and temporal arteries; in wounds penetrating deep cavities, as the thoracic and abdominal; and, lastly, when the blood issues from a considerable number of small vessels instead of from one large one. The compression may be temporary or permanent, according to the exi- gencies of each particular case. When temporary, it is made with the hand, finger, tourniquet, or compress and band- age, and is only kept up until the injured artery can be ligated, or secured in some other effectual way. In permanent com- pression, the application is continued un- til the vessel is completely obliterated, whether the time be short or long. Temporary compression becomes neces- sary chiefly in cases of sudden emergency, as, for example, when an individual is stabbed in the femoral artery, and the surgeon cannot obtain any persons to assist him in tying the vessel. Under such circumstances an attempt is made to arrest the hemorrhage by means of the tourniquet, shown in fig. 221, or by a graduated compress and bandage ; the former being placed directly over the course of the artery from which the bleed- ing proceeds, or, if this be impracticable, over the main trunk of the limb, and the latter directly over the wound as well as for some distance above it, along the track of the vessel. Whichever method be adopted, it is to be borne in mind that the compression, even if it be main- tained only for a few hours, raay become a source not only of excessive pain, but also of mortification, and that, therefore, the greatest possible vigilance should be exercised in its employment. Tourniquet applied to the femoral artery. WOUNDS AND HEMORRHAGE. 703 When the ordinary tourniquet is not at hand, very efficient compression may generally be made by tying a piece of bandage, a cravat, or a handker- chief loosely round the limb, and then twisting it to the requisite extent by means of a stick, fig. 222, or the hilt of a sword, fig. 223, inserted under- neath it. This contrivance, usually called the field-tourniquet, because it was Fig. 222. Fig. 223. Field tourniquet; handkerchief and stick. Field tourniquet; handkerchief and sword. originally employed on the field of battle, raay be resorted to with great ad- vantage when a surgeon is obliged to amputate an extremity without having a sufficient number of intelligent assistants, although it labors under the in- convenience of not always concentrating the pressure upon the spot where it is raost needed. For this reason the common tourniquet is always to be preferred. A very simple and effective tourniquet for field practice was recently intro- duced by Mr. Tiemann into this country from Prussia, where it is extensively used in the military service, every orderly sergeant being required to carry Fig. 224. Prussian field tourniquet. one in his pocket for ready use. It simply consists, as will be seen in fig. 224, of an oblong square brass ring and of a strong strap, the latter of which, 704 DISEASES AND INJURIES OF THE ARTERIES. after having encircled the limb, is passed through the former and secured to the hooks attached to one of its margins. The instrument has no pad. Compression with the hand may often be advantageously employed for the arrest of accidental hemorrhage, until the surgeon has time to apply the liga- ture ; and it is also occasionally resorted to for the purpose of controlling the circulation in the main artery of a limb during amputation. In the upper extremity it is generally applied to the brachial artery, as it courses along the inner border of the flexor muscle ; and in the lower, to the femoral artery as this vessel issues beneath Poupart's ligament, and where, consequently, it lies upon the pubic bone. The annexed drawings, fig. 225 and fig. 226, are illustrative of the subject. Fig. 225. Fig. 226. Digital compression of the humeral artery. Digital compression of the femoral artery. In permanent compression, the force is applied in one of two ways, that is, either directly or indirectly. The former method is particularly adapted to the suppression of hemorrhage frora deep wounds, as in the lateral operation for stone in the bladder; in wounds of the rectum, whether accidental or wilful; in bleeding of the nose and uterus; in the removal of tumors from the maxillary sinus; in the extraction of teeth ; in the extirpation of the eye, and, finally, in wounds of the middle artery of the dura mater, as well as in a number of other injuries and operations which will readily suggest them- selves to the mind of the reader. The great objection to this mode of compression is, first, that it is fre- quently very difficult to prevent it from becoming deranged, and secondly, that it is liable to produce severe pain and inflammation, the latter being generally sufficient to cause profuse suppuration. It should, therefore, I conceive, never be employed with a view of arresting hemorrhage from a large artery, or even from a small deep-seated one, if it be at all practicable to apply the ligature, which is, of course, always the most certain and efficient method; but this objection does not obtain when the blood proceeds from a bleeding cavity, or when it oozes from the bottom of a recent wound. In- WOUNDS AND HEMORRHAGE. 705 & b deed, in such a case, compression must be used at all hazards, for there is often no other wa*y by which the flow can be arrested. The compression raay be made with a graduated compress and roller, or by means of sponge, cotton, wool, patent lint, or any other porous substance. Whatever article be employed, the bleeding surface must be previously freed from coagula, so as to enable us to place the compress directly Fig. 227. in contact with the orifices of the vessel, as exhibited in fig. 227. When the blood proceeds from a large artery, the circula- tion must be controlled, during this part of the proceeding, by means Of the finger Or tOlirui- , «»* of a graduated compress, a. The artery wounded. ,. _■ L •>. . o, b. The graduated compress, arranged so that the apex of quet applied SOme distance the cone is in immediate contact with the arterial orifice, above the WOUnd. Ihe COm- while its mass occupies the general wound, and projects preSS is then to be thrust gently somewhat above the integumental level. but firmly into the breach, the smallest piece being placed directly upon the orifice of the vessel, the next above this, and so on until a sufficient number have been applied, when the operation is completed by bandaging the limb from its distal extremity up- wards, care being taken that the compression be made in as equable and uniform a manner as possible. The part is then put at rest, in an elevated position, and action moderated by the use of cold water, anodynes, and other suitable means. The dressings are frequently examined, but not dis- turbed under four or five days, unless they become displaced, or offensive from the discharges. When the hemorrhage proceeds from a wound, as, for example, from that made in the lateral operation of lithotomy, the part must be plugged with a sponge, or piece of patent lint, the hollow of which is filled up with similar matter, or raw cotton, an instrument having been previously introduced through the foreign substance for the purpose of conducting off the urine. A like plan is pursued in bleeding of the rectum. In hemorrhage of the uterus, the vagina is plugged, while in epistaxis both nostrils are closed. In injuries of the bones, we are sometimes obliged to use a plug of soft wood, as a piece of shingle. In compound fracture of the skull, attended with lesion of the middle meningeal artery, running in an osseous canal, such an expedient is often the only one which can be successfully opposed to the hemorrhage. Bleeding of the nutrient artery of the long bones has some- times to be stopped in a similar manner. In some cases the tissues of the part whence the hemorrhage proceeds are employed as the compressing agents. In the operation for hare-lip, for ex- ample, the simple approximation of the edges of the fissure by the twisted suture effectually arrests the flow of blood from the coronary artery. The compression is said to be indirect or lateral, when it is applied to the track of the injured vessel, and not to its orifice. It is, in general, a more eligible way of arresting hemorrhage, being free from the objections that have been urged against direct compression, with which, however, it is oc- casionally combined. The best mode of effecting it is to place a long and rather narrow compress over the course of the artery, extending from the neighborhood of the wound some distance above, and to confine it by means of a roller, commencing at the distal portion of the limb, and carried upwards in such a manner as to afford equable support at every point. In other respects, the treatment is to be conducted as in direct compression. This mode of management is often employed, with the happiest effects, in wounds of the brachial artery, at the bend of the arm, caused by venesection. VOL. i.—45 706 DISEASES AND INJURIES OF THE ARTERIES. 4. Styptics.—Styptics are remedies which arrest hemorrhage by their direct influence upon the blood, and the arteries furnishing it. They comprise a long and varied catalogue of articles, some of which produce merely an astringent effect; others act apparently mechanically, and others, again, are escharotic, destroying both the vessels and the connecting tissues. Among the less objectionable styptics are alum, sulphate of copper, and the perchloride of iron, especially the first, which I prefer to every other, when such an agent is called for, and which may be used either in strong solution, or in powder, through the medium of patent lint, applied directly to the bleeding surface, previously freed of coagula. Employed in this man- ner, it generally produces a powerful astringent effect, causing coagulation of the blood, and marked contraction of the vessels, without necessarily lead- ing to suppuration of the affected structures, which is always the case with most of the other articles of this class. Sulphate of copper raay be used in the same manner, or in the form of a stick, held firmly for some minutes upon the oozing surface. Creasote possesses none of the styptic properties which were ascribed to it twenty-five years ago, and is now seldom employed with such a view. The perchloride of iron possesses great coagulating powers, but the misfortune is that it creates so much irritation as inevitably to give rise to suppurative inflamraation, if not to destruction of the tissues. A similar remark is applicable to the tincture of the chloride of iron. Of matico, I have not made sufficient trial to enable me to form a correct opin- ion as to its styptic virtues. Judging from what has been said of it by others, we must conclude that it possesses more than ordinary properties of this kind, although further observation is necessary before we can come to a final de- cision about it. Within the last few years, the persulphate of iron has been highly recom- mended as a styptic by Mons. Monsel, a pharmaceutist of Bordeaux. It is applied either in substance, or, what is preferable, in strong solution, and possesses the property of instantaneously coagulating the blood, converting it into a very large, dense clot, which is absolutely insoluble, and which con- tinues to increase and harden for several hours afterwards. What adds greatly to the value of this remedy, is the fact that it is entirely free from causticity. It is particularly adapted to hemorrhage of the nose, mouth, and throat, as well as of other parts of the body where it is impossible to ligate the injured vessels, on account of the great depth at which they are situated. It has also been used for the cure of vascular tumors of the skin and subcu- taneous cellular tissue, a solution of the persulphate being injected into them by means of a delicate syringe. A very convenient and efficient mode of using this salt was recently intro- duced to the notice of surgeons by Mr. Henry Johnson, of Chester, Penn- sylvania. It consists of cotton thoroughly steeped in a saturated solution of the persulphate, and then dried and rolled up for use. Previously to apply- ing it, the wound should be well wiped, when it should be covered with a thick layer, supported by a compress and a roller. Cold is a powerful styptic, and may be used in various ways. A current of cold air will often promptly and effectually stop capillary hemorrhage, or even hemorrhage produced by the division of a small artery, as is exemplified in operations upon the tonsils and anus, or ano-rectal region, as well as upon other parts of the body. To prove beneficial, the air must have free access to the part, and it may often be usefully directed by means of the fan, which has the additional advantage of rendering it more cool. Cold water, refrigerating lotions, pounded ice in bladders, or lumps of ice rolled up in cloths and applied to the bleeding surface, or in its immediate vicinity, occasionally promptly arrest hemorrhage. These applications are particularly valuable in deep-seated hemorrhage, or in hemorrhage of the in- WOUNDS AND HEMORRHAGE. 707 ternal organs and cavities; they must, however, be used with a certain degree of caution, as their protracted continuance may be followed by injurious re- action, and even by mortification of the part. When the wound is situated externally, but too deeply to render the injured vessels accessible to the liga- ture, the bleeding may often be promptly and effectually checked by a full stream of iced water, directed upon the part, and maintained steadily for some time, from a large syringe. The actual cautery can hardly be considered as a genuine styptic, although it is usually classed under this head. Its effect is not to constringe the ves- sels, but to destroy them, by producing an eschar, by which the vessels are, for the time, hermetically sealed. Upon the separation of the slough, how- ever, there is frequently a reproduction of the hemorrhage, especially if the wounded vessels are at all large, owing to the imperfect coagulation of their contents. The cases to which the cautery is mainly applicable are those in which the hemorrhage proceeds from a deep and narrow osseous cavity, and in wounds of the tonsils, uterus, and rectum. The instrument, which may be of a conical form, should be heated to a black or slightly red heat, and used in such a manner as not to injure the structures around the seat of the affected vessels. When the artery is very diminutive, we may sometimes attain our object with a hot knitting-needle, a wire, or probe. 5. Torsion.—Torsion is an old procedure, reintroduced to the notice of the profession by Thierry, Amussat, Yelpeau, and others; at one time point- edly condemned, at another immeasurably lauded ; opinion being still at vari- ance, although decidedly preponderating against it. In the enthusiasm of the moment much was said and written in its favor; it was even alleged that the larger arteries might be occluded in this way, and a German surgeon, Dr. Koch, of Muuich, actually published some cases of amputation of the thigh, in which he trusted entirely to torsion as a means of preventing hemorrhage. No other practitioner, however, has, I believe, had the hardihood to imitate him, and the operation is now entirely limited to the smallest arterial twigs. The proceeding, which is said to answer most admirably in the inferior ani- mals, serving as a substitute for the ligature, is executed with two pairs of forceps, as shown in fig. 228; a small one for drawing out the artery by Fig. 228. Torsion-forceps. grasping it horizontally, and a long, stout one provided with a slide, and serrated blades, for twisting it in its longitudinal axis; from six to eight turns being required, according to the size of the vessel, to lacerate and bruise its tunics so as to intercept and coagulate its contents. I have rarely found torsion of any service even in the smallest arteries. General Means.—Whatever mode of procedure be adopted for arresting the bleeding, it is an object of primary importance to place the affected part perfectly at rest, in an easy and elevated position ; the slightest motion might be injurious, especially where no ligature has been used, and should there- fore be sedulously guarded against. Repose of the body is equally necessary 708 DISEASES AND INJURIES OF THE ARTERIES. with that of the part, and it is hardly needful to add that mental tranquillity is also of the greatest moment. Cardiac action, too, must be maintained in the most perfect quietude, as any perturbating agency of this kind cannot fail to favor a return of the hemorrhage and exhaust the system. With a view of inducing this result a full anodyne should be administered early in the disease, the dose being repeated frora time to time as occasion may seem to require the soothing and sustaining influence of the remedy. Too much stress cannot be laid upon the use of opiates in the management of arterial hemorrhage, and it is surprising that the remedy is not more generally em- ployed than it seems to be. To allow the heart to go riot, or to move and toss about tremulously, as it is so liable to do after serious loss of blood, while we take every local precaution for the suppression of the bleeding, is assuredly a strange inconsistency, and one altogether irreconcilable with ex- perience and common sense. The diet should be perfectly bland, and just sufficient in quantity to supply the wants of the body. To give less might cause irritability of the system; to give more, over-stimulation. The drink must be cold and acidulated, and not taken so freely as to oppress the stomach, which will be sure to happen if the quantity be not carefully restricted, as the thirst is always urgent after the loss of even a comparatively small portion of blood. Lumps of ice, or pounded ice, held in the mouth, and gradually swallowed, often prove most grateful and beneficial. The air of the apartment must be kept perfectly cool; and, in short, every effort must be made to maintain the tranquillity of the circulation. Secondary Hemorrhage.—Secondary hemorrhage occurs at variable pe- riods ; sometimes in a few hours, at other times not under several days or weeks. It is not necessarily preceded by primary hemorrhage, but may come on where the loss of blood in the first instance was perhaps altogether insignificant, and where everything, so far as this event is concerned, gave promise of a most favorable issue. The bleeding often supervenes without any assignable cause, generally suddenly and unexpectedly, and hence it often makes great progress before an opportunity is afforded to arrest it. When proceeding from a large vessel, it may prove fatal in a few minutes, in the same manner as when the bleeding is primary. The scarlet hue of the blood always denotes its source. The causes of secondary hemorrhage are various, but the most important are the following: 1st. A faulty application of the ligature; 2d. A diseased state of the arteries; 3d. Morbid changes iu the clot; 4th. Improper traction upon the ligature ; 5th. Tight dressing, or too great dependency of the part; 6th. Want of retraction in the vessels ; and 7th. A hemorrhagic diathesis. 1. When a ligature is properly applied it simply divides the inner and middle tunics, leaving the outer intact; this too, however, may be cut, not completely, but partially, and therefore the more insidiously, in conseqnence of the force used in tightening the ligature; or, the deligation may not have been sufficiently firm, the opposite surfaces being only slightly approximated, and the resulting adhesion, therefore, inadequate to effect hermetic closure of the artery on detachment of the cord; or, lastly, the fault may have existed in the ligature itself, on account of the rottenness of its substance, or the imperfect tightening of the knot. Whatever the cause may be, the proper remedy is more efficient ligation. 2. The hemorrhage may arise from disease of the artery, either from undue inflammation, or degeneration of its coats, rendering them incapable of sup- porting the ligature until the clot has contracted firm adhesions. The mode of procedure is obvious; a more healthy portion of the vessel must be sought for, and the ligation effected with more caution ; or, this failing, the hemor- SUBCUTANEOUS HEMORRHAGE. 709 Fig. 229. rhage may be arrested by tying the main trunk of the limb, some distance from the seat of injury. 3. Morbid changes in the clot, commencing in a process of softening and disintegration, occasionally occur after ligation, leading to its premature de- tachment, perhaps several weeks after the operation. Such changes, which are well illustrated by the annexed sketch, fig. 229, frora Erichsen, are most frequent in cases of pyemia and diffuse erysipelas, consequent upon some injuries and amputations, eventuating in a tendency to suppurative inflammation. The only remedy, under such circum- stances, is the ligation of a healthy portion of the artery. 4. Young and inexperienced surgeons sometimes bring on hemorrhage by improper traction of the liga- ture, with a view to the promotion of its separation; forgetting that they may thus tear the artery, or, at all events, break up important adhesions. Such a proce- dure cannot, as stated elsewhere, be too severely censur- ed. Re-ligation is obviously the remedy in such a case. 5. Tight dressing, causing unequel constriction of the part, or improper dependency, favoring undue afflux of blood, may induce this form of hemorrhage. The result will be most likely to happen when a number of small arteries have been divided, without any attempt having been made to secure them with the ligature. Bleeding having ceased, the dressings are applied, but too firmly, or the part is placed too low, and presently blood be- gins to appear, issuing, perhaps, with great freedom. The treatment consists in the removal and readjustment of the dressings, with strict attention to posture. 6. Secondary hemorrhage occasionally comes on after operations for the relief of anal, perineal, and other fis- # amputation. tules, chronic abscesses, and old ulcers, from an inability of the vessels to retract in consequence of the indurated condition of the divided parts. Exposure of the surface to cold air, the application of ice, direct compression, or styptics, constitute the best means of relief. In some cases the actual cautery may be required. 7. Finally, the cause may be a hemorrhagic diathesis, an affection which, as will be stated elsewhere, may occur at any period of life, and which it is often found extremely difficult to control by any mode of treatment, however judiciously conducted. \I Partial absorption of the clot, in the femoral artery, a fortnight after SECT. II.—SUBCUTANEOUS HEMORRHAGE. There is a form of arterial hemorrhage to which, from its situation, the term subcutaneous is very properly applicable. It takes place when, from any cause, an artery is laid freely open, and its contents, instead of escaping externally, are extensively extravasated among the surrounding structures. In ordinary hemorrhage, the blood issues directly from the injured vessel, because the outer wound is sufficiently capacious to admit of its free and un- restrained passage, and the consequence, generally, is that it continues until the patient faints, and the bleeding orifice is closed by coagula. In the variety of hemorrhage, however, under consideration, the opening in the in- teguments is so sraall as to prevent the blood from appearing externally, and it therefore accumulates beneath the skin, in the subcutaneous cellular tissue, when the artery lies superficially, or in the subcutaneous and intermuscular 710 DISEASES AND INJURIES OF THE ARTERIES. cellular tissue, when it is deep-seated. The accident which usually causes this hemorrhage is a puncture, such as that inflicted in venesection at the bend of the arm, where, in civil practice, it is most commonly met with. It may, however, in consequence of a stab, a bayonet wound, or the laceration occasioned by the sharp end of a broken bone, occur in any part of the body, and is sometimes most profuse, its extent being regulated chiefly by the size of the affected vessel, and the quantity and laxity of the connective sub- stance. In the superior extremity, the extravasated fluid often reaches nearly as high up, on the one hand, as the axilla, and, on the other, as low down as the inferior third of the forearm, extensively separating the muscles from each other by breaking up their cellular connections, and forming a large, ill-shaped, and confused swelling, attended with violent pain, numbness and oedema of the whole limb, and discoloration of the integuments. More or less pulsation is generally present, especially in the earlier stages of the case, and, upon applying the ear over the site of the wound, a well-marked bruit can frequently be recognized, attended occasionally with a peculiar thrill, or a whirring noise, and a vibratory sensation. It is for these reasons that this affection has usually been described by writers as a variety of aneu- rism; and, as the blood is always widely extravasated, the prefix diffuse is usually added to that term, as particularly expressive of its more important attributes. Strictly speaking, however, there is no aneurism here; there is simply a subcutaneous accumulation of blood, the consequence of external injury, without any dilatation of the vessel, or degeneration of its tunics; and, although there frequently is, as just stated, more or less concomitant pulsation in the part, yet this does not any more entitle it to be regarded as an aneurism than it would if the effused fluid were so much pus or serum. The blood which is effused in this accident usually promptly coagulates, and, exerting injurious compression upon the parts with which it is in con- tact, soon excites severe inflamraation, which, especially in persons of an irritable constitution, is liable to assume an erysipelatous character, and to terminate in suppuration, ulceration, and even gangrene. The pain is often intense, depriving the patient of appetite and sleep, and making rapid inroads upon the system. I have witnessed cases where, from the excessive distress thus produced, hectic fever soon came on, and life was placed in imminent peril. The treatment of this lesion is precisely similar to that which is necessary when there is an open wound ; that is, the artery must be secured promptly and at all hazard, and the coagulated blood thoroughly evacuated. The operation is often one of great embarrassment, owing to the confused and displaced condition of the parts, and the difficulty which is sometiraes expe- rienced in finding the injured vessel, which is not unfrequently lost in the midst of the coagulated blood. A large incision is generally required, and two ligatures must be applied, one above and the other below the wound in the vessel, precisely as in ordinary cases, the object being to prevent hemor- rhage by the recurrent circulation. As a preliminary step, the brachial artery is compressed in the middle of the arm by the finger or tourniquet, and after the operation is over, the limb is wrapped up in warm water-dressing, medi- cated with laudanum and acetate of lead, or laudanum and alcohol, to favor the reduction of inflammation. SECT. Ill--COLLATERAL CIRCULATION. Among the more interesting phenomena that occur after the deligation of the larger arteries, not the least curious and important is the manner in which the circulation is carried on and maintained in the structures beyond the seat I COLLATERAL CIRCULATION. 711 of the ligature. A long time elapsed after the discovery of the ligature be- fore surgeons could be induced to believe that such an operation could be performed in the continuity of a limb without endangering the parts below by gangrene, in consequence of the sudden abstraction of their accustomed supply of blood. Chance gradually led to the correction of this apprehen- sion, which, however, is not without some foundation, as is proved by the fact that the procedure is occasionally followed, even at the present day, in the hands of the most scientific surgeons, by loss of limb and life. Cases had been observed, from time to time, of the obliteration of the largest arterial trunks by fibrinous concretions, and yet it was perfectly certain that the struc- tures in the distal portions of the extremity had retained their normal growth, no difference being discoverable between them and those of the opposite side. Such a result, it was obvious, could only have been brought about by an enlargement of the collateral vessels, thus enabling them to keep up the nor- mal supply of blood, after the obstruction of the main artery. A number of instances had been noticed of complete closure of the aorta, both in its tho- racic and abdominal divisions, without any apparent detriment of any kind, either proximate or remote. These facts, the fruits of the cultivation of mor- bid anatomy, were eminently suggestive, and we accordingly find that they gradually paved the way for some of the most daring feats in surgery. The original trials with the ligature upon the principal arteries in the continuity of the limbs were highly gratifying, as tending to show that, although the distal structures were temporarily deprived of their accustomed supply of blood, yet this occurrence did not sufficiently interfere with their vitality to cause gangrene, the circulation being speedily re-established through the collateral routes. The process employed by nature in effecting this object has been demonstrated, in repeated instances, by dissection of the parts at variable periods after they had been subjected to operation. The moment a large artery, as, for example, the femoral, is tied, the blood is obliged to seek new channels for its transmission to the distal portion of the limb. For this purpose it passes on in every direction, entering every vessel, both large and small, into which it can find access. This, however, does not occur all at once, but gradually; for as the arteries which are to carry on this collateral circulation, as this arrangement is termed, are com- paratively small, sorae time is necessary to prepare them for the reception and accommodation of the increased flow of blood. In fact, they are com- pelled to submit to a species of preliminary dilatation, their tonicity being such as rather to resent its encroachment than to yield to its effects. This is the case both with the branches that are detached from the sides of the vessel above the seat of the ligature and with the capillaries of the various tissues entering into the composition of the limb, which, immediately after such an event, always play an important part in maintaining the distal circulation. Hence, for some time after the operation, the quantity of blood below the point of obstruction is necessarily considerably less than in the normal state, as is demonstrated by the cold and pallid state of the integuments, the de- fective sensibility, and the loss of muscular power, which is occasionally so great as to deprive the patient of motion in the affected member. The dimi- nution of temperature is liable to a good deal of variation, but in general it amounts to several degrees, and hence the surgeon is often obliged to employ artificial heat. Gradually, however, as the circulation increases in vigor, the temperature returns to the natural standard, and in many cases even exceeds it, owing to the enlargement and inordinate activity of the cutaneous capil- laries, although such an occurrence is usually of short duration. An instance occasionally occurs in which there is either no change of temperature at all frora this cause, or where it is so very slight as to be hardly perceptible. Such a phenomenon is most apt to happen in old 712 DISEASES AND INJURIES OF THE ARTERIES. aneurisms, where, owing to the obstruction in the artery connected with the tumor, the anastomosing vessels have had time to become enlarged prior to the application of the ligature, so that the operation exerts little, if any influence, upon the circulation in the distal portion of the limb, as it neces- sarily must in recent cases of that disease, and also in wounds of the arteries, in which no such opportunity is afforded for an increase in the size of the collateral channels. Coincident with this effort on the part of the affected structures to establish the collateral circulation, there is generally a feeling of uneasiness, if not of actual pain, of a burning or tingling character, obviously occasioned by the compression which the enlarged and distended vessels exert upon the neigh- boring nerves. Usually, however, this effect is of short duration, as the nerves soon accommodate themselves to their new relations. After some time, the parts gradually recover their natural functions, all disagreeable sensations vanish, the muscles increase in vigor, and the process of nutrition proceeds apparently as well as it did prior to the deligation of the vessel. Although such is the ordinary course of events after the main artery of a limb has been tied, yet important exceptions are occasionally met with. Thus, it now and then happens that the circulation remains extremely languid for an unusual length of time, perhaps for a number of days, if not several weeks, the anastomosing branches being seemingly incapable of enlarging to a sufficient extent to convey an adequate supply of blood to the affected structures; the extremity is, consequently, cold, heavy, numb, and of a red- dish or purplish hue, from passive congestion of the capillaries, and is moved with pain and difficulty. A struggle is evidently going on between nature and disease, in which the latter but too often comes off victoriously ; the limb either falling into gangrene without the occurrence of reaction, or, reaction taking place, it is overpowered by the resulting inflammation. Finally, cases occur, although, fortunately, very unfrequently, in which the parts remain permanently weak and crippled; the muscles are soft and flaccid, the adipose tissue is absorbed, and the integuments are habitually cold and congested; the circulation having never attained the normal standard after the operation. It is worthy of notice that gangrene, from defective circulation, is much less liable to occur after the ligation of an artery, in the continuity of a limb, in wounds than in aneurism. This fact, at all events, is clearly deducible from the statistical tables of Dr. Norris, from which it appears that in seven- teen cases in which the femoral artery was secured on account of recent injuries and different tumors, gangrene did not occur in a single one, whereas this result was witnessed in thirty-one cases out of two hundred and four in which the operation was performed for the cure of aneurism. May not the cause of this disparity be the compression which the tumor in this disease exerts upon the neighboring structures, thereby obstructing the circulation in the distal portion of the limb, and at the same time seriously embarrassing the functions of the nerves ? I presume that this result is very materially influenced by the nature of the wound, necessitating the deligation of the artery. If, for example, the parts are extensively divided transversely, or very obliquely, so as to destroy the continuity of a large number of its more important branches in the immediate vicinity of the wound, gangrene will be much more likely to occur than under opposite circumstances, in which the neighboring vessels being but little injured, the blood will easily find its way into the distal structures, thus affording them the requisite supply not only for the preservation of their vitality but also for the maintenance of their nutrition. Although the capillaries are greatly instrumental in carrying on the circu- lation in the distal portion of the limb, immediately after the deligation of its main artery, yet their agency is really merely of a temporary character, COLLATERAL CIRCULATION. 713 c ceasing with the establishment of the collateral circulation, properly so called, as developed by the larger arterial branches in the vicinity of the ligature. These arterial branches are occasionally given off by the affected artery itself, but most commonly they arise from some neighboring trunks. Thus, when the superficial femoral is tied high up, the collateral circulation is established through the agency mainly of the profunda, whose branches inosculate with the articular, which are offsets of the popliteal. In ligation of the brachial, the blood is transmitted to the forearm and hand by the communications naturally existing between the anastomotic and profunda arteries, branches of the affected vessel, and the recurrent branches of the radial and ulnar, in which the brachial terminates. In ligation, on the contrary, of the comraon carotid, the circulation of the corresponding side of the head and neck is kept up mainly by the communications between the occipital and deep cer- vical arteries. It has been noticed, as an interesting physiological fact, that the anasto- motic arteries, before they unite with each other, separate into several branches, often as many as Fig. 230. three or four, so as to form a kind of circle, as if nature were particularly anxious to guard against any risk that might otherwise occur to the collateral circulation from accident or disease. However established, the collateral vessels gra- dually augment in size, until, at length, their united capacity is fully equal to that of the obliterated trunk, as in fig. 230, whatever may have been its size. There are, of course, as already stated, excep- tions, but they are, probably, much less frequent than is generally imagined. A highly interesting case, beautifully illustrative of the present topic, occurred, some years ago, in the practice of Dr. Francis West, of this city, by whom the particulars have been published in the second volume of the Transactions of the College of Physicians of Phila- delphia. The patient, who was a stout, athletic man, aged thirty-two, died suddenly from rupture of an aneurism of the thoracic aorta. On dissection, it was found that this vessel was entirely obliterated, just beyond the remains of the arterial duct, its coats having a constricted appearance, as if they had been embraced by a tightly-drawn ligature. Everywhere else, excepting at the place of aneurism, the aorta was perfectly natural. All the branches of the sub- clavian arteries were much increased in size; and the internal mammary and epigastric, which served to keep up the connection of the circulation above and below the seat of the stricture, were fully as large as the external iliac, the former having coursed along the walls of the chest in a very tortuous man- ner. As no tumor was discovered at the seat of the obliteration, Dr. West was unable to determine whether the disease was the result of accident or of a congenital vice. Be this as it may, the case affords an admirable illustration of the manner in which the collateral circulation is carried on after the interrup- tion of the column of blood in such an immense vessel as the aorta. The collateral circulation is not developed with equal facility at all periods Collateral circulation shown in the thigh. At a, the femo- ral artery has been obliterated by ligature. 714 DISEASES AND INJURIES OF THE ARTERIES. of life, or under all circumstances; it is most readily established in young subjects, in whom the arteries, besides being very active, enjoy a high degree of elasticity and pliancy, well adapted for such an enterprise. In old persons, on the contrary, the functional activity of these vessels is often much impaired, many of the small branches are obliterated, and their coats are extremely liable to earthy deposits, converting them into firm, rigid tubes, ill qualified for the discharge of their duties. In many cases, loss of blood, ill-health, or defective vital power, seriously interfere with the development of the col- lateral circulation. Finally, the collateral circulation may be too active. Such an event is not likely to happen when the main artery of a lirab is tied on account of hemorrhage from a wound, but its occurrence is by no means uncommon in aneurism, and is then apt to be followed by a return of the circulation and pulsation in the tumor, in consequence of the activity of the anastomosing branches, which thus continue to feed the sac, and perhaps effectually oppose the cure. SECT. IV.—HEMORRHAGIC DIATHESIS. The hemorrhagic diathesis is that peculiar state of the system in which, generally from some slight traumatic cause, there is a strong tendency to an inordinate discharge of blood. Persons who are laboring under this consti- tutional infirmity are often placed in imminent jeopardy by the most insig- nificant scratch, puncture, or incision, which, under ordinary circumstances, would hardly emit more than a few drops of blood. Occasionally the cause of the bleeding is the accidental rupture of some of the smaller vessels of the mucous membrane, as, for example, that of the nose, lungs, rectum, or urinary bladder. The extraction of a tooth is sometimes followed by this form of hemorrhage. I recollect one case in which death was produced in this way; and another where the bleeding, having persisted for nearly four days, gave rise to severe exhaustion and great apprehension respecting the safety of the patient. Many years ago I lost a child, six months old, from hemorrhage consequent upon lancing the gums over the upper central incisors, which were nearly ready to protrude; he was affected at the time with cholera, but previously to that he had always been remarkably healthy. The bleeding commenced in less than twenty-four hours after the operation, and continued, despite all that could be done for his relief, until the end of the fifth day, when he died completely exhausted. A short time before he expired, hemor- rhagic spots appeared on different parts of the body, and blood began to be discharged from the bowels. In 1857, I operated for strabismus upon a young gentleman who possessed this peculiarity ; the division of the internal straight muscle was followed by an oozing of blood, which continued, nearly constantly, for the greater part of a fortnight, when, the wound being almost healed, the bleeding ceased. The blood in this variety of hemorrhage oozes from the injured part, as water oozes from a sponge; it does not spirt out in jets, as when it comes from an artery, or in a continuous stream, as when it proceeds from a vein. Its color is neither scarlet nor black, but intermediate between the two; it generally partially coagulates when it is received into a vessel, but rarely does so while it is in contact with the living surface. This affection has occasionally been noticed in several members of the same family. In a remarkable case, reported by the late Dr. John A. Swett, of New York, it existed in all the children, eighteen in number. All except one had died from this cause, and he was suffering under profuse hemorrhage of the nose and rectum. Twelve sisters died before the age of twelve from HEMORRHAGIC DIATHESIS. 715 bleeding of the uterus ; two of the brothers had fallen victims to traumatic hemorrhage. Mr. Wardrop gives a curious case in which this peculiarity was hereditary. The patient was a boy, in whora the hemorrhagic tendency displayed itself when he was scarcely two months old. On several occasions, he nearly lost his life from the most insignificant wounds. His brother, twenty-two years old, was frequently afflicted in a similar way. Of his five uncles, not one was free from this predisposition, three died from the division of the frsenum of the tongue, and one from the extraction of a tooth; while the other, although he suffered from the same disease, finally died from some other cause. His two aunts exhibited no signs of this diathesis; but, what is singular, all the male branches of their families, excepting one, were thus affected. A still more remarkable case has been reported by Dr. Hughes, of Ken- tucky. The predisposition here was associated with a rheumatic diathesis, and was satisfactorily traced as far back as five generations. It was confined exclusively to the male branches of the different families; but the females, nevertheless, invariably transmitted it to their offspring. Many of the indi- viduals died in infancy and childhood, death resulting, in some, from the cut of the lancet; in some, from accidental wounds ; in some, from internal he- morrhage ; and in two, simply from the application of blisters, the vesicles being filled with blood instead of water. Of the immediate causes of the hemorrhagic diathesis, we are completely ignorant. Whatever they may be, it is evident that they are deeply engrafted in the constitution, as is proved by the fact, first, that it generally shows itself at a very early age; secondly, that it often occurs in several members of the same family; and thirdly, that it is sometiraes hereditary. The immediate causes seem to be two : first, a want of coagulating power in the fibrin of the blood; and, secondly, an imperfectly organized state of the capillary vessels, which are the immediate seat of the hemorrhage. If one were inclined to speculate in regard to the cause of this defective coagulating property of the blood, it would be easy to find it in an insufficient supply of nervous power, upon the presence of which, as is well known, the vitality of this fluid essentially depends. Whatever has the effect of weak- ening this influence, proportionally interferes with the concretion of the blood, both as it circulates through the body and after its removal by vene- section. The fact that the blood remains fluid in those who are suddenly destroyed by lightning, has long been familiar to practitioners. Similar phenomena occur when a person is killed by a blow on the stomach, by prussic acid, the poison of the rattlesnake, excessive bodily fatigue, or violent agita- tion of the mind. Certain diseases, as Asiatic cholera, plague, and malignant fevers, produce the same effect. It has been satisfactorily ascertained that, when the pneumogastric nerves are tied in animals, the blood loses its pro- perty of coagulating, the coloring matter at the same time separating from the fibrin, and assuming an unusually black color. But in all these cases, the loss of nervous power is sudden, and hence it is easy to perceive how it should influence the coagulation of the blood. In persons laboring under the hemorrhagic diathesis, on the contrary, the blood is generally habitually indisposed to coagulate, so that they are more or less liable to bleeding whenever they experience any injury, however slight. The analogy, then, between these different states of the system is exceedingly re- mote, and can, indeed, hardly be said to be established. Its force, moreover, is weakened by the fact that the subjects of the hemorrhagic diathesis gene- rally enjoy as good health, and as much vigor of constitution, as those who are free from it. To say that such persons are constantly laboring under a want of nervous fluid, is to affirm that they are imperfectly organized, and deficient in genuine nerve-power; circumstances which, if true, remain to be 716 DISEASES AND INJURIES OF THE ARTERIES. proved. I am not aware that any experiments have been made tending to show that the blood in the hemorrhagic diathesis is deficient in fibrin ; such observations might be easily instituted, and they could hardly fail to throw important light upon the pathology of this peculiar affection. The other appreciable element in the pathology of the hemorrhagic dia- thesis is the want of contractility on the part of the capillary vessels. It has been supposed that this is due to the absence of the middle tunic of these vessels; but such a deficiency must necessarily be a matter of inference rather than of observation, and I am not aware that any one, whose opinion is enti- tled to much weight, any longer holds such a view. That there is a want of tone in the capillaries is certain, but how this is brought about, or in what it consists, is still a subject of conjecture. The prognosis of this form of hemorrhage is generally not very favorable, particularly when it is of a hereditary nature, in which event it is extremely liable to prove fatal. In the case related by Swett, seventeen out of eighteen members of a family thus affected had perished, and the survivor himself had repeatedly suffered from severe bleeding in different parts of the body. In the case of Hughes, in which the diathesis prevailed in not less than five generations, nearly every individual died from hemorrhage ; many of them in infancy and childhood. In the treatment of the hemorrhagic diathesis, two indications are pre- sented : the first is to promote the coagulability of the blood ; the second, to increase the contractile power of the capillary vessels. In addition to these, it will be necessary, if a good deal of blood has already been lost when the surgeon is called to the case, to support the system by tonics and a nutritious diet. The first of these objects is best fulfilled by the judicious use of acetate of lead and opium, the former of which seems to exert a direct influence upon the coagulability of the blood, while the latter affords important aid in con- trolling the action of the heart, generally rendered turbulent by the bleeding and the patient's mental anxiety. The dose of the salt should vary from half a grain to a grain arid a half, every two, three, or four hours, according to the tolerance of the stomach and the amount of hemorrhage, and should contain at least one grain of opium, or its equivalent of acetate of morphia. If heat and dryness of skin exist, a small quantity of antimony or ipecacuanha may be added to each dose, to produce perspiration. Severe depression, however, must be vigilantly guarded against. If there be much cardiac ac- tion, tincture of aconite or veratmm viride should be given, its effects upon the system being carefully watched. Whatever else be done, it is of para- mount importance, in every case, to control and quiet the heart's action. To increase the contractility of the capillary vessels, which is the next indi- cation, provided this has not been effected by the acetate of lead, recourse must be had to tonics and nutritious diet. Of the former, one of the best articles, according to my observation, is the tannate of iron, either alone or in union with quinine, in doses varying from two to five grains, administered every two, three, or four hours, in pill form. The diet should be light, non- stimulant, and nourishing, and moderate use should be made of milk punch, toddy, or wine. In general, these measures will be borne, having a tendency rather to quiet the action of the heart than to occasion undue excitement. Tranquillity of mind and body is of paramount importance, and must, there- fore, not be neglected. Purgative medicines will usually prove highly serviceable, both as evacu- ants, as counter-irritants, and as restorers of the secretions, which are nearly always much disordered in this variety of hemorrhage. Estimating these remedies at their real value, I am satisfied that they are entitled to the highest rank in the treatment of this affection ; they must not, however, be ACUTE INFLAMMATION. 717 carried too far, otherwise they may induce irritability of the heart, and thus do harm instead of good. If the patient be plethoric, he may take sulphate of magnesia, which is particularly appropriate under such circumstances, on account of its chemical action upon the blood; or, what will generally be better, especially when there is marked derangement of the secretions, a full dose of calomel and compound extract of colocynth. If the bleeding be attended with fever, or with heat and dryness of the sur- face, recourse must be had to diaphoretics, as antimony and morphia, or the neutral mixture, aided by tepid ablutions. Coldness of the extremities must be relieved by hot mustard baths. It need hardly be added, that the sooner these constitutional measures are carried into effect, the more likely will they be to prove efficient in arresting the hemorrhage; the longer the bleeding has lasted, or the greater the amount of blood that has been lost, the more difficult will it be to arrest the disease and prevent its downward tendency. Moreover, a proper plan of treatraent having been selected, it should be diligently persisted in until it is capable of exerting its beneficial influence, and not be constantly varied, as is so often the case in the hands of the timid and inexperienced ; it being never forgotten that some time must necessarily elapse, in such a case, before the system can be favorably impressed by any measures, however judicious or energetic. The topical treatment is often of paramount importance. When the hemorrhage proceeds from a wound, the affected structures should, if possi- ble, be included in a firm ligature. For this purpose, the twisted suture may be used; or, if this be impracticable, systematic compression may be made by means of a graduated compress and roller, the surface of the wound having previously been dried, so as to allow the lint to come directly in contact with the bleeding orifices of the divided vessels. The efficacy of the compression will sometimes be increased by the use of a piece of tinder, placed upon the raw surface, or by soaking the lint in a saturated solution of alum. Per- chloride and persulphate of iron may also be tried, though their efficacy has been greatly overrated as anti-hemorrhagics. Occasionally, the application of pounded ice will restrain the bleeding more effectually than anything else. Rubbing the wound freely with nitrate of silver or sulphate of copper is sometimes useful. The actual cautery, the Yienna paste, and the different acids, have all been recommended when the hemorrhage resists the more ordinary measures: but the objection to them is that, when the eschar drops off, and frequently even before, the bleeding is apt to recur with increased violence. Finally, when the blood proceeds from the nasal cavity, uterus, or rectum, the most efficient adjuvant will be the tampon. SECT. V.—DISEASES OF THE ARTERIES. The arteries are liable to inflammation, acute and chronic, suppuration, softening, ulceration, and various kinds of transformations. 1. ACUTE INFLAMMATION. Acute arteritis is generally induced by external injury, or by an extension of disease from the adjoining structures. Nevertheless, it occasionally exists as an idiopathic affection, or comes on without any assignable cause, chiefly in persons of a gouty or rheumatic predisposition, from the age of thirty to fifty. Restricted, in the majority of instances, to one or more of the larger trunks, it not unfrequently involves the smaller branches, and sometimes even the capillaries. Occasionally, the disease appears to pervade nearly the whole arterial system. 718 DISEASES AND INJURIES OF THE ARTERIES. When arising spontaneously, the disease usually begins in the internal membrane and subserous cellular tissue, from which it gradually spreads to the other tunics; the reverse happening when it is induced by external violence. The anatomical characters of acute arteritis are redness, opacity, rugosity, and softening of the lining membrane, with an engorged, lacerable, and thickened state of the outer and middle coats. When the inflammation is severe, the parietes of the affected artery are generally remarkably pulpy, and so much diminished in consistence as to be easily torn or divided by the liga- ture. The nutrient vessels are loaded with blood, and often exhibit a real varicose aspect, their ultimate twigs ending apparently in the subserous cel- lular substance. With regard to the redness of the internal membrane, it is liable to considerable diversity ; generally speaking, it occurs in small patches, which are diffused over a considerable extent of surface, and which vary in diameter between that of a split pea and a five-cent piece. In intensity, it ranges from a light pink to a deep scarlet, through numerous intermediate shades of lilac and purple. In some instances the redness is uniform. With this change of color are always associated important alterations of texture. The inner membrane, losing its smoothness and polish, assumes a rough, fleecy aspect, and, owing to the softened state of the subserous cellular tissue, is easily detached from its natural connections. Globules of lymph, either alone or blended with pus, occasionally adhere to its inner surface; and, in the larger arteries, it is not uncommon to meet with well-developed pseudo- membranes, similar, in all respects, to those of the serous textures. The other tunics are also much affected, being moist, tumid, friable, and trans- formed into a reddish, homogeneous mass, almost devoid of cohesive power. Their elasticity, naturally so great, is partially lost, and in many instances they are freely infiltrated with serosity, sanguinolent fluid, or even pure pus. A common occurrence is the formation of fibrinous concretions, closing up the caliber of the affected vessels. Suppuration of the arteries is probably more frequent than is commonly imagined. The matter being generally formed upon the inner surface of the vessels, is soon swept away by the circulating current which is, doubtless, the reason why it is not oftener noticed after death. Sometimes, however, it is entangled in the substance of the false membranes, infiltrated into the arterial tissues, or collected into small abscesses between the inner and middle tunics. Arteritis is much less liable to terminate in suppuration than phlebitis, in which respect the one resembles inflammation of the serous membranes, the other of the mucous. The arteries are almost insusceptible of gangrene. Their conservative powers are certainly very great, and hence they often escape destruction in the midst of parts that are perfectly deprived of vitality. In such cases, their outer surface becomes incrusted, at an early period of the disease, with a thin layer of fibrin ; and, long before the sloughs begin to separate, the blood coagulates in their interior, thus opposing an effectual barrier to the occur- rence of hemorrhage. Softening of the arteries is a comraon occurrence, especially in the smaller branches. It is often witnessed in organic diseases of the principal viscera, and is a frequent attendant upon acute inflammation, cancerous affections, and the application of the ligature. The lesion is characterized, as the name in- dicates, by a diminution of the cohesive power of the vessels, the coats of which are rendered friable, spongy, and inelastic. It is generally accom- panied with slight tumefaction, engorgement of the capillary vessels, and effusion of serosity, or sanguinolent fluid into the interstitial cellular tissue. The symptoms of acute arteritis are generally so obscure as to render it extremely difficult to distinguish it, especially when it occurs in the more deep-seated vessels. In the majority of cases, the attack strongly resembles CHRONIC AFFECTIONS. 719 one of rheuraatisra. The most reliable phenomena, in a diagnostic point of view, are excessive pain and tenderness along the course of the affected arte- ries, increased by pressure, cough, and change of posture, and accompanied by violent and tumultuous throbbing, which is sometimes felt over the greater portion of the body, and may often be easily perceived at a considerable dis- tance. The action of the heart is much increased in force and frequency, the pulse is hard, wiry and thrilling, and the system is disturbed by irritative fever, which rapidly assumes an asthenic type. When the disease is at all extensive, the patient soon succumbs under its influence, the immediate cause of death being either exhaustion from the violence of the inflamraation, or from the formation of the fibrinous concretions in the larger arteries, thereby arresting the circulation in some of the more important organs. There are no symptoms denotive of suppuration, ulceration, or softening of the arteries, apart from those of acute or chronic inflammation. The for- mation of matter would probably be ushered in by rigors, followed by copious sweats, hectic irritation, and excessive prostration, but the occurrence would hardly be of so marked a nature as to serve any diagnostic purpose. The treatment of acute arteritis must be conducted upon general antiphlo- gistic principles ; by the lancet, purgatives, and antimonials, if the patient be young and plethoric, or by a conservative course, if he be weak, decrepit, or exhausted by previous suffering, intemperance, or dissipation. Aconite, veratrum, or colchicum will usually form valuable additions to the other means, especially if they be combined with morphia, which is so necessary to allay pain and quiet the heart's action. If the disease is connected with a rheumatic diathesis, calomel must be given, in full and frequently repeated doses, with a view to early but gentle ptyalism. Colchicum will also prove useful in such a case. The most suitable topical remedies, when the affected arteries are superficial, are leeches, iodine, and saturnine lotions, in uuion with laudanum. 2. CHRONIC AFFECTIONS. The raost comraon chronic affections of the arteries are the fibrous, earthy, and atheromatous transformations, which, although of frequent occurrence, are chiefly interesting in relation to the influence wdiich they exert upon the production of spontaneous aneurism. It is for this reason, therefore, that they should be carefully studied. These transformations, notwithstanding that they differ from each other widely in their physical and chemical proper- ties, possess several characters in comraon, of which the most important are, first, that they are met with almost exclusively in elderly subjects ; secondly, that they render the coats of the vessels brittle, and consequently prone to rupture; thirdly, that they nearly always occur in association with each other; and, lastly, that they usually begin in the cellular tissue, between the inner and middle tunics, which, however, in time, commonly participate in the degeneration. The fibrous transformation is characterized by the appearance of small, hard, firm patches beneath the serous layer of the arteries, usually isolated, but sometimes grouped together, of no definite shape, thin, and of a whitish, grayish, or pale yellowish aspect. When the patches are numerous or unu- sually large, they convert the affected arteries into firm, inelastic tubes. The matter which gives rise to this transformation is originally deposited in the form of fibrin, which gradually assumes the properties here assigned to it. The earthy degeneration is most common in old subjects after the sixtieth year; it usually, however, begins to form as early as the forty-fifth, and cases of it have been observed in very young children. Although it may take place in any of the arteries, it is most generally met with in the aorta and its larger 720 DISEASES AND INJURIES OF THE ARTERIES. branches, as the iliac, femoral, popliteal and innominate. What is remark- able, and, in the present state of the science, altogether inexplicable, is, that, while the artery of the thigh is so frequently ossified, the humeral artery is seldom affected. Another fact, not less singular, is that this transformation is comparatively rare in the female; a fact which satisfactorily accounts for the difference in the relative frequency of spontaneous aneurism in the two sexes. We occasionally meet with an instance in which there is a strong ossific diathesis, or tendency to this degeneration, nearly all the arteries in the body being converted into rigid cylinders. The earthy matter is deposited in an amorphous form, and is destitute of bone corpuscles ; consisting essen- tially of phosphate and carbonate of lime, in combination with a small quan- tity of albumen, which apparently serves as its matrix. The calcareous matter exists in various forms; sometimes in sraall grains and nodules, now in scales, plates, and patches, and now in complete rings, which, encircling the vessel, convert it into a firm, rigid, in- Fig. 231. flexible tube, completely destitute of its natural attributes, as seen in fig. 231. The inevitable effect of these changes, which are always most conspicuous in the inner coat, is to render the artery abnormally brittle, and, therefore, ill able to withstand the pressure of its contents. The starting point of this deposit is the subserous cellular tissue, whence it gradually extends to the substance of the inner and middle tunics, both of which are sometiraes com- pletely transformed by it. It is rare that the outer coat suffers from it; such a change, however, is not impossible, and I have seen specimens in which the deposit was apparently entirely restricted to it. The exciting cause of the calcareous transfor- mation is chronic inflammation. That this is the case is ren- dered clearly manifest by the fact that it is invariably accom- panied by more or less thickening and induration of the arterial tunics, independently of those produced by the deposit itself. The atheromatous deposit, fig. 232, now usually denominated Atheromatous deposits. the fatty degeneration, is, I believe, very rare among our native inhabitants, although it appears to be sufficiently common in our emigrants, especially the Irish and English. In Europe, it is said to be more prevalent in Great Britain than in any other country; a fact which accounts for the remarkable CHRONIC AFFECTIONS. 721 frequency with which aneurism occurs in that part of the world. How- ever this may be, the deposit always begins in the subserous cellular sub- stance, generally in minute, isolated points, not larger than the head of a pin, of a pale yellowish, whitish, or brownish color, somewhat greasy to the touch, and of a semi-concrete, friable consistence. In time, many of these points, or dots, coalesce, and so form irregular-shaped patches, which, push- ing the lining membrane before them, may involve the whole circumference of the tube, and extend several lines or even inches up and down in the direc- tion of its length. Having remained stationary for an indefinite period, the deposit manifests a disposition to softening and disintegration, and is ulti- mately converted into a curdy, friable, or, more properly speaking, a pap-like substance, possessing, apparently, all the properties of scrofulous pus. At this stage of the disease, the lining membrane is often elevated into small pustules, or little abscesses, which, bursting, discharge their contents into the blood, thus leaving a corresponding number of ragged and irregular ulcers, the base of which is formed by the middle tunic. The fatty deposit is most common in the aorta, particularly its thoracic portion, near the origin of the great cervical trunks. Its occurrence is almost peculiar to the aged. What the causes are, under whose influence it is de- veloped, has not been ascertained. That it is occasionally connected with imperfect alimentation, and the inordinate use of ardent spirits is unquestion- able, but that these circumstances are essential to its production, as some pathologists contend, is what we cannot admit; because the disease, as is well known, has been frequently witnessed in the stoutest and most temperate subjects, a fact which is entirely at variauce with such a conclusion. Under the microscope the atheromatous matter is observed to consist of albuminous and earthy particles, of crystal- line plates of cholesterine, of an imperfect fibrous texture, and of oil globules. The amount of fatty substance is frequently so great that it imparts a greasy stain to paper when dried on it by heat. The minute ap- pearances of this deposit are well shown in fig. 233. In regard to the different transformations now described, there are no remedies, which, so far as is at present known, are capable of exerting any influence over their develop- Fatty granules, with crystals of choies- t,,-, -V . , . ,. \ tenne, from atheromatous deposits in the inent. What treatment might accomplish, aorta if their diagnosis could be satisfactorily established, is an interesting problem for future inquiry to solve. To speak of administering remedies for their removal when we are unable to determine the fact of their existence is one of those practical refinements which are more befitting the transcendentalist and the idle speculator than the man of sound sense. Ulceration, as a consequence of arteritis, whether acute or chronic, is sel- dom witnessed. Manifesting a peculiar predilection for the larger trunks, it commonly commences in the serous membrane, from which it gradually ex- tends to the middle and outer tunics until it leads to complete perforation. Such a termination, however, is extremely rare. The ulcers, which are very irregular in respect to their form, vary much in their size, number, and gene- ral characters. At times they are very small, scarcely exceeding the diameter of a mustard-seed ; but they may be as large as a split pea, a five cent piece, or even a guinea, according to the size of the affected tube. Their margins are usually ragged, irregular, and considerably elevated, but seldom injected; their bottom, which is rough and uneven, is commonly formed by the middle vol. i.—46 722 DISEASES AND INJURIES OF THE ARTERIES. tunic, the fibres of which frequently present a shreddy, lacerated appearance. In many instances, the erosions look like so many fissures, cracks, or chaps, with sharp, prominent, and irregular borders. This form of the disease is ordinarily dependent upon the presence of calcareous matter. The number of ulcers is seldom considerable, though in a few rare cases the inner surface of the larger trunks has been found completely checkered with them. When confined to the internal tunic they sometimes admit of cicatrization. 3. INTRA-PARIETAL SEPARATION. There is an affection of the arte- ries, occurring exclusively in old per- sons, more particularly in women, to which the term dissecting aneurism has been applied; it is not, however, in reality, an aneurism at all, but merely a separation of the lamellae of the middle tunic, as has been satis- factorily established by the investiga- tions of Dr. Pennock, and by an ex- amination by myself of nearly all the reported cases of the disease. A more appropriate name would be intra-parietal separation. The lesion, which presents nothing of any prac- tical interest, inasmuch as it is always fatal, is entirely limited to the aorta and the larger trunks more immedi- ately connected with it, and is always dependent upon organic disease of the coats of the arteries, rendering them lacerable, and, consequently, in- capable of resisting the impulse of the blood. The manner in which the affection takes place is easily under- stood. In the natural state the dif- ferent coats are so intimately con- nected together that it is almost impossible, even by the nicest dissec- tion, to detach them from each other; but when they are altered by disease, or by some of the degenerations to which they are so liable, the connecting cellular tissue is rendered soft and friable, and their separation may then be effected with the greatest facility. In this condition, moreover, the tunics themselves are frequently very much changed, so that they are scarcely able to resist the slightest impulse. Now, if under these circumstances the lining membrane gives way, whether from ulceration, erosion, or rupture, the blood will insinuate itself into the accidental opening, which is thus gradually en- larged, at the same time that the fluid is forced on between the layers of the weakened middle tunic, dissecting them from each other as with a knife, and forming thus either a blind pouch or a distiuct canal, open at both extremi- ties, or at some intermediate point. The separation is not of the same extent in all cases. It rarely embraces more than one-fourth, one-half, or two-thirds of the circumference of the tube, while in length it may vary from six, eight, or ten lines to as many inches. Occasionally it reaches nearly from one extremity of the aorta to the other, The so-called dissecting aneurism, a. Semilunar valves ; b. External vessel laid open in its entire extent, so as to expose the aorta at c; d. Val- vular opening in the coats of the aorta, showing the communication of this vessel with the artificial channel, b; the probe e passed through the abnor- mal opening ; /exhibits the foramina between the aorta and the outer canal. VARICOSE ENLARGEMENT — ANEURISM. 723 being perhaps prolonged at the same time into the carotid, subclavian, and iliac arteries. 4. VARICOSE ENLARGEMENT. The arteries are liable to a dilated and nodulated condition, similar to that of the veins, and hence very frequently termed varicose enlargement. The affection has also been described under the name of varicose aneurism and of arterial varix. Its general features are well illustrated in fig. 235. The Fig. 235. Varicose enlargement. lesion, which is exceedingly rare, is met with chiefly in the superficial arte- ries, particularly in those about the head, the forearm, hand, leg, and foot; and consists in a remarkably tortuous, elongated, and convoluted state of these vessels, evidently dependent upon the effects of inflammatory action, as is shown by the fact that their coats are always abnormally thickened, either uniformly, or alternately thickened and attenuated. In elderly sub- jects it is generally associated with the fibro-cartilaginous, earthy, or fatty degeneration. The dilatation and varicosity sometimes affect an entire artery, but more commonly they are limited to particular portions of it; it may be restricted to one vessel, or occur simultaneously in several. When the diseased artery is superficial, the character of the lesion is rendered sufficiently clear by the tortuous and nodulated course of the vessel beneath the surface; but there are no pathognomonic signs when it is deep-seated. This affection rarely requires any treatment; for, even when the enlarge- ment is considerable, it is rather an inconvenience than an actual disease. In ordinary cases, the vessels may be supported by the constant use of a well- applied bandage, or of an apparatus constructed upon the principles of the laced stocking. During the forming stage, much may be done in the way of repressing development by astringent and soothing lotions, along with rest and elevation of the parts, and the occasional abstraction of blood, provided the patient be plethoric, in order to moderate the momentum of the circula- tion. When the disease proves troublesome, by causing pain and functional disorder, the only effectual remedy is ligation of the offending vessels, at the cardiac side of the enlargement. SECT. VI.—ANEURISM. An aneurism is a pulsating tumor, occupied by blood, and communicating with an artery deprived, either in part or completely, of its integrity. The subject of aneurism has been encumbered by too many divisions and subdivisions, and the consequence is that several lesions have been iricluded 724 DISEASES AND INJURIES OF THE ARTERIES. under it which do not, properly speaking, appertain to it. The effect of this over-refinement has been to embarrass the study of this disease, and to invest it with difficulties which are altogether foreign to it. The distinction of aneurism into true and false is one of great importance, and should, therefore, be retained. The same may be said in regard to spontaneous and traumatic aneurism. The term dissecting aneurism, introduced by Laennec, and adopted by most modern authors, should be discarded, inasmuch as the affection which it serves to designate has nothing whatever in common with aneurism; it is, in fact, as already stated, merely a separation of the coats of the arteries, without any tumor or symptoms denotive of that lesion. Then, again, as to the term varicose, which I have myself employed, along with others, in my writings, to designate a peculiar form of arterial lesion, it is obviously im- proper when we come to make a practical application of it. A varicose artery is, in reality, no more an aneurism than a varicose vein ; both affections consist essentially in a dilated and tortuous state of these two classes of ves- sels, and not, like aneurism, in a pulsating tumor, caused by the destruction, partial or complete, of the tunics of an artery. An anastomotic aneurism is a pulsating tumor formed by hypertrophy of the arterial and venous capil- laries of a part; critically speaking, therefore, the terra aneurism is not applicable to it, and yet, as it has been fully engrafted upon our surgical nomenclature, it is difficult to dispense with it, or to substitute one of a more expressive and appropriate character. The term true is applied to that species of aneurism in which one or more of the arterial tunics, without being necessarily perfect, form a part of the tumor. A false aneurism, on the contrary, is one in which all the coats have given way, the sac being composed of the surrounding'cellular tissue in a state of condensation. It was formerly supposed, chiefly through the influence of the writings of Scarpa, that there was no such disease as a true aneurism, but that in every instance, whatever may be the size, form, or site of the affection, there was a complete absence of the arterial tunics at the situation of the tumor. This opinion, however, has become obsolete, experience having shown that there are cases, although they are confessedly rare, in which the aneurism clearly consists of at least one, if not more, of the coats of the artery from which it springs. Each of these great divisions comprises several varieties, founded principally upon the form and volume of the turaor. Thus, an aneurism is said to be sacculated when it consists of a distinct bag, as so often happens in aneurism of the aorta and the principal branches given off from it; the term cylindroid is used when the swelling affects the artery uni- formly in its entire circumference, while Fig. 236. the tapering tumor is known by the appel- lation of fusiform. The words circum- ---y-y ---- scribed and diffused refer merely to the dimensions of the aneurism. Fi 237. ^he annexed sketches afford a good idea of the arrangement of the tunics of A^____________ the arteries in the principal varieties of ----' ' ---- spontaneous aneurism. In fig. 236 the tumor is formed by the expansion of all Flg* 238, the coats of the vessel, an extremely rare ______________f-^ event; in fig. 237 the middle tunic has " given way, the inner and outer being pre- served ; in fig. 238 the aneurism is Fig. 239. formed by the external tunic alone; in fig. 239 the two outer membranes have been _____________ruptured, the inner projecting through the =: crevice thus left, in the form of a hernia. LOCALITY, PREVALENCE, AGE, SEX, AND CAUSES 725 This variety is very uncommon, but cases of it have been reported by differ- ent authors, especially by Haller, Laennec, Dupuytren, and Dubois. It can occur only when the inner coat of the artery has been thickened and fortified by interstitial and surface deposits. Finally, aneurisms are divided into internal and external, the former ex- pression being used chiefly in reference to the aorta and to the arteries of the viscera, the latter in relation to the vessels of the extremities, the head, and neck. The words spontaneous and traumatic sufficiently explain themselves. 1. LOCALITY, PREVALENCE, AGE, SEX, AND CAUSES. Spontaneous aneurism does not occur with equal frequency in all parts of the body; on the contrary, there are a number of arteries which are almost entirely exempt from it, or which, at all events, so seldom suffer as to be scarcely entitled to notice. The vessel which is most frequently involved is the aorta; first in its ascending portion, then in the thoracic, and, lastly, in the abdominal. Next in point of liability to the disease are the popliteal artery, the femoral, common carotid, subclavian, innominate, axillary, and external iliac. The arteries of the leg and foot, the hand, forearm, and arm, the face, upper part of the neck, and of the viscera, together with the com- mon and internal iliac, rarely suffer in this wise. Traumatic aneurism may occur in any of the arteries, but is most common in such as are most exposed to external injury. If we attempt to inquire into the causes which induce spontaneous aneurism more frequently in one artery than in another, we shall be met by difficulties. Several circumstances, however, may be assigned as affording at least a plausi- ble explanation of the circumstance. 1st. It is well known that certain arteries are peculiarly prone to the cal- careous and atheromatous degenerations, while others, on the contrary, are almost entirely exempt from them, whatever may be the condition of the rest of the arterial system, or the age of the patient. Now, dissection has shown that those vessels which are most frequently diseased in this way are also those which are most frequently affected with aneurism, and conversely. Spontaneous aneurism of the arm and forearm is among the rarest occur- rences, and everybody knows how free their vessels are from the degenera- tions in question. In the aorta and popliteal artery, on the other hand, they are extremely common, and it is here, as already seen, that spontaneous aneurism is most frequent. 2d. In the next place, some influence is no doubt due, in the production of this difference, to the force with which the blood impinges against the walls of the vessels. Thus, in the aorta, which is more prone to aneurism than any other vessel, the ascending portion, particularly its anterior and right side, suffers more frequently than any other part, and it is here that the blood exerts its greatest force, as it is pumped up from the left ventricle. The popliteal artery, which comes next in the order of involvement, is sub- jected, in a degree beyond that of any other vessel in the extremities, to a similar influence during the flexed condition of the limb. 3d. It is not improbable that some influence is also due to the weakness which the arteries experience at the origin of their larger branches. The fibres of the middle tunic suffer a species of separation here, in consequence of which they are less capable of withstanding the shock of the blood as it is directed against them. However this may be, experience teaches that aneurism is peculiarly liable to occur at these points. 4th. Another circumstance which may be supposed to favor the production of aneurism is the motion to which the arteries are subjected, especially dur- ing sudden and violent efforts. Such an influence must be particularly felt 726 DISEASES AND INJURIES OF THE ARTERIES. by the ascending portion of the aorta during bodily and mental excitement, and by the popliteal artery in the various muscular exertions of the lower extremity. How far any one of these causes alone is capable of producing aneurism is altogether a matter of conjecture. Without degeneration of the arterial tunics, they would probably exert but little influence, while under opposite circumstances it must be very great. Indeed, it is very questionable whether aneurism would be one-twentieth part as common as it is, if the arteries were altogether exempt from the earthy and atheromatous deposits; nay, we may go further, and assert, positively, that if these deposits could be prevented, spontaneous aneurism would almost cease to exist. The occurrence of aneurism would seem to be influenced by climate or locality. The infrequency of the lesion in the inhabitants of the southwestern States of North America, is proverbial. In a practice in Ohio and Kentucky of twenty-three years, in which I witnessed almost every surgical disease in- cident to the human race, it rarely occurred to me to meet with an example of spontaneous aneurism. My experience, in this respect, is fully sustained by that of Dr. Dudley, of Lexington, whose practice embraced a wide field, which has since been so successfully cultivated by Professor Bush, of Transyl- vania University. Both these gentlemen assured me, some years ago, that this affection had been extremely rare within the range of their observation. Professor T. G. Richardson, now of New Orleans, superintended, while De- monstrator of Anatomy in the University of Louisville, the dissection of several hundred bodies, and yet he hardly met with an instance of the malady. The testimony of Dr. Bayless, who formerly occupied the same position, is precisely to the same effect. To what this extraordinary immunity is due, we have no means of determining. The population of that region of the United States is a mixed and laborious one, made up from all parts of the civilized world, and pursuing all kinds of occupations, from the most delicate and refined to the most rude and vigorous, and yet a case of spontaneous aneurism, in any class of its citizens, is absolutely an anomaly. My impres- sion is that the disease is equally uncommon in our northern and middle States; but upon this subject it is necessary to speak with some degree of reserve, as we have no positive data to guide us. In regard to the prevalence of aneurism in our larger towns and cities, our information is also very imperfect. Professor Gibson, formerly of the Uni- versity of Pennsylvania, asserts that the disease is quite infrequent in Phila- delphia, and this I am inclined to believe to be the fact, from the results of ray own inquiries. In New York, on the contrary, it would seem, according to the statement of Dr. Mott, to be quite frequent; a circumstance which is, perhaps, not surprising, when we consider the heterogeneous character of the people of that city, and, above all, the extent of its commerce, and the numerous accidents incident to its pursuits. What is remarkable, however, is, that nearly all the cases met with by this distinguished surgeon, during a period of upwards of forty years, occurred among native-born citizens of the United States. In opposition to this fact, however, I have the authority of Dr. John Watson and others, of Isew York—as communicated to me by Dr. Lente—for stating that the great majority of cases of aneurism in that city, especially in hospital practice, are met with among those of foreign birth. The negroes of that city would also seem to be particularly obnoxious to the disease. Aneurism is uncommon in the East and West Indies, in the British Pro- vinces of North America, and on the continent of Europe, especially France, Italy, and Germany. In Great Britain, on the contrary, it is sufficiently fre- quent ; more so, perhaps, than in any other part of the globe. According to the report of the registrar-general, it appears that the number of deaths LOCALITY, PREVALENCE, AGE, SEX, AND CAUSES. 727 from aneurism, in England and Wales alone, during a period of five years__ namely, from 1838 to 1842—was 593; being an annual average of one in about 131,000 of the inhabitants. The various hospitals of London receive every year a large number of cases of this disease. The people of Ireland are said to suffer more frequently from aneurism than any other race. The causes of aneurism are divisible into predisposing and exciting. Of the former, the most constant, and, therefore, the most important, is a dis- eased condition of the arterial tissues, usually presenting itself in the form of the earthy and atheromatous degenerations. These degenerations, by ren- dering the coats of these vessels preternaturally brittle and lacerable,"cause them to yield more readily under the impulse of the blood and the various extraneous circumstances which have a tendency to stretch and twist them. I have already expressed the belief that, but for these alterations, spontaneous aneurism would be almost unknown. The influence of age and climate in the production of this disease, is adverted to in the preceding paragraphs. All laborious pursuits, involving sudden and violent muscular exertion, power- fully predispose to its occurrence. Hence, it is more comraon among sailors, and those who* are much accustomed to athletic exercises, than among any other class of individuals. Soldiers suffer much less frequently than was formerly supposed. Men engaged in agricultural pursuits, although their labor is often severe, are, in great measure, free from the disease, owing, doubtless*, to the want of liability of their arteries to abnormal deposits. Protracted courses of mercury, a syphilitic taint of the system, and the con- stant and inordinate use of ardent spirits, are supposed to predispose to the formation of aneurism ;.but how far, or in what degree, remains to be demon- strated. The immediate cause of aneurism is rupture of the coats of the arteries, in consequence of severe muscular exertion unduly stretching these vessels; or, as in the case of the aorta and its larger offsets, an inordinate impulse of the blood, during the sudden and violent contraction of the left ventricle of the heart. The vessels, weakened by the degeneration of their tissues, and de- prived of their elasticity, readily yield to the forces thus applied, commonly at a particular point, which is afterwards converted into a distinct pulsating tumor, composed generally, in great measure, if not exclusively, of the external tunic of the artery along with more or less of the circumjacent cellular tissue. Sometimes the exciting cause of the disease is ulceration, but such an occur- rence is comparatively rare, especially as an affection unconnected with the earthy and atheromatous deposits. This process, as stated in a previous section, should not be confounded with the cracks or fissures which so often follow these deposits, seeing that the latter are usually the result, not of a vital action, as is the case in true ulceration, but of a mere mechanical one, gradually effected under the impulse of the blood, as it rushes over the inner coat of the diseased vessel. Aneurism occasionally exists simultaneously in several arteries. Thus, it is by no means uncommon for a patient to have one tumor of this kind in the aorta and another in the carotid, subclavian, popliteal, femoral, or external iliac artery. I have seen several instances of the co-existence of popliteal aneurism in the same individual. When the disease affects a considerable number of arteries, it constitutes what is termed the aneurismal diathesis; a circumstance which imperatively contraindicates surgical interference, how- ever favorably the external tumor raay be situated for operation. Weak, sickly persons, of depraved constitution, and intemperate habits, are the most common subjects of this diathesis. Several remarkable examples of this pre- disposition to the formation of aneurism are upon record. Pelletan gives one in which the number of tumors was upwards of sixty, and in another, related by J. Cloquet, there were more than two hundred, the patient being 728 DISEASES AND INJURIES OF THE ARTERIES. a man fifty years of age. The aneurisms, in this instance, affected nearly all the arteries in the body, but they were most numerous in those of the extre- mities, the axillary, humeral, radial, ulnar, femoral, popliteal, tibial, and peroneal being all closely studded with them. It has long been known that the formation of aneurism is influenced, in a remarkable degree, by age. Prior to the age of thirty, the disease is extremely rare, and up to the period of puberty it is almost unknown, even in the aorta, which is so much more frequently affected than the other vessels. The greatest number of cases, by far, occur between the thirty-fifth and fiftieth year; a good many cases are also met with during the next decennial period and a half, but after that time the malady is very rare ; probably not that the pre- disposition to it ceases, but because, as it seems to me, in the first place, the number of subjects is comparatively small; and, secondly, because persons at this age are much less exposed to violent muscular and mental excitement than during the meridian of life. That this supposition is true, is rendered highly probable by the fact that the earthy and atheromatous deposits gene- rally exist iu greatest abundance in advanced life. The absence of these deposits in young subjects readily explains the non-occurrence of aneurism in children and adolescents. An instance of spontaneous popliteal aneurism in a boy only nine years old occurred iu the practice of Mr. Syme, of Edinburgh, in 1844, and is the only case at this early age upon record. Males suffer frora aneurism more frequently than females, but in what pre- cise proportion has not been determined. The question has hitherto engaged but little attention, and it is obvious that it can be decided only by the ana- lysis of a much larger number of cases than have yet been adduced for the purpose. It has been alleged that the relative frequency of carotid aneurism in the two sexes is nearly equal, and the occurrence has been attempted to be accounted for on the supposition that the arteries of the neck of the female are nearly as much exposed to all kinds of violence and muscular exertion as those of the male. Little confidence, however, can be placed in such opin- ions ; for, before we can receive them as true, we must be satisfied that the disease is as common in women as in men, which I am very certain it is not. Mr. Crisp, in his excellent work on the diseases of the arteries, states that of 551 cases of aneurism of all kinds, more than seven-eighths occurred in men. Having long been impressed with the belief, founded upon numerous dis- sections, that the difference in the relative frequency of aneurism in the two sexes was due, not to any difference in their occupation, but to the difference in the relative frequency of the earthy and fatty degenerations of the arteries, I was induced to institute special inquiry into the subject, and am gratified to be able to say that my views are fully confirmed by the statements of Dr. D. Hayes Agnew, Dr. C. E. Isaacs, Professor T. G. Richardson, and Pro- fessor J. B. S. Jackson. The testimony of these teachers, who are all well known as able and experienced practical anatomists, tends to show, indispu- tably, that females are much less subject to chronic disease of the arteries of every description than males. Neither their information, however, nor my own, is such as to enable me to determine the relative proportion of these degenerations in the two sexes, in a given number of cases. That it corres- ponds very closely with the difference in the number of cases of aneurism is what may readily be believed, and what future observation will, no doubt, abundantly verify. If we assume what is here said to be true, it follows that the opinion which ascribes the greater frequency of spontaneous aneurism in males than in females to their more laborious occupation, their more intemperate habits, and their greater exposure to all kinds of disease, is entirely untenable, and, VARIETIES OF ANEURISM. 729 therefore, unworthy of confidence. Women, it is true, are not sailors, car- penters, blacksmiths, or hod-carriers, but in many parts of the world they are tillers of the soil, and engaged in almost every variety of pursuit calcu- lated to rupture the arterial tunics if they were in a serious state of disease, such as we so often meet with in the other sex. 2. VARIETIES OF ANEURISM. True aneurism presents itself under two varieties of form, differing from each other materially in their appearance and mode of formation, although their essential symptoms and effects are usually perfectly similar, if not iden- tical. These two varieties are the tubular and the sacciform, terms which are sufficiently expressive of their general conformation. Each consists of one or more of the arterial tunics, and forms a tumor, which, in time, is capable of exerting the most injurious effects upon the neighboring struc- tures, and of causing the death of the patient. The sacciform variety, fig. 240, is by far the more common of the two. It essentially consists, as the name denotes, in the formation of a pouch, bag, or sac, connected with the side of the affected artery. In the tubular variety the tumor is formed at the expense of the entire circumference of the vessel; in this, on the contrary, it occupies only a limited portion of it. The arteries which are most liable to suffer from sacciform aneurism are the aorta, particularly its thoracic di- vision, the popliteal, femoral, innominate, carotid, and subclavian. The number of tumors is subject to considerable diversity; cases have been reported in which there were so many as to constitute a genuine anenrismal diathesis, nearly all the princi- pal arteries in the body affording several examples of its occurrence. In general, however, there is only one, although others may form during its progress. Thus, it oc- casionally happens during the march of popliteal aneurism that an aneurism forms in the aorta, the carotid, or in the popli- teal artery of the opposite side. The co-existence of aneurism in different parts of the body, and the tendency to its successive development deserve special attention on account of their practical relations ; a subject to which allusion will again be made in another part of this chapter. The sacciform aneurism is capable of assuming a great variety of forms ; the most common, however, is the globular, or ovoidal; in rare cases it is conical, elongated, or irregularly flattened, like a shot-pouch. Much diver- sity also obtains in regard to its dimensions; thus, while in some instances it is hardly the volume of a hazelnut, in others it is as large as the fist, or the head of the patient; in general, however, it does not exceed a hen's egg, or a medium sized orange. The largest aneurisms of this kind are usually found in the aorta and in the popliteal, iliac, and innominate arteries. The attachment of the tumor to the artery is comraonly affected by a narrow footstalk ; but cases occur in which it takes place by a broad and extended base, and, under such circumstances, it is not unusual for the artery to suffer serious compression during the progress of the disease. Sacculated aneurism, a. Artery ; 6. Aneu- rismal pouch. 730 DISEASES AND INJURIES OF THE ARTERIES. The orifice of communication, fig. 241, between the sac and the artery varies in different preparations. When the tumor arises by a narrow foot- stalk the opening is usually proportion- Fig. 241. ably small, with smooth and well-de- fined margins. When, on the other hand, it is attached by a broad base, the aperture is always much larger, and its edges are also more irregular, some- times, indeed, quite shreddy and ragged, as if they had been torn. The situa- tion of the orifice is commonly towards the centre of the sac, but it may be at one side, or even at one of its extremi- ties. The form of the opening is ex- Aneurism of the aorta; the greater part of tremely variable, and admits of no the cyst being filled with clots, and the aperture specific description. In the early stage of communication being small. of the disease, and in nearly all cases where the tumor is small, the orifice is of a rounded or circular configuration, while in cases of an opposite cha- racter it is generally more or less irregular. The internal and middle tunics may terminate abruptly at the margins of the opening of communication, or they may extend into the cavity of the sac, and thus serve to give it a par- tial lining. The composition of the sac is easily understood. For the most part it consists simply of the external tunic, the inner and middle having given way either prior to, or during, the development of the disease. The first thing, in fact, that usually happens, in all such cases, is the destruction, by ulcera- tion or some other disorder, first, of the internal, and, soon after, of the middle layer of the artery, leaving thus a kind of crevice, which gradually enlarges under the influence of the impelling column of blood, and thus permits the corresponding portion of the vessel, now of course greatly weakened, to be converted into a pouch. This pouch, usually called the aneurisraal sac, is originally, then, composed exclusively of the external coat of the affected vessel, the other strata terminating abruptly at the raargiu of the opening of communication, neither of them being prolonged into its interior. But this pouch would be very weak, and, consequently, ill adapted to withstand the shock of the blood as it rushes into its interior, if it were not strengthened by adventitious aid, derived from interstitial deposits in the surrounding cel- lular tissue. We accordingly find that nature, ever on the alert to save the part and system, is prompt in supplying the required relief by setting up in- flammation and pouring out plastic matter, both in the substance of the sac aud in the neighboring structures, thereby thoroughly gluing them together, at the same time that they are greatly increased in thickness and density, and thus enabled more effectually to resist the effects of the ever-beating, dashing, aud tumultuous sanguineous current within. Such aid, then, is wise and needful, and, fortunately, always comes in play at an early stage of the dis- ease, the laceration of the inner and middle tunics of the artery, and the pressure of the blood against the tumor, being sufficient causes of inflamma- tion. Although the sac is generally composed of the outer tunic alone, cases, nevertheless, occasionally occur where it consists, in the first instance, exclu- sively of the inner coat, the other two having given way. That such an arrangement is exceedingly infrequent, is proved by the fact that many sur- geons of large experience have warmly contested the possibility of its exist- ence. Haller and his cotemporaries, however, met with undoubted cases of it, and, in more recent times, it has been witnessed by Breschet, Dupuytren, VARIETIES OF ANEURISM. 731 and other observers, who have given particular descriptions of it. One ground for assuming that this form of aneurism cannot occur is, that it has never followed the numerous attempts that have been made to produce it iu the in- ferior animals, by exposing the carotid artery and dissecting off its outer and middle tunics. In every experiment of this kind, the denuded membrane maintained its integrity, and the breach was speedily repaired by a free de- posit of plastic matter. There is, however, no analogy between a sound and a diseased artery, and this fact should be borne in mind in the discussion of the subject. When the outer and middle tunics are destroyed by ulceration, as they always must be in such a case, not rapidly, but by slow degrees, it is not difficult to suppose that the inner membrane may, at the injured and weakened part of the vessel, be made to bulge across the opening, in the form of a thin, translucent cyst. Interstitial deposits would soon aid in strengthening the cyst, although ere long, and before it has acquired any con- siderable bulk, it would be obliged to yield to the resistless impulse of the blood within. Haller designated this form of aneurism by the term hernia of the inner coat of the arteries. Cases in which the sac consists of the outer and inner coats of the artery, the middle having been destroyed, although also exceedingly infrequent, are more common than those in which it consists of the internal tunic alone. Such an arrangement is occasionally observed in aneurism of the carotid, femoral, and popliteal arteries; but, in time, the lining membrane is sure to give way, leaving thus the cyst composed of the outer coat aud the surround- ing tissues, as in the ordinary form of sacculated aneurism. The thickness of the sac varies, in different cases and under different cir- cumstances, from the fourth of a line to the fourth of an inch. Its consistence is often remarkably tough, and, in cases of long standing, it is generally composed of several distinct strata, of a gray- ish, whitish, or drab-colored aspect, consisting of fibres which intersect each other in every conceivable direction. The outer surface of the tumor is rough and shreddy ; the internal, on the contrary, is smooth and polished, only, however, as a general rule, in its earlier stages, for in time it also becomes rough, and is finally incrusted with fibrinous matter. Notwithstand- ing the thickness of the aneurismal sac, and the efforts which nature makes to strengthen it, it gradually dilates, as in fig. 242, under the impulse of the inflowing column of blood, and at length, after the lapse perhaps of several months, manifests a disposition to yield at one or more points, very much as an abscess does, the activity of the absorbent vessels exceeding that of the capillary vessels. The sacciform aneurism always contains, even at an early period after its formation, fibrinous concretions, the presence of which constitutes one of its most interesting and im- portant features, as they are evidently designed, not only to strengthen the turaor, but to aid in its obliteration, and, consequently, in the production of a permanent cure, although such an event is extremely rare. In their arrange- ment, these clots are always concentric, not unlike the layers of an onion, one being piled upon, and closely connected to, another. Their color and density vary according to the period of their formation, the older being usually of a pale, yellowish appearance, and of a firm, fibrous consistence, while such Fig. 242. Sacciform aneurism of the aorta ready to give way. 732 DISEASES AND INJURIES OF THE ARTERIES. as are of a comparatively recent date, exhibit very much the aspect and con- sistence of a common heart clot. Their thickness ranges from the fourth of a line to that of a sheet of paper; and their number is often immense, thou- sands existing in a tumor perhaps not larger than an ordinary fist. That these concretions are organized, at least in many cases, is evinced by their intimate adhesion, not only to each other, but also to the inner surface of the sac, by their extraordinary density, and by their yellowish hue, which con- trasts most strikingly with that of recently deposited fibrin and coagulated blood. These circumstances show that these lamellae undergo most import- ant changes after they have been deposited ; that absorbent vessels are busily engaged in carrying away the serum and coloring matter of the blood, and in solidifying the fibrin after it has been extricated from the general mass; while the successive development of concretions clearly denotes that the pro- cess is as much a vital as a mechanical one. No one, I believe, has yet suc- ceeded in demonstrating any vessels in these strata; but that they are always present, and often in great numbers, in cases of long standing, does not admit of any reasonable doubt. We may look upon these clots, then, as ex- ceedingly interesting structures, capable, after a certain period, of maintain- ing a kind of independent existence, and whose primary object, in all cases, is to strengthen the aneurismal sac, and, under favorable circumstances, to fill it up, so as to effect a radical cure. What adds to the force of this con- clusion is the fact that, when a cure of this description has been effected, the tumor is gradually brought under the influence of the absorbent vessels, by which it ultimately entirely disappears, with the exception, perhaps, of a little nodule, not larger than a pea, and just sufficient to indicate the former site of the disease. It is proper to observe that the recently-formed strata of an aneurismal sac are, in general, very imperfectly, if at all, organized ; they are certainly not vascularized and furnished with absorbents. How are these aneurismal concretions formed ? Upon this subject there still exists some contrariety of sentiment. Most pathologists, however, sup- pose, and very correctly, as I think, that they are deposited from the blood as it sweeps over the inner surface of the sac, during which more or less of its fibrin is disengaged, while the other elements of the fluid are sent forward to mingle with the current in the affected artery. This opinion derives plausibility from the fact that the development of these strata always pro- ceeds most rapidly when there is a comparatively small orifice of communi- cation, with a languid state of the systemic and aneurismal circulation. It has been conjectured that the clots had their origin in an effusion of plastic matter, such as occurs in traumatic injuries and ordinary inflamraation ; but for such a view I can myself perceive no just ground, as it is impossible to discover the slightest similarity between the two processes. I have stated in the preceding paragraph that the act of formation is both a mechanical and a vital one ; mechanical as far as the mere separation of the fibrin from the * blood is concerned, and vital as it respects the decolorization, condensation, and intimate adhesion of the concretions. The tabular aneurism is extremely rare ; it is observed principally in the aorta, and the branches which are immediately detached from it, especially the innominate, carotid, and iliac, and consists in a uniform dilatation of the vessel, usually composed of all its tunics in varying degrees of alteration. In its shape, the tumor is commonly somewdiat spindle-like, and hence it is often described under the name of fusiform aneurism ; the term cylindroid has also been applied to it, as its conformation occasionally partakes strongly of that character. The word tubular, however, is more expressive of its appearance, and I therefore adopt it in preference to any other. The annexed drawing, fig. 243, from a specimen in my collection, affords a good idea of this variety of the disease. VARIETIES OF ANEURISM. 733 243. The size of the tubular aneurism varies from slight increase of the normal diameter of the vessel to a tumor capable of receiving a large fist. When it occupies the arch of the aorta, it often projects up into the neck Fig. so as to form a prominent swell- ing above the sternum, admitting of satisfactory examination, both by touch and auscultation. The distance between the origins of the carotid arteries is greatly in- creased, and the aneurism gene- rally encroaches sensibly upon the heart. In nearly every in- stance its length considerably exceeds its diameter. The dila- tation of which it consists seldom terminates abruptly, butis usually lost by insensible degrees in the vessel above and below, thus giving the tumor the appearance of two cones united at theirbases. In the sraaller arteries, as, for ex- ample, the innominate, the aneu- rism sometimes involves the whole length of the vessel. The structure of the tubular aneurism is usually made up of all the tunics of the affected ar- tery, in a notable state of alter- ation, of which hypertrophy constitutes the most striking feature. In two remarkable specimens in my collection, the different tunics are immensely thickened, and increased in strength and density, the effect, evidently, of long- continued interstitial deposits ; they both occupied the arch of the aorta, extending as far as the origin of that vessel, and were taken from male sub- jects upwards of fifty years of age. The lining membrane has lost its white and glossy appearance, and has been replaced by a thick, opaque, and rugose structure, having none of the properties of the original texture. The middle coat is at least ten times as thick as naturally, very strong, elastic, and de- prived of its yellowish hue ; the outer one is also greatly changed in its ap- pearance, being remarkably strong, thick, and firm. No evidence whatever exists in any of the tunics of the earthy, atheromatous, or fatty degeneration. From a careful examination of this form of aneurism, it appears to me to consist essentially in a dilatation of the caliber of the artery with hypertro- phy of its different tunics. The first step, probably, in its formation is chronic inflammation, causing weakness of the walls of the vessel, and uni- form enlargement of its diameter. By and by, however, as the dilatation increases, the coats become strengthened in every direction by interstitial deposits, and it is thus that a tumor is at length formed capable of offering great resistance to the impulse of the blood. It is owing to this superaddi- tion of matter that the tubular aneurism so seldom gives way by rupture, a circumstance in which, as well as in several others, it differs remarkably from the sacciform variety of the disease. It is not to be supposed, from what precedes, that this form of aneurism always consists of the different tunics of the affected artery ; this is unques- tionably true in most cases, but we now and then meet with an instance in which the lining membrane, and perhaps, also, the middle layer, are partially Tubular aneurism of the aorta, a. The aorta, much hypertrophied. b. The heart. 734 DISEASES AND INJURIES OF THE ARTERIES. deficient, thus causing irregularity in the dilatation, unless, as occasionally happens, the defect is atoned for by plastic deposits. Indeed, the retention of all the tunics would seem to be an essential condition to the formation of the true tu- bular aneurism; if the inner and middle lamellae be destroyed, even to a small ex- tent, the blood will dilate the vessel un- equally, and inevitably give rise to a saccu- lated tumor. It is in this way that we may explain the occasional coexistence of the two forms of the malady. The tubular aneurism is remarkable, besides some of the characters already pointed out, for the absence of fibrinous concretions, which are so comraon in the sacciform ; and the circumstance may be employed as an additional evidence of the correctness of the view, so long and so generally entertained, that the formation of these substances takes place directly from the circulating fluid, and not as an effect of the deposition of plastic matter, conse- quent upon inflammation, as some have conjectured. If the development took place in the latter way, it ought to be of frequent, if not of constant occurrence, inasmuch as the inner coat of the affected artery is sel- dom entirely free from inflammation, and would thus afford a large surface for the effusion of fibrin; but every one who has ever examined a specimen of tubular aneu- rism, knows how extremely rare it is to find its walls incrusted with anything. In the annexed sketch, fig. 244, from Hodgson, a tubular aneurism is seen occupied by con- centric concretions, with a central canal, which preserved the continuity of the vessel, and thus permitted a continuance of the circulation. The stratification ap- pears to have been very perfect. Aneurism, by dilatation. The abnormal space is almost entirely filled up by fibrin; the arterial canal remaining clear. Spon- taneous cure exists in an advanced stage. 3. SYMPTOMS OF ANEURISM. The symptoms of aneurism exhibit, as might be supposed, much diversity, the principal circumstances which influence them being the nature, seat, and age of the tumor. Hence, in order to comprehend the subject thoroughly, it must be studied with special reference to these points. In spontaneous aneurism, which usually depends upon rupture of the coats of the artery, the patient is often apprised of the commencement of the dis- ease by the occurrence of a sharp pain, not unlike that produced by an elec- trical shock ; he feels as if he had received a smart blow, and perhaps turns round to see who inflicted it. Occasionally, also, he is conscious of some- thing having suddenly given way—he may even have heard a slight noise— and on examining the part a small pulsating tumor is found. Upon being interrogated as to the cause of the accident, he will usually state that it took place while he was engaged in sorae severe bodily exertion, as leaping, run- ning, lifting, or coughing. But the origin of the disease is not generally SYMPTOMS OF ANEURISM. 735 thus marked ; in the majority of cases, in fact, the patient has no distinct perception of its occurrence, and he is only apprised of its existence by de- grees ; not, perhaps, until it has already made serious progress. Such an event will be particularly apt to happen when the lesion consists essentially in a dilated condition of the arterial tunics, unattended with rupture, as it is then often extremely stealthy in its mode of invasion. In traumatic aneu- rism, on the contrary, the characteristic symptoms ordinarily show themselves immediately after the receipt of the injury of the vessel upon which the dis- ease is situated. The aneurismal tumor is usually quite small at its commencement, not ex- ceeding, perhaps, the volume of a filbert, a small hickory-nut, or an almond; by degrees, however, it increases in size, and ultimately may acquire a bulk equal to that of a man's fist, or even of an adult's head. In its form it may be globular, elongated, ovoidal, conical, fusiform, or cylindrical; or so irre- gular as to defy description. However this may be, it is a living, beating tumor, rising and expanding synchronously with the contraction of the left ventricle of the heart. Its pulsations are often perceptible at the distance of a number of feet, especially in strong, plethoric subjects, and are always increased in force and frequency by whatever has a tendency to excite the general circulation. It imparts a distinct impulse to the hand, rising and falling as the blood enters and passes out; it is soft and elastic, and in its earlier stages permits itself to be emptied by steady and uniform pressure. Upon applying the ear to the tumor a peculiar noise is perceived, differing very much in its character and intensity. In general, it is a sort of saw- ing, rasping, or bellows sound, and so loud as to be heard with great dis- tinctness at a distance of several inches; occasionally it is of a peculiar whiz- zing, whirring, or purring nature, and cases occur, although they are rare, iu which it strongly resembles the buzzing of a fly in a bottle. The imme- diate cause of the sound is the manner in wdiich the blood rushes into the tumor; its pitch is always greatest, other things being equal, when there is a comparatively small opening of communication, and when the sac, contain- ing but little solid matter, is seated superficially. The phenomena now described are, in general, susceptible of great modifi- cation by pressure applied to the artery above and below the tumor. In the former case, the size of the swelling is notably diminished and all motion and noise disappear; in the latter, it is sensibly augmented, the tumor heaves and rises under the resistance, and the blood, rushing violently against the inner surface of the sac, at each systole of the heart, produces great tumult, with a corresponding increase in the intensity of the different sounds. Con- siderable changes in the aneurismal sounds are sometiraes occasioned by the rugose condition of the margins of the orifice of communication, and by par- tially detached clots, or projecting filaments, within the sac, intercepting the column of blood, and causing various murmurs and vibrations, together with a tremulous shaking of the tumor, isochronous with its pulsations. The pain attendant upon aneurism is constant, but subject to variation in its intensity; slight early in the disease, and while the swelling is still small; more severe and harassing as it progresses and encroaches upon the surround- ing parts. Diversified in its character, it is generally dull, aching, and throb- bing, as if matter were about to form; in some cases it is sharp and darting, in others dull, heavy, or gnawing. Occasionally it is of a neuralgic nature, coming in fits and starts, or, as sometiraes happens, in regular paroxysms, once or twice in the twenty-four hours. The immediate causes of the pain are, inflamraation of the sac and the pressure of this upon the neighboring structures; hence it is always greatest, as a general rule, in large and old aneurisms, and in those parts of the body which are most abundantly supplied with nerves. 736 DISEASES AND INJURIES OF THE ARTERIES. For the same reason that the pressure of the tumor causes pain, the distal parts usually suffer from numbness, and a sense of aching and weariness. Their temperature is diminished ; and they are weak and crippled. Great swelling, of an cedematous character, is often present, the result, evidently, of the compression of the veins and lymphatics impeding the return of their contents. As the tumor enlarges, the distal portion of the artery contracts and conveys less of its wonted supply to the lower parts. Gradually, how- ever, this is compensated for by the collateral vessels, which, naturally exist- ing, augment in size, and, in time, amply atone for the diminished stream in the main trunk. If it were not for this arrangement, the parts would soon shrivel and wither, or, worse, fall a prey to gangrene. Fortunately, such an event can only happen when the aneurism is of extraordinary bulk, or of very rapid development, thereby compressing also the collateral vessels and the principal nerves. Aneurism of the thoracic aorta, and of the innominate and carotid arteries, is nearly always attended with distressing dyspnoea, severe pain, and palpita- tion of the heart, which is itself often seriously implicated in the disease, being especially liable to suffer from hypertrophy, softening, and fatty degene- ration, along with chronic endocarditis and disorder of the tricuspid and semilunar valves. As the tumor enlarges, the respiratory difficulty rapidly increases, rendering walking painful, and the maintenance of the recumbent posture ultimately impossible. Compression of the trachea may induce as- phyxia, and of the oesophagus, inanition. In the abdomen and pelvis, aneu- rism of the larger arteries, besides causing violent pain, may occasion serious functional disturbance, by interfering with the return of the blood in the vena cava, and thus leading to ascites and anasarca. 4. DIAGNOSIS OF ANEURISM. Although the symptoms of aneurism are, in general, so well marked as to render it difficult to mistake their import, yet, as the disease may be simulated by other affections, and as doubts may thus arise in the mind of the inquirer concerning its true nature, it is necessary, in every case, however well-charac- terized it may apparently be, before he comes to a final decision, to institute a faithful examination into its history, progress, and present condition. It has been for the want of proper care in the investigation of this disease that some of the most serious and disgraceful blunders that disfigure the records of surgery have been committed ; and, although such errors are now less fre- quent than they were formerly, owing to the more general use of the exploring needle, and a better acquaintance with pathological anatomy, yet it cannot be denied that what has occurred once may happen again, and that with ten- fold effect, as it respects the character of the surgeon, who, to his skill as an operator, is always supposed to unite that of an enlightened diagnostician. The affections with which aneurism is raost liable to be confounded are, chronic abscesses, glandular tumors, and encephaloid growths. Attention to the following circumstances will, if carefully remembered, enable the practitioner to avoid error. 1. Aneurism is always, from the first, seated in the direction of one of the larger arteries, whose course may often be distinctly traced by the finger; it is soft and elastic, pulsates more or less violently, is free from pain, and is unattended with discoloration of the integuments. Abscess, on the contrary, begins as a hard swelling, and becomes soft only after it has passed through its different stages; if chronic, matter will form very slowly, and, although it raay surround the artery, and thus receive its impulse, yet the peculiar fluc- tuation of the swelling, and the changes that raay be induced in it by pres- sure and posture, will always suffice to prevent error. In acute abscess, DIAGNOSIS OF ANEURISM. 737 there is severe pain, pus is poured out rapidly, and there is marked discolora- tion of the surface, with more or less constitutional disturbance. Glandular lymphatic swellings are most common in the neck, axilla, and groin in children and young persons of a strumous diathesis; they generally advance pretty rapidly, and, after having attained a certain bulk, either remain stationary, or alternately advance and recede ; they are usually multiple, and not unfre- quently occur simultaneously on both sides of the body. External aneurism, on the contrary, is most common in the popliteal, femoral, innominate, and carotid arteries, in middle-aged and elderly subjects, and, progressing slowly but steadily, never recedes, and rarely exists in more situations than one at the same time. Encephaloid growths occur at all periods of life and in nearly all regions of the body ; soon acquire a large bulk; are of varying degrees of consistence, some parts being solid, some soft, and some semi-solid; are attended with great enlargement of the subcutaneous veins; and soon give rise to that pale and sallow state of the features known as the cancerous cachexia. Aneurism, as just stated, advances tardily, is of uniform consist- ence, especially in its earlier stages, is not accompanied by any enlargement of the subcutaneous veins, and, although the general health may seriously suffer, there is an entire absence of cancerous? impress. 2. Aneurism pulsates the moment it is developed ; no matter how small it may be, it throbs and heaves isochronously with the action of the heart, and possesses all the characteristic traits that distinguish it in its later stages, although they are perhaps less strongly marked. Abscesses and solid tumors, on the contrary, are seldom affected by the beating of the underlying vessel until they have acquired some bulk, and even then the impulse is often very faint, occurring rather as an undulatory movement than as a distinct shock. 3. In aneurism the tumor is generally firmly fixed, any attempt to grasp and lift it up proving abortive ; possibly, it may be pushed gently to one side or the other, but this is all. Moreover, whatever changes may be effected in its relations none can be effected in its pulsations ; it throbs and heaves as before. With solid growths this is not so ; unless very large, they can be readily isolated from the vessel, and be thus deprived of all impulse, however strong. 4. The pulsation in aneurism is generally uniform, being perceived equally at every point of the circumference of the tumor, which rises and falls syn- chronously with the systole and diastole of the heart; in abscess and solid growths, on the other hand, it is very irregular, and is usually limited to a particular spot. In aneurism the swelling bounds and recedes under the hand; it feels as if it were alive and panting; in solid tumors the morbid mass rises at each impulse, but there are no expansion and contraction. 5. When an aneurism is firmly and uniformly compressed, it sensibly dimi- nishes in bulk, which, however, recovers itself the moment the hand is re- moved ; in solid growths and abscesses, pressure, however great, produces no such result. 6. In aneurism, the size of the swelling is diminished by pressure upon the cardiac side of the tumor, and increased by pressure upon the distal side. In morbid structures not aneurismal, no change of bulk follows this procedure. 7. The sounds of aneurism are different from those of solid tumors. Both may yield a sawing, bellows, or rasping noise, but in the latter this is never conjoined with the peculiar thrill, or whirring noise, which constitutes so prominent a symptom in the former. 8. Aneurism of the larger arteries ordinarily affords two alternate shocks, one of which corresponds with the diastole of the heart, the other with its systole. These phenomena are never present in solid tumors and abscesses, and are therefore pathognomonic. vol. i.—47 738 DISEASES AND INJURIES OF THE ARTERIES. Such are the distinguishing characters of aneurism and of the more im- portant diseases with which it is liable to be confounded. It must be obvious, from what has been said respecting them, that mistake can only be avoided by the most rigid and thorough examination, made not once, but repeatedly, in every case of tumor situated along the course of an artery and influenced by its pulsation. Where, after such a pains-taking process, no satisfactory decision can be arrived at, our only resource is to insert a delicate exploring- needle, which, while it can do no possible harm, if it be properly employed, will at once determine the diagnosis. 5. EFFECTS AND TERMINATION. The effects which aneurism exerts upon the surrounding parts vary accord- ing to circumstances, of which the most important are, the situation of the affected vessel, and the size of the tumor. An aneurism of the arch of the aorta will, other things being equal, produce more serious disturbance, both organic and functional, than one of the abdominal portion of that vessel, and an aneurism of the carotid artery than one of the popliteal. It is obvious also that a small tumor will, as%, general rule, cause less serious effects than a large one. The effects which such a disease produces upon the parts with which it is in contact are purely of a mechanical character, eventuating in their displace- ment, compression, or ulceration, or in all these occurrences combined. An aneurism of the thoracic portion of the aorta must, necessarily, encroach more or less upon the contents of the chest, pushing the heart and lungs out of their natural position, and thereby interfering essentially with the perform- ance of their proper functions. In aneurism of the carotid artery there will be displacement of the trachea, oesophagus, and the great vessels of the neck, along with compression of these parts, and also of the pneumogastric and sympathetic nerves. In popliteal aneurism the part of the limb below the site of the tumor generally suffers from obstructed circulation, as is evinced by the occurrence of anasarca and decrease of temperature, with a feeling of numbness, the result of interruption of the nervous current. When the em- barrassment to the flow of blood is very great, or long continued, mortifica- tion of the distal portion of the limb is liable to ensue. When the turaor is situated externally it may produce serious changes in the muscles, which, in many cases, are not only widely separated frora each other, but remarkably pale, flattened, and attenuated, exhibiting more the appearance of thin ribbons than of thick, solid, fleshy bodies. The nerves, too, are often very much spread out, the vessels are thrust aside, and the aponeuroses are stretched out like tense sheets. When pressing upon an important joint, the tumor is sure to impede its motion, and may even cause permanent anchylosis, as occasionally happens in aneurism of the popliteal artery. The effect produced by aneurism upon the osseous tissue is sometimes very remarkable, and is generally most conspicuously displayed in the dorsal por- tion of the spine. When the disease involves the thoracic aorta, the tumor, which often attains a large size, being crowded into a comparatively small space, is liable to encroach sadly upon the bony walls of the chest, pressing upon and eroding the bodies of the vertebrae behind, as seen in fig. 245, the sternum in front, the ribs at the side, and the clavicle above. There is hardly an osteological cabinet, of any extent, that does not afford striking evidence of the truth of this remark. I have seen specimens where as many as four of the bodies of the dorsal vertebrae were completely absorbed as far as the spinal canal, which, forming the posterior boundary of the turaor, was thus fully exposed to its pulsations. The sternum suffers mostly at its lateral and SPONTANEOUS CURE. 739 upper aspect, but occasionally, as in an instance now under my care, it is per- forated at the centre, the movements of the aneurism being distinctly visible at that part. The ribs and their car- tilages do not generally participate to Fig. 245. any considerable extent in the erosion, and the clavicles are rarely affected, unless the tumor is of great bulk, and projects unusually high up into the neck. It is not surprising, after what has been said respecting the effects which aneurism is capable of exerting upon the osseous tissue, that the tumor should occasionally cause serious lesion in the soft structures, apart from their mere compression. In its earlier stages, be- fore the swelling has attained any con- siderable bulk, the inroads are slight, and, consequently, well borne, the parts manifesting no disposition tO resent its Erosion of the vertebrje from aneurism. encroachments ; by and by, however, as it progresses, its pressure bears heavily upon the adjacent textures, which, taking on inflammatory action, become matted together by interstitial de- posits, which, for a time, thus materially strengthen the aneurismal sac. But this state of things is not destined to last long ; gradually the morbid action increases, the superincumbent tissues are more and more expanded, and, at length, ulceration setting in, the integuments yield over the more prominent portion of the sac, followed by destructive hemorrhage. 6. SPONTANEOUS CURE. Unfavorable as the prognosis of aneurism generally is, it is extremely gratifying to know that a cure may occasionally be effected spontaneously, without the intervention of art in any way. That such an event is rare, forming merely an exception to the great law, is unfortunately too true; yet it sometimes occurs under circumstances apparently the most desperate, bid- ding defiance alike to medical and surgical skill. There are, indeed, few practitioners of enlarged experience, who have not met with cases of this disease in which, contrary to all calculations of the doctrine of chances, the patient made an excellent recovery, after having literally hovered, for days and weeks, over the very verge of the grave; where, in short, everything portended speedy destruction, and yet every vestige of the aneurism ultimately disappeared, the person living for years afterwards in the enjoyment of good health, and in the exercise of his former occupation. How the cure is effected in these cases, our information does not enable us to explain, as an opportunity is seldom afforded of making a dissection of the body after the event has taken place, in consequence of the individual being usually lost sight of. A knowdedge, however, of the possibility of such a cure is highly en- couraging, and holds out the hope that it may be of more frequent occurrence than has hitherto been imagined. Although we are not always able to account for the manner in which the patient gets well in this disease, yet observation has demonstrated that it generally occurs in one of five ways, all leading, essentially, to the same result, namely, the formation of clots, by which not only the aneurismal sac is closed up, but also the artery immediately above and below it. When the cure is gradual, the clots are usually arranged concentrically, and exhibit every mark of organization; but the reverse is the case when it is effected suddenly, for 740 DISEASES AND INJURIES OF THE ARTERIES. An aneurismal tumor obliterated by the deposition and organ ization of fibrin. then they are nothing but soft, red blood-masses, similar to what we so often observe after death in the heart and large vessels. 1. The most common way in which the cure takes place is by the gradual filling up of the sac by the formation of clots, thereby ultimately converting it into a firm, solid tumor. Fig. 246. The most beautiful and per- fect specimen of this kind, represented in fig. 246, that I have ever seen, was pre- sented to me, some years ago, by an old pupil, Dr. Shumard, who had removed it from the body of a young steer. What renders it still more interesting, is the cir- cumstance that it was con- nected with the hepatic ar- tery, which had given way at one side from the rupture, apparently, of its inner and middle tunics. The tumor, which is of a rounded shape, and nearly three inches in diameter, is occupied by hundreds of lamella?, many of them not thicker than a sheet of paper, of a pale grayish color, closely ad- herent to each other, concentrically arranged, of a dense, firm texture, and, beyond question, thoroughly organized, even those most recently deposited. At the centre of the tumor, a small irregular cavity exists, which still ad- mitted some blood, as is proved by the fact that the hepatic artery is com- pletely pervious. This mode of reparation is greatly facilitated by the small size of the opening of communication between the artery and the aneuris- mal sac. 2. Another mode of spontaneous cure is the occurrence of inflammation, followed by the coagulation of the contents of the sac, and the ultimate ob- literation of its cavity as well as of the artery in its immediate vicinity. The disease may begin in the turaor itself, or be propagated to it frora the circum- jacent structures; if it be mild and slow, the cure may be easy and safe, but if it be very active, it may terminate in suppuration, and thus endanger life by hemorrhage, the matter being evacuated along with the clots before the artery is hermetically sealed by an internal coagulum. 3. The reparation occasionally occurs through the intervention of gangrene, either beginning in the tumor itself, or extending to it from the parts imme- diately around it. The blood coagulates in the sac as it does in an artery in ordinary gangrene, and when the sloughs separate the clots are discharged, the gap being afterwards closed by the granulating process. Such a mode of restoration must necessarily be infrequent, inasmuch as the morbid action by which it is effected generally terminates fatally. 4. The contents of an aneurism are sometiraes solidified by the compres- sion of the artery leading to it, caused either by the turaor itself or by sorae morbid growth in its immediate vicinity. Such a result may follow with nearly equal certainty, whether the pressure be applied to the cardiac or to the distal portion of the vessel. 5. Finally, a very rare mode of spontaneous obliteration may take place, consisting in the detachment of a small clot and its introduction into the distal portion of the artery, thereby more or less completely blocking it up. The blood, being thus checked in its onward flow, soon coagulates, just as it does in artificial compression. It was upon a knowledge of this species of SPONTANEOUS CURE. 741 spontaneous cure that Mr. Fergusson recently attempted to found a new mode of treatment of aneurism by breaking up the contents of the tumor by manipulation, and thus urging them on into the communicating vessel. When, by any of the above modes, a radical cure is effected, the tumor is gradually brought under the influence of the absorbent vessels, and is ulti- mately completely obliterated, or, at all events, so far reduced as to leave only a small nodule, indicative of the former site of the disease. The period required for the perfection of these changes varies from three or four weeks to as many months, according to the size of the aneurism and the state of the part and system. Although an aneurism may, as we have just seen, occasionally get well by the unassisted efforts of nature, yet such an event forms merely an exception to a great law, in conformity to which the disease almost uniformly proves fatal. The period at, and the mode in, which this takes place vary in dif- ferent cases and under different circumstances, and can, therefore, be pointed out only in a general manner. In aneurism of the aorta, especially in the arch of this vessel, the disease often produces death in less than three months from its commencement; in the innominate its course is also generally rather rapid, aud a similar remark applies to aneurism of the primitive iliac; in aneurism, on the contrary, of the carotid, subclavian, axillary, external iliac, femoral, and popliteal arteries, the fatal event is often postponed several months longer. To these statements there are, of course, many exceptions; thus, on the one hand, we occasionally meet with an aneurism which ends fatally in a few weeks, the tumor expanding rapidly, and perhaps bursting quite suddenly during a violent muscular effort; and, on the other hand, the disease raay continue, with very little variation, as to size, for a number of years. There are three distinct modes by which aneurism may cause death: 1. By the injurious compression which the tumor exerts upon the neighboring organs. 2. By the sudden rupture of the sac, and the occurrence of hemor- rhage. 3. By the development of inflammation, suppuration, or mortifi- cation. 1. Aneurismal tumors of the neck and chest often cause death by compres- sion of the trachea and bronchial tubes, although perhaps not as frequently as has been generally supposed, owing to the wonderful power which these tubes possess of flattening themselves, so as to make room for the entrance of the air into the lungs. Indeed, I am inclined to think, from my knowledge of this subject, that death frora direct suffocation, from this cause, is an un- common event. Great difficulty is often produced by the pressure of the sac upon the pneumogastric and phrenic nerves, and it is extremely probable that life is sometiraes destroyed in this way, the more especially if the pressure be conjoined with serious lesion of the air-passages. Finally, death occa- sionally proceeds from compression of the heart and lungs, interfering with the circulation and respiration; or from compression of the oesophagus, causing inanition. In the abdominal and pelvic cavities, and also in the extremities, the danger from corapression is much less, as the structures here are less important to life, as well as more disposed to yield under the en- croachment of the tumor. 2. After an aneurismal tumor has attained a certain bulk it is extremely apt to give way, as in fig. 247, either suddenly or gradually, under the im- pulse of the blood, or under severe muscular exertion. Such an occurrence will be the more likely to happen when the tumor has been of rapid growth, and especially if its interior has not been fortified by the formation of hard, organized clots, so as to increase the thickness and strength of its tunics. It is in this manner that most of the internal aneurisms, which do not cause destruction by mere corapression, ultimately terminate, the immediate cause 742 DISEASES AND INJURIES OF THE ARTERIES. Fig. 247. of death being hemorrhage into some internal and contiguous organ. Thus, in the chest, the tumor usually opens into the trachea, the bronchial tubes, the pleura, pericardium, mediastinum, or oesophagus. Sometimes a communication is established between the sac and the heart, between it and the pulmonary artery, or, lastly, between it and the vena cava. An aortic aneurism has also been known to burst into the spinal canal, some of the bodies of the vertebrae having previously been destroyed by absorption. In the abdomen, the tumor may break into the peri- toneal cavity, or into one of the hollow viscera, as the stomach, intestine, or urinary bladder. In the neck, axilla, groin, and extremities, the aneurism, if permitted to pursue its course, generally finds its way to the surface, very much after the manner of an abscess. The hemorrhage succeeding to the rupture of an aneurism may be slight, as when the aperture is small or devious, or copious and destructive, as when the opening is large or straight. Most com- monly, life is worn out by the frequent recurrence of the bleeding; thus, twenty ounces of blood may be lost to-day, in a week twenty or thirty ounces more, and so on until the patient dies completely exhausted, his condition being, in the meantime, perhaps seriously aggravated by serous effusions into some important cavity. Occasionally the aneurism gives way by a large rent, and the patient expires instantly in consequence of the hemorrhage. 3. More or less inflammation attends all aneurisms; whatever may be their volume or situation, their age, or character, they play the parts of intruders, encroaching upon, compressing, and irritating the surrounding structures, and thus giving rise to various deposits, especially of serum and plasma. It is by means of the latter that, as was previously stated, the sac increases in thickness and density, so as to qualify it the better to bear with impunity the impulse of the inflowing current of blood; without such an occurrence few tumors of this kind would be able to raaintain themselves for any length of time, but would soon yield to the resistless pressure from within; in a word, speedy rupture of the sac, and fatal hemorrhage would, in most cases, be inevitable. But, although inflamraation is set up for wise and beneficial pur- poses, the process, unfortunately, is not always kept within the strict limits required to fortify the sac and protect it against early rupture; on the con- trary, many circumstances occur to provoke its increase, and to cause it to pass into ulceration, suppuration, and even mortification. Among these cir- cumstances some are of a constitutional, and others of a purely local character; thus, mere plethora and the use of stimulating food and drink raay power- fully augment the inflammation, and bring about these untoward results. In general, however, it will be found that the mechanical compression of the tumor, in consequence of the resistance offered to its extension, has more to do with its production than anything else. Sometiraes a clot is accidentally detached, and thus becomes a cause of mischief. In external aneurism, the manipulation employed in examining the tumor is occasionally productive of severe inflammation, and similar effects often follow the injudicious use of the affected limb. Suppuration of the tumor is an infrequent event. A case occurred in 1857, at the Pennsylvania Hospital, in the service of Dr. Pepper, in which Aneurism of the descending aorta, burst, the patient dying suddenly in consequence. TREATMENT. 743 an abscess had formed in connection with an aneurism of the innominate, and killed the patient, a man aged 38/ by bursting into the trachea. A report, with a drawing of the case, has been published by Dr. Humphreys, in the Transactions of the Pathological Society of Philadelphia. Ulceration and mortification are more common, and are particularly liable to take place when the turaor is of large size. Finally, aneurism may prove fatal by exciting inflamraation in an important internal organ, as the lung, heart, or pleura. In popliteal aneurism, the pressure of the tumor upon the nerves and arteries below sometimes causes death from mortification of the leg and foot. Treatment. Notwithstanding the vast amount of attention that has been bestowed upon aneurism, from the earliest periods of medical science down to the present, it may truly be affirmed that there is no subject connected with practical surgery which has been so little understood by the great mass of the profession as this. This circumstance has arisen, it seems to me, not so much from a want of ability on the part of the practitioner to comprehend the nature of this lesion, as from the obscure and imperfect manner in which it is usually dis- cussed in our lecture-rooms and in our systematic treatises. Much difficulty also has grown out of the defective nomenclature of aneurism and of the ambiguity which, until recently, existed in regard to the pathology of this affection, both tending to give rise to erroneous ideas of practice. Light, however, is gradually breaking in upon us; and it is highly probable that the advances of modern science will enable us, ere long, to treat aneurism with as much confidence as any other class of maladies. Leaving, for the present, out of view the treatment of internal aneurism, as belonging as much to the department of medicine as that of surgery, I shall proceed to consider the various remedies that have been proposed for the cure of the external form of the disease, or, more properly speaking, of those cases of aneurism which are more directly and immediately amenable to the art and science of surgery. In doing this, it will be necessary to bear in mind the divisions of aneurism pointed out in the commencement of the section, as each of them will require corresponding modifications of manage- ment. In the time of Celsus, as well as for a long period subsequently, the treat- ment of aneurism was conducted in the most cruel and unscientific manner. The only operation which appears to have been known was to lay open the tumor by a bold incision, and, after turning out its contents, to apply the hot iron to the extremities of the affected artery, so as to seal up their mouths. The effect of such a procedure may easily be imagined ; upon the separation of the eschar, hemorrhage was sure to take place, and in this way nearly every patient perished, either at the first onset of the bleeding, or by its frequent repetition. This miserable practice continued in vogue until the introduction of the ligature by Ambrose Pare. A different mode of procedure wras now adopted, although it can hardly be said to have been much of an improve- ment upon the one just described. It certainly, however, possessed the advantage of being more scientific, and of being less frequently followed by hemorrhage, notwithstanding it could claim little on the score of simplicity as far as its execution was concerned. It consisted in ligating the artery above and below the tumor, which was then freely opened, thoroughly cleared out, and stuffed with charpie, to promote suppuration and occlusion, the object being to heal the wound from the bottom. Occasionally the more adventurous surgeon took the more speedy route of extirpating the tumor, adopting a plan similar to that which is soraetimes pursued at the present 744 DISEASES AND INJURIES OF THE ARTERIES. day in treating aneurism at the bend of the arm consequent upon venesection. The result of this operation, too, was often most disastrous; many of the patients died of the effects of inflammation, some of secondary hemorrhage, and not a few of the shock of the amputation performed as a dernier ressort, to save them from impending destruction. To prevent these sad occurrences, and afford the sufferer a better chance of recovery, the removal of the limb was often the only operation thought of for his relief. a. DELIGATION OF THE ARTERY AT THE CARDIAC SIDE OF THE TUMOR. It is amazing to think that some of the operations above described should have continued in vogue until near the close of the last century. The fact attests, more fully than any other circumstance with which we are acquainted, the low state of surgery up to that period. The merit of performing the first operation for the cure of aneurism upon strictly scientific principles is due to Mr. John Hunter, who flourished in the latter part of that century, and whose labors have shed so much lustre upon the healing art. From having witnessed so many failures from the ordinary procedure, he was led to the conclusion that the cause consisted in the fact that the artery was always diseased for some distance above the aneurism, and that it was, therefore, incapable of becoming sufficiently occluded prior to the detachment of the ligature to pre- vent hemorrhage. Acting under this conviction, amply confirmed by dissec- tion and observation, he determined, upon the first favorable opportunity, to apply the ligature upon a sound portion of the vessel. While thus revolving the matter in his mind, a man, laboring under popliteal aneurism, was ad- mitted into St. George's Hospital, of which he was then one of the surgeons. The patient was a coachman, forty-five years of age, and the tumor, first per- ceived three years previously, was not only quite large, but was attended with great swelling of the foot and leg. The operation was executed in December, 1785, the femoral artery being exposed a little below its middle, and surrounded by four ligatures drawn so gently as simply to bring the sides of the vessel together. " The reason for having four ligatures was," as is stated by Sir Everard Home, by whom the case was reported, " to com- press such a length of artery as might make up for the want of tightness, it being wished to avoid great pressure on the vessel at any one part. The ends of the ligature were carried directly out of the wound, the sides of which were now brought together and supported by sticking-plaster and a linen roller, that they might unite by the first intention." It is unnecessary to enter into any details respecting the after-treatment of the case. It will be sufficient for my purpose to state that on the second day after the operation the tumor had lost more than one-third of its original bulk ; that the ligatures, some of which came away on the fifteenth day, ex- cited severe inflammation in the artery, as well as in the surrounding parts; and that the man left the hospital on the 8th of July following, in good health, and with no appearance of any tumor in the ham. He subsequently resumed his former occupation as coachman, and died from an attack of re- mittent fever, fifteen months after the operation. The limb being dissected, the femoral artery was found to be impervious as high up as the profunda, while below the site of the ligatures, as far down as the turaor, it was open, aud contained blood, except just where it entered the aneurism, where it had become obliterated. The sac was a little larger than a hen's egg, but more oblong and flattened, and contained a solid coagulum adherent to its internal surface. I have been induced to give a brief outline of this case for two reasons. In the first place it deserves to be commemorated because it embodies the application of a new principle to the cure of a disease which, until then, was DELIGATION OF ARTERY AT CARDIAC SIDE OF TUMOR. 745 almost uniformly fatal ; and, secondly, because it will enable us to establish, in a more satisfactory manner than we could otherwise do, the claims of Mr.' Hunter to the credit of having originated the operation, which has been so sturdily denied him by the French surgeons, who have, almost with general consent, ascribed it to their countryman, Dominic Anel. I have no dispo- sition to enter into the merits of this dispute, especially at this remote period, when everything relative to it should be fully understood ; I shall, therefore! content myself with a recital of a few of the more prominent and important facts of Anel's operation, for these will be sufficient to show that it differs wholly and entirely from that of Mr. Hunter, and that, so far from involving any new principle, it was merely a simplification of the old procedure. The case of Anel, to whom surgery is indebted for some of its most valu- able improvements, fell accidentally into his hands during a visit which he made to Rome in 1710. His patient was a Catholic priest, who, in conse- quence of having had the brachial artery pricked in venesection, was affected with an aneurism at the bend of the arm ; the turaor was large, and, being the seat of slight ulceration, seemed to have been on the point of bursting. Having controlled the circulation in the limb by means of the tourniquet, he cut cautiously down upon the artery, and, after separating it from the accom- panying nerve, he raised it upon a hook, and tied it as near to the tumor as possible. All pulsation in the tumor instantly ceased, the ligature came away on the eighteenth day, and at the end of a month the friar was able to use his arm quite as well as before the accident. It will thus be perceived that the operations of the English and French surgeons differed from each other in every particular ; and it is only surprising that there ever should have existed any contrariety of opinion respecting them. The procedure of Anel was executed for the cure of a traumatic aneurism ; the artery was perfectly healthy, and it was tied in as close proximity to the tumor as possible, the Frenchman never supposing that he was about to establish a new principle in operative surgery ; he nowhere alludes to such an intention, and his only object seems to have been to afford his patient, who was suffering great agony, and who might bleed to death at any moment from the sudden bursting of his tumor, prompt relief. The Englishman, on the contrary, had studied the subject with infinite care and attention ; he had made numerous dissections and even performed some experiments upon the inferior animals, as the dog and horse, with a view of ascertaining the condi- tion of the artery in aneurism and its ability to bear the ligature ; and he had clearly perceived that, as the cause of failure of the old operation was that the ligation was always made too near to the tumor, the only safety would be.to tie a sound portion of the vessel, even although this should be at a very considerable distance from the aneurism. His object was not to cut off the supply of blood at once, but simply to weaken its passage through the tumor, thereby giving its contents an opportunity of undergoing gradual coagulation, and at the same time preventing the distal parts of the limb from perishing from the sudden stoppage of the circulation. The result of the case above detailed proved the correctness of his reasoning, and established, upon a firm and immutable basis, what is now universally recognized in Great Britain and in this country, as the Hunterian operation for aneurism. The operation of Hunter has been performed upon almost every artery of the body liable to suffer from aneurism. Even the aorta itself has been re- peatedly tied, and, although the cases have all proved fatal, yet the result has been such as to show, most conclusively, that the event has been due much more to the injury inflicted upon the surrounding structures than to the vio- lence done to the circulation by cutting off so great a quantity of blood from its accustomed channels. Great simplicity now characterizes the operation ; a healthy portion of artery is selected, great care is taken, in exposing the 746 DISEASES AND INJURIES OF THE ARTERIES. vessel, to disturb its sheath as little as possible, and only one ligature is used, but that is drawn so tightly as to lacerate the inner and middle tunics, when, a double knot being made, one extremity is cut off, and the other is brought out at the nearest point of the wound, which is then treated in the ordinary manner. Cessation of pulsation usually occurs at once upon tightening the ligature, although not necessarily so ; sometimes, indeed, several days elapse before it is fully established, but even then it is commonly very much dimi- nished in force, thus paving the way for the formation of clots upon which the cure ultimately depends. The persistence of the circulation, after the main artery of a limb has been ligated, arises from the anastomosing branches continuing to pour their contents into that portion of the vessel which lies between the cord and the sac, as well as into the sac itself, and perhaps also into the distal portion of the artery. When these branches are inordinately large, or numerous, they raay keep up such a supply of blood as to compro- mise effectually the success of the operation. The operation is generally followed by a slight diminution of temperature in the limb, but this rarely lasts beyond a few hours, when it is succeeded by a marked increase of heat, owing to the augmented activity of the cutaneous circulation, in consequence of the blood being forced principally through the superficial capillaries. Subsequently, however, as the anastomotic branches enlarge, and the circulation becomes equalized, the temperature sinks again, and now perhaps somewhat below the normal standard, the parts really feeling, for the first time, the loss of blood occasioned by the ligation of the artery. In not a few cases the limb retains its temperature after the opera- tion with hardly any variation, as if nothing at all had happened. Instead of the ordinary silk ligature, Dr. Stone, of New Orleans, in a case of aneurism, in 1859, tied the common iliac artery with a silver wire, simply approximating the sides of the vessel, and leaving the wire in the wound, con- vinced of its entire harmlessness. The patient died on the twenty-sixth day, but, as no autopsy was made, the disposition of the ligature was not ascer- tained. At my College Clinic, last June, I secured, in a similar manner, the femoral artery in a case of popliteal aneurism ; the patient rapidly recovered without any untoward symptom, and the wdre still remains in the thigh, nearly the entire wound having healed by the first intention. After-treatment..—The treatment after the operation must be conducted with great judgment and attention. The patient being carried to bed, the limb is placed in an easy and relaxed position, but not elevated, lest arterial influx be interfered with; and it is well, especially if there be a diminution of temperature, that it should be enveloped for some time in wadding. Cold applications must be carefully avoided, even if the skin manifest inordinate heat with some degree of swelling, as they could not fail to be prejudicial by lowering the vital powers, and so laying the foundation for mortification. A full anodyne should be administered immediately after the operation, to tran- quillize the action of the heart; light diet is to be observed, with cooling drinks ; and the temperature of the apartment is not permitted to exceed 65° of Fahrenheit. The bowels must not be opened for several days, and then only by the mildest laxatives, drastic purgatives being particularly objection- able on account of their tendency to cause excitement and throbbing of the arteries; occurrences which would inevitably be injurious after such an operation. Causes of Failure.—The causes of failure after the Hunterian operation are, first, violent inflammation, followed by mortification ; secondly, death of the limb from deficiency of blood; thirdly, secondary hemorrhage, either from premature detachment of the ligature, or rupture of the sac; and, fourthly, maintenance of the circulation by means of a redundant anastomosis. None of these accidents, save the last, and that is a very improbable one, will DELIGATION OF ARTERY AT DISTAL SIDE OF TUMOR. 747 be likely to happen if the part and system have been thoroughly prepared for the operation, if the disease has not made too much progress, and, finally, if proper care and judgment be employed in managing the case after the appli- cation of the ligature. Deligation of the carotid arteries for the cure of aneu- rism is liable to be followed by inflammation of the brain and lungs, with softening of the former of these organs and hepatization of the latter. Much of the mortality from the operation is caused by this disease. No recent statistics of the Hunterian operation, on a large scale, have appeared. The most satisfactory, so far as I know, are those of Mr. Thomas Inman, of Liverpool, published in 1844. His table was made up of all the reliable cases that had been recorded up to that period in the various medi- cal and surgical periodicals. Name of the artery. No of cases. Deaths. Proportion Innominate artery .... 6 6 Subclavian artery 40 18 lin2 Carotid artery . 40 11 1 in 4 Abdominal aorta 3 3 Common iliac . 8 3 1 in 2| Internal iliac 4 2 1 in 2 External iliac . 27 9 1 in 3 Femoral . 42 7 1 in 6 Total .... 170 59 1 in 3 b. DELIGATION OF THE ARTERY AT THE DISTAL SIDE OF THE TUMOR. It is well known that aneurism occasionally occurs so near the trunk as to render it impracticable to perform the Hunterian operation, or that the artery, although accessible at the cardiac side of the tumor, is too much dis- eased to enable it to support the ligature. Mons. Brasdor, a professor in the old school of surgery at Paris, upwards of seventy years ago, after much reflection upon the subject, arrived at the conclusion that gradual and effi- cient coagulation of the blood in the aneurism might be produced by placing the cord upon the artery at its distal aspect. He had no opportunity, how- ever, of solving the problem upon the human subject. The merit of this was reserved for Descharaps, although the case upon which he tried it could hardly have been worse for such an undertaking. The patient, besides being old, was worn out by suffering, and the turaor, which occupied the upper part of the thigh, extending to within a short distance of Poupart's liga- ment, was nearly seventeen inches in circumference. The operation was tedious and difficult, on account of the depth of the artery and the absence of pulsation, but the vessel was at length discovered and effectually secured. Contrary, however, to expectation, the aneurism, which had made marked progress for some time previously, now rapidly increased in volume, and on the fourth day, when it appeared to be on the point of bursting, it was re- solved to perform the ordinary operation, notwithstanding the reasons which had just before been urged against its adoption. Two ligatures were applied, but the operation was attended with copious hemorrhage, and the man died in eight hours after. The operation of Brasdor was next performed by Sir Astley Cooper, in a case of aneurism of the external iliac artery, extending so high up into the abdomen as to render it impossible to place a ligature between it and the heart. The femoral artery was, therefore, tied a short distance below Pou- part's ligament, between the epigastric and profunda. The patient did well for some days, when the tumor, which had been gradually diminishing in volume, burst, causiug death by hemorrhage. What the results of these two attempts might have been, if the cases had 748 DISEASES AND INJURIES OF THE ARTERIES. been of a more favorable character, is a matter which must, of course, be left to conjecture. It is certain, however, that no attempt was made to repeat the operation until 1825, when, almost forgotten by the profession, it was performed by the late Mr. James Wardrop, of London, in a case of aneu- rism of the carotid artery. The success was complete. The ligation was followed by an immediate diminution of the tumor, which gradually pro- gressed until, at the end of the fifth week, the neck had nearly regained its natural form; the ligature had dropped off, and the general health was en- tirely re-established. The patient, a woman, aged seventy-five, continued to be perfectly well three years after the operation. Having been equally successful in several other cases, Mr. Wardrop was induced to extend the priuciple of Brasdor's operation to aneurism of the innominate artery. It occurred to him that, by tying one of the branches of this artery, the force of the circulation might be so far diminished in the tumor below as to cause the solidification of its contents; and a favorable opportunity soon after arising, he was not slow in putting his ideas in prac- tice. The patient, a female, aged forty-five, had a pulsating swelling, of the size of a turkey's egg, in the inferior part of the neck, its base being con- cealed by the sternum, and evidently connected with the innominate artery. For the cure of this disease the right subclavian was tied in July, 1827, with the effect of a gradual amelioration of the distressing symptoms, and the ultimate disappearance of the tumor, its site being occupied merely by an unnatural hardness, the result, probably, of the remains of the aneurism. This was the condition of the patient fourteen months afterwards, at which time the carotid artery still pulsated, although not so vigorously as the left, and the woman was in better health than slie had been for a long time. The procedure now described constitutes what is called Wardrop's opera- tion, although it is in reality, as was before intimated, merely an extension of that of Brasdor; and is only applicable to aneurism of the innominate artery. It has been performed within the last fifteen years in a considerable number of cases, generally by tying the common carotid; but the results have, for the most part, been unfavorable, Fig. 248. Fig. 249. Fig. 250. owing, as has been alleged, and as is probably the fact, to the occurrence of violent inflamma- tion both in the aneurismal sac and in the vessels in immediate communication with it, termi- nating fatally in a few days, or, at most, in a few weeks. Deligation of the artery at the distal side of the sac has hitherto been most disastrous. Thus, of 27 cases, collected by Mr. Erichsen, death speedily occurred in 20, while in the re- maining seven, although the pa- tients escaped with their lives, no benefit whatever resulted in regard to the cure of the aneu- rism. The annexed cuts afford an illustration of the various rue- Hunter's. Brasdor's. Wardrop's. tliods of ligating arteries for the cure of aneurism, above de- scribed. A glance will serve to show how inefficient such an operation must be when performed according to the plan suggested by Mr. Wrardrop. — ^ INSTRUMENTAL COMPRESSION. 749 C. INSTRUMENTAL COMPRESSION. The treatment of aneurism by compression dates back to a very early period of the profession, and, although the principles upon which it was formerly conducted were far from being scientific, numerous cases have been published illustrative of its efficacy. It is not my design to inquire into the history of the operation, or to seek out its inventor for the purpose of awarding him praise for his ingenuity and enterprise ; it is sufficient to state that the com- pression was originally applied directly to the tumor, or to the tumor and the limb upon which it was situated, either by means of an apparatus spe- cially constructed for the object, or by a compress and roller, extended from the distal portion of the extremity upwards, beyond the seat of the disease. The practice was most frequently employed for the relief of traumatic aneu- rism, especially that form of it consequent upon injury of the brachial artery, at the bend of the arm, and, although it proved occasionally successful, not a few cases occurred in which it was followed by violent inflammation of the sac and limb, eventuating in ulceration, abscess, or gangrene. In the latter part of the last century, Vernet, a French military surgeon, conceived the idea of curing aneurism by applying compression upon the artery immediately beyond the tumor, upon the same principle as that upon which Brasdor soon afterwards suggested the use of the ligature. He thought that the operation was particularly adapted to aneurism situated so near to the trunk as to forbid a resort to the ligature, or corapression upon the cardiac side of the swelling. It would appear, however, that he practised it only in one instance—upon a man affected with inguinal aneurism—and that so great was the disturbance which it created in the pulsations of the sac, that he was obliged, in a very short time, to abandon it. From the want of success attending the case, ill adapted as it was to test the principles of a new pro- cess, no one, it seems, felt afterwards disposed to make further trial of it, and it was accordingly forgotten, or remembered only as an ingenious sugges- tion. Compression of the artery above the tumor, or between it and the heart, was first distinctly insisted upon as a remedy for the cure of this disease, by the late Mr. Freer, of England, in his observations on aneurism, published early in the present century. In the work here referred to, he gives particular directions for applying the compression, enjoining that it should be made by enveloping the whole limb with a bandage, and placing upon the vessel, in the most superficial portion of its extent, a small pad, which was then to be screwed down by means of a tourniquet. To render its action more effective, a plate was secured to the opposite side of the limb, which, while it defended the integuments and muscles frora injurious constriction, concentrated the force upon the particular point of the artery where it seemed to be most needed. Notwithstanding this precaution, the application of the tourniquet was soon followed by pain and oedema of the extremity, generally so violent as speedily to necessitate its removal. Short, however, as the compression was, it occasionally laid the foundation of a cure, which was afterwards per- fected by the steady but cautious use of the ordinary compress and bandage. Acting upon the suggestions of Freer, Dupuytren and others applied them- selves to this mode of curing aneurism, devising useful and ingenious instru- ments as substitutes for the more clumsy contrivance above described. The French surgeon, in particular, invented a most admirable compressor, at once simple and efficient, which still bears his name, and which he employed suc- cessfully in several cases of aneurism of the inferior extremity. The cures, however, that were effected in this way were few compared with the great number of failures, and the consequence was that the treatment never met 750 DISEASES AND INJURIES OF THE ARTERIES. with much favor. What added to the dissatisfaction of practitioners was that in quite a considerable number of cases, it was followed by results highly prejudicial to the limb, if not to both lirab and life. Thus stood the treatment of aneurism by compression, when, in 1843, it was destined to experience a complete revolution in the hands of several eminent surgeons of Dublin, particularly Hutton and Bellingham, the latter of whom, in a short tract upon the subject, was the first to point out, upon correct and scientific principles, the manner in which it acts in curing the disease. Prior to this period, one replete with interest to the progress of surgery and humanity, compression was a very painful aud hap-hazard pro- ceeding, conducted without any discrimination and judgment, and, conse- quently, without any certainty as to its results. The idea was that, in order to succeed, it was necessary that it should be applied firmly and steadily, so as to arrest the circulation, and cause adhesion of the sides of the artery, very much as in the operation of ligation. Hence the poor patient was generally subjected to immense torture, often compelling the speedy discontinuance of the treatment, which, however, notwithstanding this, was occasionally fol- lowed by the worst consequences, as manifested in the violent swelling of the affected limb, and perhaps its ultimate loss by gangrene. The procedure was altogether a blind one, and, therefore, just as likely to prove prejudicial as useful. It was employed by one practitioner simply because it had occa- sionally been employed successfully by another, and not because any one had, as yet, been so fortunate as to lay down any broad and definite rules of ac- tion. It was for this reason that it was so long in acquiring the confidence of surgeons; that it was totally abandoned at one time, and resumed, with doubts and misgivings, at another. Its principles were not yet fully deve- loped, or placed upon a just and comprehensive basis. This labor was per- formed by Dr. Bellingham and his able associates, who thus created a new era in the treatment of aneurism, hardly less brilliant than that of the liga- ture. What the ultimate fate of this treatraent will be time alone can determine; that it is destined to supersede entirely, as some have predicted, the use of the ligature, is extremely questionable, and yet, considering the remarkable success which has attended it, such an occurrence seems not im- probable. Compression, as now conducted, is not only safe,, but comparatively free from pain; and, although it is often tedious, yet few cases will ultimately resist its influence. It is more particularly applicable to the cure of popli- teal aneurism, in which its greatest triumphs have hitherto been achieved, but it has also been successfully employed in aneurism of the lower part of the femoral artery, and in aneurism of the brachial, particularly at the bend of the arm. It is applied at the site of the Hunterian operation, that is, upon a sound portion of the vessel, at the cardiac side of the tumor, and generally at a considerable distance from it; gently and intermittently, not firmly and persistently, as in the old method; just sufficiently to retard and weaken the circulation in the sac, not to arrest it, and so as to favor the gradual formation of clots; allowing time for the development of the colla- teral vessels, and the maintenance of the nourishment of the distal portion of the member. Occlusion of the artery at the site of compression is not wished for; on the contrary, it is desirable that the vessel should remain pervious, and retain as many of its normal properties as possible. As the stratifica- tion of the sac proceeds ; as layer after layer of fibrin is deposited, and becomes firmly cemented to that which preceded it, the hollow pouch is gradually filled up, and usually, along with it, also the upper orifice of the artery. To this rule, however, there are occasional exceptions, the blood continuing to flow from the artery in a direct stream across the sac in a sort of ditch, groove, or narrow channel. INSTRUMENTAL COMPRESSION. 751 Fig. 251. For the purpose of making the compression, various instruments have been devised, one of the most simple and efficient of which is represented in fig. 251; it is a modification of that of Char- riere, and was successfully employed by Dr. Gibbons, of this city, in a case of aneurism of the popliteal artery. It consists of a long, wide, concave, steel plate, supporting three semicircles of the same metal, arranged in two segments, which slide upon each other, and are connected each at their free extremity with a screw and pad. The whole construc- tion of the instrument is such as to enable the surgeon to regulate the pressure with the greatest nicety ; making it more or less firmly, and at one or more points, or alternately at different points, as circumstances may seem to require. The annexed drawings, figs. 252, 253, and 254, are added for the purpose of enabling the reader to avail himself of the use of other compressors, if the one here described should prove inadequate. Gibbons's modification of Charriere's compressor. Fig. 252. Fig. 253. Carte's compressor for the cure of femoral and popliteal aneurism. Hoey's clamp. It will generally be well, if the patient is at all intelligent and trustworthy, to instruct him in the use of the instrument, so that he may regulate the compression, according to its effects; lessening it if it be productive of pain, and conversely. One important principle in the treatment is to compress the artery against the bone, as a point of support; if the pressure be widely diffused it will only serve to embarrass the venous circulation, and to retard the cure. The preliminary treatment should be the same as in the Hunterian operation ; and during the progress of the cure the limb should be kept constantly bandaged from its distal extremity upwards, to support the capillary vessels, and prevent oedema. Strict quietude, both of mind and body, should be observed; the diet should be mild but sufficiently nutritious; and free use 752 DISEASES AND INJURIES OF THE ARTERIES. should be made of aconite, opium, and acetate of lead, as suggested under the head of the treatment of internal aneurism. If the case is very pro- tracted, and the health is likely to suffer Fig. 254. from the consequent confinement, gentle exercise may be permitted in the open air, the instrument being worn several hours in the morning and evening. If any con- siderable swelling arise in the limb, all treatment must be temporarily suspended, and measures adopted for the relief of the morbid action. To continue the compres- sion under such circumstances would be to jeopard the safety both of the part and patient. The period at which a cure may reason- ably be looked for in this treatraent, is sub- ject to much diversity; iu some instances compression for a few hours has sufficed to produce this event; in others, and these Carte's circular compressor. embrace the greater majority of cases, a number of days are required; occasionally, several weeks elapse ; and cases have been reported where the stratification and obliteration of the sac were not completed under two months. As a general rule, it may be assumed that, other things being equal, the cure will be more rapid in proportion to the sraallness of the tumor, the tolerance of the part to compression, and the absence of complications. The results of the treatment of aneurism by instrumental compression are, on the whole, highly flattering, contrasting most favorably with those of the Hunterian deligation. Thus, of 127 cases of compression, rigidly analyzed by Broca, 116 were successful, or in the proportion of 91 to the 100. Alto- gether, not more than five or six cases have died from the effects of the operation. On the other hand, the statistics of Dr. Norris, of 188 cases of aneurism of the femoral artery, treated according to the Hunterian principle, show a mortality of 46, or in the ratio nearly of one death to three recove- ries. The tables of Mr. Inraan, given in a previous page, exhibit a similar result. Besides its indisputable safety, compression has the advantage, if it fail, that it does not preclude the propriety afterwards of a resort to the ligature. d. DIGITAL COMPRESSION. Digital compression for the cure of external aneurism has, during the past few years, attracted some attention, both in this country and abroad, but not in so great a degree as its importance demands. Originally proposed as a distinct measure, in 1846, by Professor Vanzetti, of the University of Padua, it was first successfully employed, a year later, by Professor Knight, of New Haven, in a case of popliteal aneurism, in which he cured his patient in forty hours, the compression having been maintained by assistants. In a communication in the North American Medico-Chirurgical Review for January, 1859, Dr. S. W. Gross has reported the details of a case of femoral aneurism cured by digital compression, and he has accompanied his paper by a statistical report of twenty-two other examples treated by the same method. As this paper gives a more full account of the subject than any other which has fallen under my notice, I shall freely avail myself of its contents. It is to aneurisms of the extremities that this procedure is mainly, if not DIGITAL COMPRESSION. 753 exclusively, applicable, as the corapression must be made to bear upon some point of the principal artery of the limb. So far as we have been able to ascertain, the brachial has been compressed in three instances only; once for aneurism of the radial artery near the wrist, and twice for arterio-venous aneurism at the bend of the elbow. In all these cases, the pressure was easily maintained, and the cure was effected in a short time. The femoral artery, at different portions of its course, has been the seat of compression nineteen times for popliteal and femoral aneurisms, of which thirteen cases have been cured. The external iliac has been subjected to the same procedure in two cases of inguinal aneurism ; in one the pressure was insupportable, and in the other the assistants became so fatigued that it was discontinued. More- over, it is very difficult in this situation to keep up the pressure, and such cases should, therefore, be excluded. It has been shown that digital compression has been successful when me- chanical compression was unbearable, or had failed, whether alone or conjoined with other means, interrupted or continued, complete or incomplete; it has even, in several cases, been applied by the patients themselves, and in these instances either a cure was effected, or the turaor was so modified that sub- sequent ligation, or mechanical compression of the artery always resulted in recovery. In no case has it ever been followed by any bad consequences, as is so apt to happen in ligation. The pain produced by the pressure of the finger is not greater than that caused by the pad of an instrument; should the point of pressure become tender, flour may be sprinkled upon the surface, or a thin, wet cloth may be interposed between the finger and skin. However this may be, suffering, both local and general, may easily be allayed by the free exhibition of ano- dynes, which should never be neglected. Of the twenty-three cases tabulated in the paper of Dr. Gross, fifteen were popliteal, with ten cures, and five failures; four were femoral, with three cures and one failure ; two were inguinal, both being unsuccessful; and two were arterio-venous, both of which eventuated favorably. Thus, of the twenty- three cases, fifteen were perfectly successful. Of these fifteen cases, the com- pression in five was employed independently of other means; in five the digital alternated with mechanical compression ; in four cases, apparatus had been abandoned, when digital compression effected a cure; and in one the com- pression was of a mixed character. Of the failures, in six cases digital com- pression was employed before other means, and in two after trial by apparatus had been abandoned. An examination of the facts here detailed will serve to show that digital compression, alternating with the use of apparatus, succeeded in every in- stance in which it was resorted to, and that, when employed primarily and alone, there were five cures out of seven cases. It seems to me, therefore, that the double method, in which digital and instrumental compression alter- nate with each other, is the most eligible, not only on account of its having effected cures in every case in which it has been used, but because it is more easy of application, and gives rise to much less inconvenience to the assist- ants ; in fact, the patient himself may sometimes regulate the pressure with perfect success. The period required for the cure of aneurism by this method is incompara- bly shorter than by any other known plan of treatment. Thus, of fourteen cases, the shortest time required for a cure was three and a half hours, the longest being seven days, and the average two days and two-thirds. When compared with the cases cured by instrumental compression, the length of time is most striking. In the London hospitals, according to Mr. Hutchin- son, the average time for the cure of twenty-six cases of femoral and popliteal aneurism was nineteen days; while Broca found that the mean duration of vol. I___48 754 DISEASES AND INJURIES OF THE ARTERIES. treatment in ninety-nine cases was about fifteen days. The greatest objection to digital compression is the difficulty of procuring a sufficient number of competent assistants; but in hospital practice, and in large cities, it will always be possible to do so. Since the publication of Dr. (Jross's paper, not less than from fifteen to twenty additional cases of cure by digital corapression have been reported. e. FORCIBLE FLEXION. This mode of treatment, for the introduction of which the profession is indebted to Mr. E. Hart, of England, is applicable chiefly, if not exclusively, in aneurism of the ham and bend of the arm; possibly cases might arise in which it might be employed with advantage in aneurism of the groin and axilla. The principle of the treatment consists in moderating and retarding the flow of blood in the tumor by bending the leg forcibly upon the thigh, so as to approximate the heel to the buttock, and confining it there by means of a strap, the limb being previously enveloped in a bandage. Care is taken to move the knee occasionally, lest anchylosis should occur. The cure is always tedious, from three to six weeks being generally required for the complete arrest of the pulsation, and in a number of the cases in which this treatment has been pursued it has signally failed; in several, the patient was unwilling to bear the restraint which it imposed, and in one at least it caused the rup- ture of the sac into the joint, necessitating the ligation of the femoral artery. It is obvious that this mode of treatment, which commends itself by its great simplicity and freedom from pain, is more likely to succeed in small and recent aneurisms than in large and old, in which it must of necessity be occa- sionally attended with failure. Indeed, it can hardly be considered as applica- ble to the latter class of cases, as it might induce rupture of the sac, as in the instance related by Mr. Moore, or be even productive of gangrene of the leg. /. GALVANO-PUNCTURE. It would seem that this operation for the radical cure of aneurism was first suggested, in 1832, by Mr. Benjamin Phillips, of Loudon ; so far, how- ever, as my information extends, it was not practised by him upon the human subject, and the idea had almost been lost, when, several years ago, it was revived, principally through the agency of Mons. Petrequin, of Lyons. The operation is founded upon a knowledge of the fact that the galvanic current has the effect, if properly directed, of coagulating the blood as it circulates through the different parts of the body. It is executed by means of two long, slender steel needles, introduced into the aneurismal sac at right angles, and in such a manner as to touch each other, their heads being then con- nected to the chain of a galvanic battery of moderate tension. The action of the battery is maintained uninterruptedly for a period varying from ten to twenty-five minutes, according to the tolerance of the part, and is usually required to be several times repeated. When the tumor is large the number of needles is increased, and the direction of the current frequently changed, so as to afford a better chance for the formation of clots. As the operation is generally very painful, it is proper that the patient should be placed under the influence of chloroform during its performance. Moreover, as there is danger of seriously charring the integuments, and thus endangering the sac by mortification, the needles should be carefully coated, in a part of their extent, with gum-lac. The success of the procedure is enhanced by com- pression of the artery above and below the tumor, thereby preventing the clots from being washed away, before an opportunity has been afforded them of becoming consolidated and united with each other and the walls of the aneurism. The after-treatment consists in the application of ice to the part, INJECTION. 755 in perfect quietude, and in the administration of a full anodyne, to tranquillize the action of the heart and arteries. Experience has not yet fully determined the value of this mode of treat- raent. That it is liable to occasional failure is sufficiently evident from the unsuccessful cases that have from time to time been published in England and on the continent of Europe. On the other hand, a considerable number of cases have been reported where its employment was followed by a perfect cure. Of twenty-two cases, collected by Mons. Boinet, in 1851, in which the operation had been practised, nine are stated as having been successful, and thirteen as having been failures. Cases of cure, by this method, of aneurism of the brachial, subclavian, popliteal, and external iliac arteries have been reported by different observers since that period, and, doubtless, others have occurred of which I have no knowledge. Galvano-puncture is not only painful, but far from being devoid of danger. In some of the reported cases it produced severe inflammation and even sup- puration of the sac, followed by great swelling of the limb, together with excessive constitutional disturbance threatening the destruction both of the part and system. The operation is, therefore, a hazardous one, and on this account should never be attempted without due consideration of its conse- quences, especially when the aneurism is large and situated at, or near to, the trunk. Coupling this circumstance with the want of success of the opera- tion, and the severe pain attending its execution, not to say anything of the danger of producing sloughing in the skin and sac by the action of the galvanic fluid as it is being transmitted frora the battery to the tumor, it is questionable whether it is worthy of repetition, notwithstanding the high estimate placed upon it by Petrequin, Burci, and some other surgeons. The force of this conclusion derives additional support from the facts collected by Mons. Boinet, that in seven of the successful cases, above referred to, com- pression and ice were employed simultaneously, thus creating a just doubt in the mind of the inquirer whether these agents had not as much to do with the cure as galvano-puncture, if, indeed, not more. I am not aware that this operation has ever been performed in this country, and I trust that it may never be undertaken by any one who is not perfectly familiar with the patho- logy of the disease. g. INJECTION. Attempts have been made in modern times to effect the radical cure of aneurism by the injection of certain fluids with a view of favoring the con- cretion of the blood, the consolidation of the sac, and the obliteration of the affected artery at the seat of the disease. The practice was originally sug- gested, early in the present century, by Professor Monteggia, of Milan, who proposed the use of solutions of acetate of lead, tannin, and other astringents, as, in his opinion, well adapted to the purpose, although he never, it would seem, performed the operation. His idea was that, by throwing these sub- stances into the sac, so as to bring them fully into contact with the blood within, it might be possible to provoke the rapid formation of coagula, and thus effectually arrest the circulation. He supposed, moreover, that the remedy might occasionally be advantageously combined with Brasdor's operation and with compression of the artery upon the cardiac side of the tumor, applied by means of a tourniquet or some other suitable instrument, very much as it is performed at the present day. The suggestion of the Italian surgeon, however, received little, if any, attention, until within a comparatively recent period, when it became the subject of numerous experi- ments upon the inferior animals, as the sheep, dog, and horse, principally by the French practitioners, who, after having tried various articles, have at 756 DISEASES AND INJURIES OF THE ARTERIES. length been induced to give a decided preference to a concentrated solution of perchloride of iron in water. The fluid is introduced into the sac by means of a small glass syringe, invented by Mons. Pravaz, of Lyons, and represented in fig. 255, a puncture having previously been made with a deli- Fig. 255. Pravaz's syringe. cate trocar and canula, the latter of which is retained in the sac until the injection is completed. The piston of the syringe is moved by means of a screw, so as to enable us to perform the operation more steadily, and with- out the risk of throwing in more than five or six drops of fluid, that quantity having been found to be quite sufficient for the purpose. As it takes at least half a minute before the blood can be made to coagulate, during which the heart performs not less than thirty-five pulsations, it is necessary to keep the contents of the tumor perfectly quiet, while the injection is progressing, by compression of the artery immediately above and below the aneurism. The operation is generally productive of severe pain, and as it is liable to be followed by considerable inflammation, it often becomes necessary to make use of antiphlogistic measures, both locally and constitutionally. Its repeti- tion must be governed by circumstances; if everything passes off well, and the sac is promptly solidified, no further interference will, of course, be demanded; but if the reverse be the case, a similar quantity of the solution is thrown in at the end of the third or fourth day, and in the same cautious manner as before. The slightest inflammation of the tumor contraindicates the repetion of the injection. Since 1853, when Mons. Pravaz first published the results of his experi- ments on animals, a number of cases have been reported in which injections of the perchloride of iron have been employed in aneurism of different parts of the body, as well as in aneurism of different kinds, as spontaneous, trau- matic, and varicose. The arteries upon which the disease occurred were the supra-orbital, carotid, humeral, ulnar, femoral, popliteal, and tibial. Although a few cures have been effected by this treatment, yet such is the great risk of inflammation, suppuration, and even gangrene, both of the sac and of the surrounding structures, that it is extremely questionable whether any prudent surgeon should repeat it. Of eleven cases, reported by Mal- gaigne in 1854, it is announced that four had proved fatal, that every one had had bad symptoms, and that only two had been successful. This state- ment alone, if true, as no doubt it is, is sufficient to condemn the operation as unsafe, and to render its adoption improper in the face of the more unex- ceptionable methods of ligation and compression. The great desideratum is to discover an article, which, while it shall promptly coagulate the blood, will not cause any severe irritation in the sac and the parts around it. It has been supposed that the acetate of the peroxide of iron might have this effect, but, although at least one successful cure by its use has been reported, yet it has not been tried sufficiently often to enable us to pass any definite judgment respecting its true merits. I should myself have more confidence in the effi- cacy and safety of the persulphate of iron, generally known as Monsel's salt, than in any other preparation of this metal. It is perfectly destitute, or nearly so, of caustic properties, and is the most prompt and efficient coagu- lator of the blood of which we have at present any knowledge. VALSALVA'S TREATMENT OF INTERNAL ANEURISM. 757 h. MANIPULATION. Very recently the attention of the profession has been called to a new treatment of aneurism by Mr. Fergusson, of King's College, London. It is termed the method by manipulation. It consists in the forcible squeezing of the tumor, with the intention of breaking up its fibrinous contents in order that sorae of the fragments thus detached may be carried by the circulation into the distal extremity of the artery, thereby closing its orifice, and so effecting a radical cure. The operation was first performed in 1852, in a case of aneurism of the right subclavian artery, seated partly within and partly on the outside of the scalene muscles, the tumor being about the size of a hen's egg. The sac being emptied of fluid blood, its sides were forcibly rubbed against each other, with the immediate effect of an arrest of pulsation in all the vessels in the limb below. The pulsation, however, returned in about seven hours, and the manipulation was accordingly repeated the next day with a similar result, but it was not until the end of a week that any permanent impression appears to have been made upon the circulation. The tumor now gradually diminished in size, and everything gave evidence of an ultimate cure, when suddenly, seven months afterwards, the patient was seized with violent fever attended with excruciating pain in the part, and died after a few days' illness. Although the axillary artery was found, on dissection, to have been blocked up, the tumor, instead of being obliterated, not only remained hollow, but had extended downwards over the axillary plexus of nerves, the pressure upon which had probably caused the excessive pain which immediately preceded dissolution. In another instance, operated on by the same gentleman, the result was more fortunate, but the cure was not finally effected until towards the end of the second year. Within the last few years several other cases, also successful, have been reported by other surgeons, among whom I raay mention Professor Blackman, of the Medical College of Ohio. In a case of popliteal aneurism recently reported by Mr. Teale, of Leeds, this plan of treatment was successfully conjoined with digital compression. After the latter had been carried on for sorae time with, apparently, very little effect, a portion of clot was detached, leading at once to the consolidation of the tumor. I have not had an opportunity of trying Mr. Fergusson's plan of treat- ment, but it is, I think, extremely questionable whether it ought to be re- peated. The great objections to it are, first, the uncertainty of the operation, even when the distal end of the artery has been blocked up; secondly, the tardiness of its progress; and thirdly, the danger that some of the detached clots may find their way into the brain, as in aneurism of the neck, thus caus- ing fatal apoplexy, as has already happened in several cases in which the method has been tried. If employed at all, therefore, it should, in my judg- ment, be restricted to aneurism of the subclavian, axillary, femoral, and pop- liteal arteries, in the early stage of the disease, before the tumor has acquired any considerable bulk. I. VALSALVA'S TREATMENT OF INTERNAL ANEURISM. Internal aneurisms, inaccessible to the ligature and compression, occasion- ally recover under a regular and systematic course of treatment designed to promote the coagulation of the blood in the interior of the tumor, by increas- ing the plastic properties of this fluid, and quieting the action of the heart and arteries. This treatment, which was originally suggested by "Valsalva, and which still bears his name, consists in the strict observance of the recum- 758 DISEASES AND INJURIES OF THE ARTERIES. bent posture, perfect mental quietude, the occasional abstraction of blood from the arm, and the use, simply, of a sufficiency of food and drink to pre- vent starvation. When, writes Morgagni, Valsalva had taken away as much blood as was deemed necessary, he diminished the diet " more and more every day, until only half a pound of pudding was taken iu the morning, and in the evening half that quantity, and nothing else except water, the weight of which was also regulated, and which he medicated with what is called quince- jelly, or the lapis osteocolla, ground down into a very fine powder. After the patient had been sufficiently reduced by this method, so that he could scarcely raise his head from the bed, to which, by Valsalva's direction, he was confined, the quantity of aliment was day by day increased, until the strength that was necessary to enable him to get up had returned." Most modern writers, in speaking of this method, recommend, as important adju- vants, the internal exhibition of digitalis, acetate of lead, and opium, with a view of insuring more speedily and effectually the ends proposed by "Valsalva and his followers; the digitalis being given to diminish the number and force of the pulsations of the heart and arteries, the lead to increase the coagulability of the blood, and the opium to allay pain and nervous irrita- bility. We have no account of the number of cases of aneurism successfully treated by Valsalva by this method, but that he cured several persons with it is a conjecture warranted by the statements of Morgagni, by whom it was first described. What is still more to be regretted is the fact that we are equally ignorant in regard to the results obtained by others. But, notwithstanding this, it seems to me that the treatment is worthy of more attention than it has hitherto received, especially of late years, when so little has been said and done concerning it. The question, however, arises whether it might not be beneficially modified, so as to render it better adapted to the attainment of the object which it is designed to accomplish. In reflecting upon the sub- ject, some years ago, it occurred to me that, instead of bleeding and starving the patient, upon which so much stress was laid by the Italian practitioner, the end might be more easily and speedily obtained by the abandonment of the lancet altogether, and the substitution of nutritious food, in as dry, con- centrated, and non-stimulant a state as possible. If the object be to procure a more plastic and coagulable condition of the blood, to promote the forma- tion of clots, this can certainly be done much more advantageously, as well as in a much shorter time, by such a course than by one of an opposite charac- ter. Repeated bleeding and a light farinaceous diet, comprising a little pudding and jelly, taken twice a day, must, unquestionably, render the blood very thin and watery, and therefore less disposed to fibrinization, the very reverse of what is really needed for the cure of aneurism. It would be more in accordance, then, with sound physiology and practice, to refrain from venesection entirely, and to put the patient upon a moderate allowance of food, as a few ounces of equal parts of hashed meat and bread, potato, or rice, at dinner, with a suitable quantity of stale bread, toast, or cracker at breakfast and supper; tea, coffee, and all other drinks, excepting water and lemonade, as well as all kinds of condiments, being scrupulously avoided. The patient should be kept perfectly at rest, in the recumbent posture, with the mind in as tranquil a state as possible, while the system should be steadily maintained under the free use of the tincture of aconite, or of veratrum viride conjoined with acetate of lead and opium, or, what would probably be better, the persulphate of iron. The pulse should be brought down, if practicable, to forty or forty-five beats in the minute, and the chances of success would be all the greater if a prolonged state of somnolency could be maintained, the patient sleeping the greater part of the twenty-four hours. Protracted constipation of the bowels should be aimed at; if purgatives become indis- FALSE ANEURISM. 759 pensable, they must be of the mildest character, as all irritating and griping articles are sure to do harm by exciting the action of the heart and arteries. The length of time during which this treatment should be continued must vary according to the circumstances of each individual case, and no attempt should, therefore, be made to reduce it to any general principles. It certainly might, with judicious mauageraent, be kept up, without detriment, for several consecutive weeks. As the patient emerges from it, he should return, but most gradually and cautiously, to his accustomed diet, except that, for a long time afterwards, it should be free from all stimulants; nor should he, for many months, take any, except the most gentle, exercise. In short, everything should be done calculated to second nature in her efforts to effect the cure thus auspiciously begun, and which, other things being equal, will always be so much the more likely to take place if the aneurism be small and of recent standing. Since the publication of the first edition of this work, I have had an oppor- tunity of treating three cases of iutra-thoracic aneurism according to the plan here sketched; but, although the patients seemed to be materially bene- fited, as far as their pain was concerned, and the pulse was brought down below fifty, I was not able to satisfy myself whether the progress of the disease was at all retarded. It is proper, however, to add that all the cases were far advanced when they fell into my hands. j. GENERAL MEDICAL TREATMENT. Persons affected with aneurism often experience, as stated elsewhere, great pain and other suffering, both from the inflamed condition of the tumor and from the pressure which it exerts upon the surrounding parts. In aneurism of the thoracic portion of the aorta and of the arteries at the root of the neck, the pain and dyspnoea are sometimes excessive, demanding prompt and vigor- ous measures for their relief. If the patient be plethoric, and the pulsation in the tumor uncommonly active, the loss of twelve, fifteen, or twenty ounces of blood will be useful, but care must be taken not to carry the venesection too far, otherwise injurious reaction may take place, and thus aggravate the suffering. When the tumor is accessible, or situated externally, whether partly or entirely, the blood is often most advantageously abstracted directly from the part by means of leeches, which, even when employed only in small numbers, generally afford immense relief, both as it respects the pain and the difficulty of breathing. Topical depletion is always extremely serviceable in inflamed aneurism, aud it is here also that fomentations and refrigerating lotions, simple or medicated, come into play, frequently exerting their hap- piest influence. Our choice of these remedies must be governed in these, as in other cases, by the tolerance of the part and system. Attention to posi- tion and rest must be enjoined, and strictly carried out. The bowels are not neglected, but great care is taken to avoid active purgation, experience hav- ing shown that such a procedure always produces undue excitement of the vascular and nervous systems. Anodynes are always well borne in these cases, and should be administered in full doses, either alone or in union with diaphoretics and expectorants, according to the state of the skin and of the respiratory organs. Any complications that may arise during the progress of the disease, whether self-existent or dependent upon the irritation produced by the pressure of the tumor, must be treated upon broad general principles. FALSE ANEURISM. A false aneurism consists, as already stated, of a pulsating tumor formed external to the affected artery, and, consequently, without any aid from its 760 DISEASES AND INJURIES OF THE ARTERIES. tunics, which are altogether excluded from its composition. A number of affections, of a very opposite character, have been described under this appel- lation, and the result has been, as might have been anticipated, much confu- sion. To remedy this evil, I shall limit myself, in the account which I am about to give of the disease, to two varieties of false aneurism, the arterial and arterio-venous, the tumor in each being strictly circumscribed, and con- nected, in the former, with an artery, and, in the latter, both with an artery and a vein. What is called a diffused aneurism is, in fact, as stated else- where, no aneurism at all, but merely an accumulation of blood in the subcu- taneous and intermuscular cellular tissue, which, although it raay be somewhat condensed around it, yet does not, in reality, in the true meaning of the word, constitute a proper aneurismal sac. The most common cause of the spurious arterial aneurism is external injury, as a stab or puncture, such, for example, as is so often inflicted in venesection at the bend of the arm, permitting the blood to escape in small quantity into the surrounding cellular substance, which is soon condensed into a firm, cir- cumscribed, pulsating cyst, often not exceeding the volume of a pullet's egg, and of a rounded or ovoidal figure. Similar effects occasionally follow the laceration of an artery, as that of the ham, from the sudden and forcible ex- tension of the leg, from the intrusion of the sharp end of a broken bone, or from ulcerative action. Sometimes the aneurismal formation is secondary ; that is, consequent upon the partial cicatrization of the wound, the interposed or overlying plasma being unable to withstand the impulse of the blood, and so yielding before it. However induced, all the tunics of the artery are at once perforated, and the blood is sent abroad into the circumjacent cellular tissue, iu the manner and with the effect just stated. The sac in this variety of aneurism, formed originally, as has just been remarked, out of the neighboring cellular tissue, is speedily strengthened by the effusion of plastic matter, so that, in time, it often acquires considerable thickness with an extraordinary degree of density. I have seen a number of cases where the cyst, even at an early stage of the disease, was of a very firm, compact, fibroid consistence, and of a white, glistening appearance, its sub- stance being convertible, by dissection, into several distinct strata. The tumor, particularly in cases of long standing, generally contains well organ- ized concretions, arranged in the same concentric manner as in the true sac- culated aneurism, and presenting a similar hue and consistence. The course, symptoms, and termination of this disease do not require any special notice, as they do not differ, in any respect, from the ordinary form of the affection. The treatment raay be conducted by compression, or, this failing, by liga- ture. The compression is applied, as in true aneurism, upon the cardiac aspect of the tumor, four, six, or eight inches from it, with the instrument already described, retardation of the circulation and gradual obliteration of the sac being steadily kept in view. If an operation becomes necessary, a free incision is carried across the tumor, and a ligature applied immediately above and below, as in an ordinary wounded artery. The tumor may then be dissected out, or, as some prefer, though I think improperly, it may be left to the influence of the absorbents. As a preliminary step, a tourniquet is cast around the limb to control the circulation in the affected vessel. Although one ligature is occasionally sufficient to effect a cure iu this dis- ease, yet I would strongly advise the ligation of the vessel both above and below the swelling, lest trouble should arise on account of the recurrent cir- culation, and thus lead to the necessity of doing at a subsequent period what ought to have been done in the first instance. The memorable case of Anel affords an excellent illustration of the fact that an aneurism of this kind, espe- FALSE ANEURISM. 761 cially when seated at the bend of the arm, may occasionally be cured by a ligature applied just above the tumor. 1. The arterio-venous aneurism, originally described under the name of varicose aneurism, consists of a tumor which is situated, as the term implies, between a contiguous artery and vein, so as to admit of a ready interchange of the two kinds of blood. The most comraon site of the lesion is the bend of the arm, as seeu in figs. 256 and 257, where it is generally caused by a puncture in bleeding, in which the overlying vein, usually the median basilic, is completely transfixed along with the superficial wall of the brachial artery. A similar accident may, of course, happen in any other part of the body, from a stab or wound of a contiguous artery and vein, as between the femo- ral, or between the aorta and vena cava. Sometimes, again, the aneurism forms in consequence of ulceration, beginning in one vessel and gradually extending to the other, and so eventually establishing a communication between them through the intervention of a sac. In whatever manner the aneurism is formed, the cyst is usually of small size, seldom exceeding, and not often equalling, that of a pullet's egg. It is Fig. 256. Varicose aneurism ; external appearance. composed partly of condensed cellular substance and partly of plastic mat- ter, the latter always greatly predominating, as is shown by its extraordinary thickness as well as density, which closely resembles that of Fig. 257. the fibrous tissue. The tumor, although it is seldom the seat of much pain, interferes more or less with the functions of the affected limb. The opening of communication being always very small, the blood rushes into it with a peculiar noise, not un- like that produced by the buzz- ing of a fly in a paper box, or the purring of a cat. Some- times it is of a whirring charac- ter, similar to the prolonged articulation of the letter R. It is perceived both by the ear and finger, and is so extraordinary that it may be regarded as pathognomonic of the nature of the affection. The sac rarely contains any well-formed fibrinous concretions, and, on laying it open, it is often found to be perfectly smooth and white, like the interior of an artery. Manifesting little disposition to increase, it sometimes remains stationary for years, but seldom, if ever, undergoes spontaneous cure, or terminates in rupture, ulce- ration, or gangrene. When the tumor is very small, not exceeding the volume of a filbert or a pigeon's egg, and does not occasion any suffering, interference is neither desirable nor proper; it is merely an inconvenience, and had better be let alone. The reverse, however, is usually the case, and then the same treat- Varicose aneurism ; internal view. a. The artery, b. The vein. c. The intermediate cyst. 762 DISEASES AND INJURIES OF THE ARTERIES. raent will be required as in spurious aneurism connected with an artery only; that is, the vessel is tied just above and below the tumor, which is left to undergo absorption, lest its removal should give rise to phlebitis in conse- quence of the unavoidable injury inflicted upon the affected vein. When the disease occurs in connection with the aorta and vena cava, ope- rative interference will, of course, be out of the question; nor can anything be hoped for frora medical treatment. The case, in fact, is irremediable, and will be sure, in time, to cause death, either by the gradual giving way of the sac, or by exciting violent irritation, pain, and constitutional disorder. 2. Aneurismal varix, fig. 258, consists in a direct communication between a contiguous vein and artery, without the intervention of a sac; it differs, therefore, essentially from a varicose aneurism, in which, as has just been seen, there is always a distinct cyst, formed out of the surrounding tissue, along with more or less plasma. The affection is altogether so unlike aneu- Fig. 258. Aneurismal varix. rism, whether true or spurious, that it is surprising it should ever have been included under the same category. The cause of aneurismal varix—a disease first described by Dr. William Hunter, in 1756—is usually some external injury, such as a puncture, trans- fixing a vein and piercing the contiguous wall of an underlying artery. Hence, the lesion is most common at the bend of the arm, between the me- dian basilic vein and brachial artery, in consequence of venesection. It may, however, occur between other veins and arteries lying in juxtaposition with one another, either through accident, or from the effects of ulceration com- mencing in the coats of one vessel and gradually perforating those of the other. The orifice of communication is usually small, and of a circular shape, •with well-defined margins, although there is, in this respect, no particular uniformity. The adhesion between the twro vessels is generally very firm, as well as of considerable extent, and it is well that it should be so, otherwise there would be constant danger of the connection giving way. Owing to the incessant interchange and commingling of the two kinds of blood, the vessels gradually undergo important changes, the most interesting of which are that the vein assumes the properties of an artery, and the artery those of a vein. The vein, from the impetuous manner in which the arterial blood is sent into it at each stroke of the heart, becomes greatly enlarged both above and below the abnormal opening, at the same time that it acquires an extraordinary degree of density, and pulsates with unusual force. In the arm, where I have met with several instances of this disease, I have found the dilatation of the vein extend, on the one hand, nearly as high up as the axilla, and on the other, as low down as the middle of the forearm. The artery, which now receives black blood, but not in any large quantity, is eventually transformed into a soft, thin, flexuous tube, which, possessing ra- ther the properties of a vein than those of an artery, pulsates but feebly under the finger. The formation of this disease is generally attended with some degree of pain and swelling, along with interstitial effusions, causing the integumeuts ANEURISM OF THE THORACIC AORTA. 763 to pit slightly on pressure. The parts below the seat of the lesion are im- perfectly nourished, and hence they usually feel somewhat cold and numb until the circulation is fully re-established through the agency of the collateral branches. As the blood passes from one vessel into the other it produces a peculiar jarring sensation and a singular whirring noise, not unlike the pur- ring of a cat, which often extends to a great distance along the dilated vein, now performing the vicarious functions of an artery, and which may be re- garded as the pathognomonic signs of the disease. In the cases of this lesion which have fallen under my observation, the inconvenience has been so trifling that I have not considered it proper to resort to operative interference. In one instance the patient had an aneu- rismal varix on the right arm from venesection performed upwards of fifteen years previously, and, although he was a blacksmith and a hard working man, it did not in the slightest degree interrupt his occupation. Wrhen trouble arises so as to render treatment necessary, relief may be attempted by com- pression of the brachial artery, as in varicose aneurism ; this failing, the artery should be exposed by a careful dissection, and a ligature applied both above and below the orifice of communication, all disturbance of the vein being avoided. SECT. VII.—ANEURISM OF PARTICULAR ARTERIES. ANEURISM OF THE THORACIC AORTA. The merest glance at the situation of this vessel is sufficient to impress us with the great importance of its relations, and to show that any deviation from its normal condition, however slight, may be productive of the most frightful consequences. The disease may exist, 1st, as a fusiform expansion ; 2dly, as a dilatation of the coats of the vessel, affecting the greater portion, if not the whole, of its circumference; or, 3dly, as a true, false, or mixed aneurism, properly so called, of variable size and shape, generally connected with the anterior or lateral aspect of the artery, the posterior part being seldom implicated. The ascending portion and arch of the aorta, especially the latter, are by far the most frequent seats of the disease, owing to their vicinity to the heart, which thus imparts to them its impulsive and expansive movements, and to their greater proneness to fatty and other degenerations, rendering their tunics weak and brittle, and consequently liable to laceration. In most cases, the aneurism is of the true species, commencing as a sac-like enlargement, which, as it increases, usually inclines to the right side of the chest, and is capable of acquiring a volume equal to that of a double fist. It soon becomes occu- pied with organized clots, which occasionally, though very rarely, accumulate to such an extent as to lay the foundation of a spontaneous cure. The open- ing of communication between the tumor and the artery varies in size from that of a dime to that of a twenty-five cent piece. The disease, which is more common in men than in women, not unfre- quently arises at a comparatively early age, as from twenty-five to thirty, in consequence, apparently, of severe straining and other bodily exertions. Sail- ors and mechanics are peculiarly liable to it. The astonishing frequency of aneurism of this vessel is shown by the tables of Mr. Crisp, embracing 915 cases, of which 382 affected the thoracic aorta. The duration of thoracic aneurism varies from a few months to upwards of three years, the average being from nine to twelve months. The tumor usu- ally bursts into the left pleura, pericardium, trachea, bronchial tubes, oeso- phagus, or posterior mediastinum; sometimes into the heart, lungs, or spinal 764 DISEASES AND INJURIES OF THE ARTERIES. canal, and sometimes, again, but also very rarely, externally. Dr. Darrach, of Illinois, has shown by an analysis of twenty-three cases that aneurism of the descending aorta terminates pretty uniformly by rupture, while that of the arch generally ends by exhaustion and irritation, or some concomitant disease of the heart, brain, lung, or kidney. Occasionally the tumor gives way when it is not larger than a pullet's egg. The symptoms of aneurism in this situation are chiefly of a mechanical character, arising from the pressure of the tumor upon the surrounding struc- tures. They consist mainly of pain, cough, dyspnoea, dysphagia, enlarge- ment at the sterno-clavicular region, and of various kinds of sounds, synchro- nous with the action of the heart. Pain, from the constancy of its occurrence, is a symptora of great value. It comes on early in the disease, is more severe in sacculated than in fusiform aneurism, and is evidently dependent, at first, or so long as the tumor is com- paratively small, upon the pressure which the aneurism exerts upon the spinal and sympathetic nerves, and afterwards upon this cause and upon the erosion and perforation of the tissues, especially the sternum, ribs, and vertebrae. It varies much in degree, character, and situation. In the earlier stages of the disease it is most conspicuous on the left side; it is sharp, lancinating, and intermittent, not unlike the pain of neuralgia, darting about in different direc- tions; at one time into the neck and face, at another through the chest and spine, now along the shoulder and arm, and now through the diaphragm and even the loins. As the tumor enlarges, and erodes, by its pressure, the neighboring structures, the pain becomes more steady, fixed, and severe; it gradually shifts to the right side, and is generally of a burning, gnawing, or boring character. Cough is also a comraon symptom ; it generally begins early in the dis- ease, and is liable to severe exacerbations, often productive of intense suffer- ing. It is of a crowing, stridulous, or ringing character, and it obviously depends upon the irritation caused by the pressure of the tumor upon the air-passages. Sometiraes it is short, spasmodic, and laryngeal. Dyspnoea is always more or less distressing, especially when the disease has made considerable progress, and is invariably aggravated by severe bodily exertion, as in walking up a hill, or ascending a flight of stairs. It is occa- sionally extremely violent, although the tumor may not exceed the size of a walnut, owing to the pressure which it exerts upon the trachea, or the tra- chea and bronchial tubes. During the latter stages of the complaint, the breathing is always so difficult as to prevent the patient from lying down, perhaps for days before he expires. Dysphagia is seldom present until after the disease has made considerable progress, although it is sure, in the end, to become a prominent symptom; so that, ultimately, the sufferer finds it very difficult to swallow anything either in the form of food or drink. It is not often that there is any external turaor, except when the aneurism points in front of the chest, as it frequently does in the latter stages, after it has partially destroyed the sternum and the ribs, or the ribs and intercostal cartilages. In the great majority of cases it shows itself on the right side of the chest from three to four inches below the collar bone, as a pulsating swelling, lifting up the integuments synchronously with the contraction of the heart, furnishing a distinct bellows, sawing, or purring sound, and being exquisitely tender on pressure. Occasionally the sac projects into the neck above the fourchette of the sternum, inclining towards the right sterno- clavicular articulation. When this is the case, it must necessarily overlap the innominate, common carotid, and subclavian arteries on the right side, and may even so effectually compress them as to cause their obliteration, although such an event is very unusual. ANEURISM OF THE THORACIC AORTA. 765 A distinct aneurismal sound, or purring tremor, is usually perceptible at an early stage of the disease, although it is extremely difficult, if not impossi- ble, always to refer it to its proper source. It is synchronous with the beat of the heart, and gradually becomes more and more faint as the disease ad- vances, in consequence of the progressive filling up of the sac by coagula. Among the less constant symptoms are, palpitation of the heart, wheez- ing, panting, or asthmatic respiration, tracheal and bronchial rales, sense of constriction of the chest, oedema and lividity of the face, feebleness and irre- gularity of the pulse at the wrist, from the pressure of the tumor upon the innominate or subclavian artery, and anasarca of the extremities, espe- cially the inferior. Alteration of the voice is by no means uncommon, and occasionally amounts to complete aphonia. In the more advanced stages of the disease there is also frequently an enlarged and varicose state of the subcutaneous veins over the upper part of the chest, generally towards the right side. Now, although intra-thoracic aneurism manifests itself by numerous symp- toms, yet there is not one that can be considered as absolutely diagnostic. It is not surprising, therefore, that the disease should occasionally terminate fatally, without any suspicion as to its true nature. Such an error will be most likely to happen when the tumor is small, or when it bursts into some neighboring canal before it has sensibly encroached upon the walls of the chest. As it increases in volume, its character becomes daily more and more apparent, and all doubt must, of course, vanish when the tumor points externally, although even then a careless practitioner might regard it as an abscess, and, under this supposition, be perhaps even induced to open it, as I have known to be done in two cases, notwithstanding the heaving and pulsating nature of the swelling, and the existence of all the other signs of aneurism. When the aneurism arises from the summit of the aorta, the tumor projects into the root of the neck, and may indeed ascend so high up as to simulate aneurism of the innominate or carotid artery. From this, however, it may in general be readily distinguished by the history of the case, by the impossibility of tracing with the finger the lower boundary of the tumor, by the dulness on percussion of the upper part of the chest, and by the presence of a larger amount of dyspnoea than usually attends cervical aneurism, particularly in its earlier stages. The auscultatory signs rarely afford any conclusive evidence of intra-tho- racic aneurism. Few surgeons are able to discriminate between the sounds of the heart and those of such a tumor, and the difficulty must necessarily be much increased when, as not unfrequently happens, aneurism and cardiac disease co-exist. When the heart is sound, and the aneurism has attained a considerable bulk, the diagnosis will be less ambiguous; but even then it will require a very practised ear to detect the varying shades of difference. The sound of a thoracic aneurism is more like the purring of a cat than the clear murmur attending the first sound of the heart, and its distinctive features are still further defined by the presence of a peculiar tremor or vibratory move- ment. In the sacculated variety of the affection, it is often impossible to distinguish any abnormal sound whatever; at first, because of the small size of the swelling and subsequently, because the tumor is filled with coagula, impeding, if not preventing, the transmission of sound. In fusiform aneu- rism, and also in simple but extensive dilatation, the sound characteristic of the disease is generally easily recognized throughout its entire progress. Dulness on percussion, in a marked degree, can exist only in the event of the tumor being of considerable bulk ; a small aneurism may be present, and even prove fatal, without any change of resonance. When there is dulness, it is always most conspicuous at the upper aud middle parts of the chest. Sometiraes valuable diagnostic information may be derived from the dis- 766 DISEASES AND INJURIES OF THE ARTERIES. placement of the heart by the tumor, its pulsations being perceived in an abnormal position, where there is no evidence of pleuritic effusion or disease of the lung to account for the change. Among the affections with which aneurism of the thoracic aorta is most liable to be confounded are malignant tumors of the chest, especially ence- phaloid, disease of the heart, as hypertrophy and valvular derangement, and aneurism of the innominate, carotid and subclavian arteries. The best secu- rity against error will be an attentive consideration of the history of the case, and a thorough study of its progress, time often throwing more light upon the character of the malady than the most elaborate auscultatory explora- tions. The treatment of intra-thoracic aneurism resolves itself into the adoption of measures calculated to relieve the patient's sufferings rather than to cure his disease, of which there is, in any case, hardly even a remote possibility. If plethora exist, an occasional bleeding cannot fail to ameliorate, at least for a time, the pain and difficulty of breathing. The circulation should be controlled by the cautious exhibition of veratrum viride, the diet be light and concentrated, the bowels maintained in a soluble state, and suffering allayed by anodynes. Perfect quietude of mind and body must of course be observed. ANEURISM OF THE INNOMINATE ARTERY. The relative frequency of aneurism of the innominate artery does not admit of any definite statement, owing to the great discrepancy in our statis- tics. Thus, in 179 cases of spontaneous aneurism, excluding those of the aorta, analyzed by Lisfranc, the innominate is mentioned only four times, while the carotid is mentioned seventeen times and the subclavian sixteen. In Mr. Crisp's table of 551 cases, embracing 234 of aneurism of the aorta, the innominate was affected in 20, the carotid in 25, and the subclavian in 23. The disease, as in the other arteries, is much more common in men than in women, and in the laboring than in the higher classes of persons. The greatest number of cases occur between the thirty-fifth and fifty-fifth year. It may exist by itself or be associated with aneurism of the arch of the aorta, the carotid, or subclavian. The extent of involvement varies from the slightest increase of the normal size to an enormous tumor, either tubular, fusiform, or sacculated in its character. Whether every portion of the vessel is equally liable to be affected is uncertain, but observation has shown that the disease is sometimes situated so low down as to become identified with the arch of the aorta, while at other times it is so high up as to extend into the carotid and subclavian. Occasionally, it is limited to the middle of the vessel, each extremity retaining its healthy appearance. Symptoms.—Aneurism of the innominate, artery usually begins as a small tumor at the right sterno-clavicular articulation, between the trachea and the inner edge of the mastoid muscle, immediately above the inner third of the clavicle. In some cases, the patient is conscious of the moment when the accident takes place, there being a feeling as if something had given way while he was shaken by a violent paroxysm of coughing or engaged in lifting a heavy weight. The tumor, at first, is generally very small, probably not exceeding the size of a little almond, of a rounded or ovoidal shape, distinctly circumscribed, and slightly movable on pressing the finger firmly down into the hollow at the top of the sternum. It is not long, however, before it in- creases in volume ; commonly, in fact, it grows rapidly, soon attaining a large bulk, extending upwards into the neck, and laterally towards each side, but especially towards the right, where there is least resistance. As it progresses, it gradually pushes forwards the mastoid muscle, and even the steruo-clavicu- ANEURISM OF THE INNOMINATE ARTERY. 767 lar articulation, forming thus a large prominence, beating and throbbing vio- lently beneath the skin. Now and then, upon escaping from the chest, the tumor ascends high up into the neck, perhaps nearly on a level with the larynx, and when this is the case it is not uncommon for it to present a constricted, hourglass-like appearance, as if a cord had been drawu tightly across its middle. Effects on Neighboring Structures.—The effects which the tumor exerts upon the neighboring parts, fig. 259, are chiefly of a mechanical character, and must be considered with refer- ence, first, to the vessels of the Fig. 259. superior extremity, neck, and head ; secondly, the trachea and oesophagus ; thirdly, the aorta, heart, and vena cava ; fourthly, the nerves of the neck and chest; and, lastly, the sternum, clavi- cle, and ribs. The pressure of the tumor upon the subclavian has the effect of weakening the force of the circulation at the wrist, and in some cases even of entirely suppressing it. Occasionally, the pulse is extremely irregular, beating not only more feebly than that in the Opposite limb, Aneurism of t]ie innominate artery, proving fatal by burst- but Ceasing tO act Synchro- ing into the trachea. nously with it, the blood hitch- ing and halting, as it were, on its way to the hand. Any tumor may of course produce such an effect, and hence there is nothing characteristic in it. In aneurisra of the aorta, the signs of enfeebled circulation are, as a general rule, most strongly marked on the left side, owing to the fact that the tumor, from its proximity to the left subclavian, exerts a more direct and controlling influence upon that vessel than it does upon the right subclaviau. The pul- sation of the carotid and its branches is sometimes diminished both in in- nominatal and aortic aneurism, but more frequently in the former than in the latter. It is, however, a rare occurrence in either case, and therefore of no diagnostic value. Compression of the veins at the root of the neck, as the innominate, jugular, and subclavian, but especially the first, by impeding the return of blood to the heart, will occasionally cause oedema of the right side of the head, face, and eyelids, and of the corresponding limb, extending as low down as the hand and fingers. The occurrence, however, is uncomraon, and it is probable that it may be due, in part, to injury sustained by the right lymphatic duct, situated just behind the tumor. As the tumor enlarges, it necessarily encroaches more and more upon the trachea, pushing it over towards the left side, and at the same time somewhat backwards. When the displacement is considerable, the patient will breathe with difficulty, and will occasionally be unable to lie down, owing to the mechanical obstruction to the introduction of the air. Should the tumor be situated unusually low, or be of extraordinary size, it may compress and flatten the right bronchial tube. Dyspnoea frora both of these causes, how- ever, is less frequent in aneurism of the innominate artery than in aneurism of the arch of the aorta, owing to the fact that, in the latter disease, the turaor enlarges most in a backward direction, its progress forwards being interfered with by the sternum and clavicle. Displacement of the oesophagus 768 DISEASES AND INJURIES OF THE ARTERIES. is sometimes present in both affections, but not as often as has generally been supposed. When existing in a high degree, it may seriously embarrass the function of deglutition, especially the passage of solids. When the aneurism occupies the inferior portion of the artery, but more especially when it extends downwards into the chest, it follows, as a neces- sary consequence, that it must press upon the aorta, heart, and vena cava, pushing them out of their natural position, and perhaps seriously diminishing their capacity. The particular effect which such compression must exert cannot always be diagnosticated, but it is reasonable to conclude that it will manifest itself in disordered circulation, especially in tumultuous and confused cardiac action, enfeebled pulse, and more or less dyspnoea. An aortic aneu- risra will of course be more likely to produce such a state of things than an innominatal. Pressure of the turaor upon the nerves of the neck and chest induces not only pain and cough, but gives rise, in many cases, to severe dyspnoea and dysphagia, the two latter symptoms being not always, by any means, exclu- sively dependent upon the displacement and flattening of the trachea and oesophagus. On the contrary, they sometimes exist in a very marked and even in an aggravated degree when there is apparently very little, if any, compression of these tubes. We must therefore look for some other expla- nation of these phenomena, and the most plausible oue that suggests itself is that they are due to the compression of the pneumogastric, phrenic, laryn- geal, and sympathetic nerves, which are thus disqualified for carrying on their appropriate function, that, namely, of receiving and transmitting, in a regular and harmonious manner, their peculiar influence to the organs to which they are distributed, and in which they play so important a part in the natural state. The dyspnoea, although not a constant symptom, is yet often enough pre- sent to render it one of great importance. It varies in degree from the slightest change in the natural respiration to the most frightful embarrass- ment, in which the patient is almost suffocated, and unable to maintain the recumbent posture. It is of course most severe and distressing when the tumor has acquired an unusual bulk, compressing the pneumogastric and other nerves, and so interrupting their healthy action. It may be constant, or paroxysmal, coming on at irregular intervals, lasting for some time, and then gradually receding, though perhaps at no time wholly absent. The dysphagia is also variable in degree, being at one time very slight, and at another so severe as almost to prevent the patient from swallowing any kind of food, whether solid or fluid. In the more aggravated cases, the difficulty is constant, and the patient finally dies exhausted from starvation. It is a remarkable fact that in almost every case of dysphagia this symptom is preceded by dyspnoea. The pain which accompanies the disease is most severe in the right side, in the situation of the tumor, from which it runs in various directions, par- ticularly along the right side of the neck and head, and the corresponding side of the chest, shoulder, and arm. Occasionally, though rarely, it is also felt keenly on the opposite side. It is generally of a dull, aching, or gnawing character, and is often so excessive as to compel the use of large doses of anodynes for its temporary subjugation. Cough is occasionally present, probably in one case out of every three or four, but it is less common than in aortic aneurism, and is a symptom of no special value. It is evidently produced by the pressure of the turaor upon the laryngeal nerves, and varies ranch in frequency and severity in different cases and under different circumstances. From the same cause there is some- times an altered state of the voice. When the tumor is very large, and extends outwards and downwards, so as to compress the cervical and brachial plexus of nerves, it may induce par- ANEURISM OF THE INNOMINATE ARTERY. 769 tial paralysis, as well as, in some cases, partial loss of sensation, in the upper extremity. Such an occurrence, however, is extremely rare, as the sac seldom attains such a magnitude. There is sometimes marked alteration in the respiratory sounds; more fre- quently, however, in aortic than in innominatal aneurism. The breathing, when affected, is disposed to be stridulous, or wheezing, and this is sometimes the case even when the patient is in the erect posture. The respiratory mur- mur is seldom affected in innominatal aneurism, obviously because the tumor encroaches but little, if any, upon the lungs; it is only when it extends deep down into the thorax that it is likely to produce such an effect, and then, but not otherwise, there will, also, of necessity, be dulness on percussion of the chest, over the site of the disease. Both these phenomena are more frequent in aortic aneurism, because the tumor in that disease always encroaches more upon the lungs than in the former case. Finally, the pressure of the tumor occasionally induces serious disease in the neighboring bones, as the sternum, clavicle, and first rib, the contiguous portions of which are liable, in the first instance, to be displaced, then to become carious, and ultimately to be wholly absorbed. In some cases there is complete dislocation of the sterno-clavicular joint. Diagnosis.—After what has just been said, it will be easily understood that the diagnosis of innominatal aneurism must often be extremely difficult, its situation at the root of the neck rendering it liable to be confounded with aneurism of the arch of the aorta, the carotid, and subclavian. Then, again, certain tumors—fatty, fibrous, and encysted—sometimes form at the inferior portion of the cervical region, and receiving an impulse from the innominate, or even from the aorta itself, may thus simulate the disease in question. Finally, I have occasionally encountered great difficulty in determining the diagnosis of disease occurring in this situation in consequence of abnormal pulsation either of this vessel, or of the aorta, apparently dependent upon an anemic condition of the system, or neuralgia of the arteries, and so violent as to communicate a severe shock at every contraction of the left ventricle of the heart to the innominate and its two branches, the carotid and subclavian. The embarrassment, in these cases, is increased if, superadded to the pulsa- tion at the root of the neck, there is an unusual quantity of fat, or some solid growth, and the sharp thrill so common in the arteries of anemic subjects. On the whole, the most reliable diagnostic signs of aneurism of the inno- minate are, first, the situation of the tumor at the right sterno-clavicular joint, immediately above the inner third of the clavicle, where it forms a dis- tinct, well-marked prominence; secondly, stoppage of aneurismal beat, thrill, and bellows' sound, by pressure upon the carotid and subclavian ; and, thirdly, unnatural weakness of the pulse at the right wrist, with pain and oedema on the corresponding side of the neck, shoulder, and arm. In aortic aneurism, the tumor seldom projects sensibly above the sternum; certainly not before it has attained a considerable bulk, and then it is situated rather in the middle line than ou the right side; the arterial pulse, if affected at all, is weakest 011 the left side, and there also the oedema and pain are most con- spicuous; the dyspnoea, dysphagia, cough, stridulous respiration, and change of voice are more frequent than in the innominatal disease; and compression of the carotid and subclavian produces no diminution in the sounds of the tumor. Prognosis.—The prognosis of brachio-cephalic aneurism is extremely un- favorable. The1 disease, it is true, may last for a considerable time, but this is very rare; in general, it progresses very rapidly, and soon reaches a fatal crisis, the tumor either opening externally, into the trachea, or into the chest, or else, as is commonly the case, wearing out the patient by constitutional irritation, asphyxia, or inanition. No instance of spontaneous cure has ever been known to occur in this disease. vol. 1.—49 770 DISEASES AND INJURIES OF THE ARTERIES. Treatment.—The treatment of aneurism of the innominate has hitherto been most unsatisfactory. Owing to the short and stunted character of this ves- sel, and the close proximity of the aneurism to the arch of the aorta, deliga- tion on the Hunterian principle is, of course, altogether impracticable, and hence the only resource is either to treat the disease upon the plan of Val- salva, or to tie the carotid and subclavian at the distal side of the sac, according to the method originally suggested by Brasdor. The treatment of the Italian surgeon holds out but little encouragement, the disease gene- rally going on from bad to worse until it reaches its fatal crisis, despite the most abstemious course of dieting, rest in the recumbent posture, the use of the lancet, and the exhibition of digitalis, opium, and acetate of lead, to pro- mote the formation of clots. With the exception of Air. Luke's case, there is hardly an instance upon record in which it was followed by any ultimate benefit. Squeezing the tumor, if practicable, would certainly not be justi- fiable, as the detached clots might, and probably would, fall into the aorta, and thus cause serious, if not fatal, results on the spot, from mechanical obstruction to the circulation. The operation of Brasdor has been performed in a number of cases, which I shall place before the reader in tabular form. In only one case have the carotid and subclavian arteries been tied simul- taneously. The patient died at the end of six days. At the autopsy, the left carotid and right vertebral arteries were found occluded, showing that the circulation of the brain had been carried on by the left vertebral alone. Rossi wras the operator. In three cases, the carotid and subclavian have been successively tied, as recommended by Mr. Fearn, of Derby, England. o Operator. M V m 6 28 55 Carotid ligature. Subclavian ligature. Remarks. 1 2 3 Fearn Wickham Malgaigne F. M. M. Aug. 30, 1836 Sept. 25, 1839 March, 1845 Aug. 2, 1838 Dec. 3, 1839 Oct. 17, 1845 Died from pleurisy three weeks after second opera tion. The aneurismal sac was found filled with dense, organized coagula, except a channel the size of the artery for the passage of blood. The aneurism increased, and burst with mortal hemorrhage 63 days after the second operation. Four days after the operation, the tumor increased rapidly in size, the tumefaction became dif-fused, and the patient died on the 7th Nov. At the autopsy, the sac could not be dissected; it was confounded with the muscles; in other words, the aneurism was diffused. In four cases, the subclavian alone has been tied, with a result of three deaths and one recovery. 6 Operator. ►4 o CO < 40 57 45 Result. Remarks. 1 2 3 4 Dupuytren Laugier Wardrop Blackman M. M. F. Death Death Re-covery Death The subclavian was tied immediately above the clavicle. The tumor diminished, but the pulsations continued. The patient died on the 9th day, from exhaustion following cough and secondary hemorrhage. At the autopsy, aneurism of the sub-clavian was found, with dilatation of the innominate and aorta. The vessel was tied immediately above the clavicle. The patient died from asphyxia, one month after the operation. The ope-rator had supposed the case to be one of subclavian aneurism. The patient, cured of an aneurism occupying the upper part of the innominate, died two years after the operation, of a new aneurism formed above the first, apparently on the same trunk. Tubular aneurism of the innominate and arch of the aorta; left carotid and subclavian obliterated ; death on the eighth day from hemorrhage caused by jumping out of bed. ANEURISM OF THE INNOMINATE ARTERY. 771 The carotid alone has been tied in eleven cases, of which two were cured, and the rest died. Operator. Evans Mott Dohlhoff Key Vilardebo Fergusson Hutton Porta Campbell Morrison Wright M. 30 Result. Re covered 55 Died — Died 70 Died Died Died Died Died Died Re- covered Died Remarks. The tumor still existed, with constant pulsation, at the end of a year. The next year, the sac suppurated, and discharged much pus. At the expiration of nine years, there was no sign of any increase in the affection. After the operation, the tumor was much diminished ; but the patient died of asphyxia seven months after the operation. The aneurism was much improved, but the patient died from the effects of the ligature of the carotid upon the brain. At the autopsy, the aneurism was found occupying the external side of the innominate near its bifurcation ; it was as large as the fist, and filled with fibrinous clots. The patient died a few hours after the operation from its effect upon the brain. The vertebral arteries were found smaller than natural. The patient was a negro. He died on the twenty-first day after the operation. At the autopsy, two aneurisms were found ; one of the inferior extremity of the right primitive carotid, the other of the trunk of the innominate. The patient died of pneumonia on the seventh day. The tumor had diminished, and, at the autopsy, was found nearly filled with firm laminated coagula. The size of the tumor and the pulsations diminished after the operation, but the sac inflamed, suppurated, and opened into the trachea, and the patient died on the sixty-sixth day. The patient died forty hours after the application of the liga- ture. The autopsy showed an arterial dilatation of the inno- minate and its two branches, without true aneurism. The tumor began to disappear after the vessel was ligated, but the patient died of pneumonia on the nineteenth day. The patient recovered from the operation, and died suddenly twenty months afterwards. The cause of death is not given. At the autopsy, the right carotid was found dilated in the form of a sac, and filled with a resisting fibrinous deposit. The brachio-cephalic trunk and curve of the aorta were found larger than usual, and the walls were diseased, but these ves- sels were not aneurismatic. The patient died on the eighty-eighth day from hemiplegia. The tumor was solidified by fibrin, a canal leading through it to the subclavian. Four abscesses were found in the right hemisphere of the brain. A careful examination of the above cases affords the following conclusions concerning the deligation of the primitive carotid for the cure of innominatal aneurism :— 1. It reduces the volume of the tumor. Thus, in the case of Mr. Evans, of Derby, in 1828, although the aneurism was as large as a walnut, it entirely disappeared in a little upwards of a month. In Dr. Mott's case, in 1829, it was of the size of a pigeon's egg, and disappeared in twenty-six days. 2. The operation leads to fibrinization of the contents of the sac. These changes, which are due, not to arteritis, but to remora of the blood, were well displayed in the cases reported by Mr. Morrison, of Buenos Ayres, in 1834, aud of Mr. Fergusson, of London, in 1841. In the former, the inno- minate artery was reduced to at least one-half its previous bulk; in the latter, the tumor was nearly filled with firm clots. 3. The operation does not involve any special risk. In five of the cases it was followed by death, not, apparently, from any agency of the aneurism, but because of the danger which naturally follows the ligation of the comraon carotid, for whatever purpose. Thus, in the case of Mr. Key, in 1830, the patient died of syncope, produced by coarctation of the left carotid and ver- 772 DISEASES AND INJURIES OF THE ARTERIES. tebral arteries. In two other instances, one by Fergusson, in 1841, and the other by Campbell, of Montreal, in 1845, death resulted from pneumonia. In Hutton's case, the cause of death was inflamraation and ulceration of the sac, also a very common effect of the operation for carotid aneurism, whether the ligature be placed above or below the tumor. In the interesting case of Professor Wright, of Montreal, in 1855, the patient died of abscesses of the brain, the first example of the kind on record after Brasdor's operation, although severe cerebral symptoms often succeed the ligation of the common carotid for accidents and tumors of the head, eye, and face. 4. The operation has not been productive of a long after-life : chiefly, per- haps, because the cases demanding it were nearly all inherently hopeless, from being associated with organic disease of the aorta, or of this vessel and of the heart. Distinct evidence of this fact existed in at least seven of the cases; in the rest no accurate examination was made. The influence of such complications is shown by the results which followed Brasdor's operation in aneurisra of the root of the carotid unmixed with any other lesion. Of five cases of this kind, three completely recovered; one was successful so far as "the aneurism was concerned ; and in only one was there no improvement. 5. The operation lengthens life if perilled by rupture of the sac, or pres- sure on the windpipe. In fact, here is its great triumph. In the case of Professor Wright, although the man was in imminent danger before the ope- ration, yet he survived it eighty-eight days. The mean duration of life after deligation of the carotid, under ordinary circumstances, is about four months and a half. 6. The operation has occasionally failed to effect any local improvement. This result followed in three of the cases, in consequence of a want of fibrin- ization of the contents of the sac. The facts above stated, deduced mainly from the paper of Professor Wright, in the Montreal Journal of Medicine, clearly point, as that gentleman justly remarks, to a division of cases in regard to the applicability of the operation. 1. The most suitable cases are those of uncomplicated innominatal aneurism, being akin to the pure carotid form, the sac, which is confined to the part of the vessel near the bifurcation, springing from the left segment of the artery, and not coexisting with degeneration of its tunics or cardiac disease. 2. Those imperatively requiring it are such as entail imminent danger from external rupture of the tumor or from other causes. 3. The most favorable cases are aneurisms proceeding from the left segment of the artery, because then the introduction of blood into the sac is most effectively impeded, as it is derived from the current destined for the vessel which is tied, whereas, when the aneurism is dextro-lateral, the same benefit cannot be afforded, as the supply is furnished by the subclavian. Next to this situation, the most preferable, anatomically, would be the origin of the tumor from the anterior circumfer- ence of the vessel. 4. The less advantageous cases are those in which the external tumor extends towards the middle of the clavicle, for this occurrence denotes such an engagement of the subclavian as must effectually counteract any benefit derivable from ligature of the carotid. WThen the swelling is equal on each side of the innominate, or symmetrical, then the only hope of a certain stasis of blood would be afforded by tying both branches. 5. The cases contra-indicating the operation are those having complications with aortic aueurisra, or serious disease of the heart, unless excepted by extreme urgency. ANEURISM OF THE COMMON CAROTID ARTERY. Aneurism of the carotid, although less frequent than that of some of the other arteries, especially the popliteal and femoral, has, nevertheless, always ANEURISM OF THE COMMON CAROTID ARTERY. 773 attracted much attention, for the reason, probably, that its exposed situation in the neck has afforded unusual facilities for its observation and study. However this may be, its history is perhaps, on the whole, better understood than that of aneurism of any other artery. The relative frequency of the disease has been placed before the profession by several writers. Thus, in the table compiled by Lisfranc, comprising 179 cases of aneurism, exclusive of those of the aorta, 17 refer to the carotid, the subclavian having been affected in 16, the axillary in 14, the femoral in 26, and the popliteal in 59. In the table of Mr. Crisp, the carotid is stated to have been engaged in 25 cases out of 551, embracing 234 of the aorta, giving thus a considerably larger proportion than that of the French author. Spontaneous aneurism of the carotid is more frequent in men than in women, but not by any means in the same relative proportion as spontaneous aneurism of the other arteries. Thus, in 34 cases analyzed by Dr. Norris, 27 were males, and 7 females, being in the ratio of nearly four of the former to one of the latter; a ratio which is altogether unequalled by that of any other vessel. An idea formerly prevailed that the disease occurred here with nearly equal frequency in both sexes, but such a conclusion is totally at vari-' ance with the facts of the case. The disease, although occasionally observed at an early age, is most com- mon between the thirtieth and the sixtieth year. It occurs with nearly equal frequency on both sides, and, in fact, sometimes exists simultaneously in both arteries. No occupation is exempt from it. One would suppose, from re- flecting upon the peculiarity of their pursuits, that acrobats, who are in the habit of making such violent and long-continued use of their necks, often sustaining enormous loads upon their heads, would be particularly prone to carotid aneurism, and yet the disease is hardly known among them. The site of carotid aneurism is variable. Sometimes the tumor is situated very low down in the neck, close to the origin of the vessel; on the other hand, it may be seated high up, near its bifurcation. In the great majority of cases, however, it will be found to be between these two points, at or near the middle of the artery ; usually rather above than below. Symptoms.—The tumor, when first observed, is generally quite small, perhaps not exceeding the size of a filbert, and of an irregularly globular, rounded, or ovoidal shape. The patient, upon being questioned as to the history of the case, usually expresses his ignorance as to the time of its occurrence, though occasionally he is rendered conscious of it by a peculiar stabbing sensation in the neck, or a feeling as if something had suddenly snapped asunder. Commonly the surgeon is not consulted until the turaor has made considerable progress, and acquired the volume of a hen's egg, or of a small orange, the patient, perhaps, having all along supposed that the swelling was merely an enlargement of some of the cervical ganglions. A care- ful inspection, however, promptly reveals its true character, its pulsation, thrill, and bellows' sound affording unmistakable evidence of its close and intimate arterial connection. Pressure upon the cardiac side of the aneurism, by stopping its circulation, arrests these symptoms, and causes a sensible dimi- nution of the size and consistence of the tumor, while pressure upon its distal side produces an opposite result. As long as it is small, the tumor may readily be moved about, and even raised out of its bed, especially if it be grasped with the thumb and forefinger during the relaxed condition of the sterno-mastoid muscle; as it augments in volume it becomes more fixed in its position, and is eventually rendered almost, if not entirely, stationary. The symptoms of carotid aneurism are altogether of a mechanical charac- ter, being such as arise from the pressure of the tumor upon the neighboring parts; hence, their gravity is generally in proportion to the volume of the morbid growth. In the earlier stages of the disease, there is either no 774 DISEASES AND INJURIES OF THE ARTERIES. functional disturbance whatever, or it is so insignificant as not to attract any special attention ; by and by, however, as it progresses, the turaor necessarily encroaches more and more upon the delicate and important structures of the neck, thus occasioning congestion of the brain by retarding the return of blood in the jugular vein, numbness, pain, and cough, by compressing the cervical, pneumogastric, and phrenic nerves, and difficulty of respiration, and, perhaps, even of deglutition, by bearing against the trachea and oeso- phagus. The surface of the swelling, at first perfectly natural, becomes gra- dually indurated and inflamed, the subcutaneous veins are unusually conspi- cuous, and the ueck is stiff, distorted, and almost immovable. The greatest enlargement of the tumor is generally in the direction of the median plane, as the resistance is much less there than externally, under the edge of the sterno-cleido-mastoid muscle. Diagnosis___Notwithstanding that the symptoms of carotid aneurism are usually well-marked, cases, nevertheless, occur in which they are so obscure as to render it extremely difficult to determine the diagnosis, even after the most careful and patient investigation. The affections of the neck which are most liable to be confounded with carotid aneurism, and to render the discrimination doubtful, are diseased lymphatic ganglions, abscesses, encysted tumors, goitre, dilatation of the internal jugular vein, and aneurism of the innominate artery and arch of the aorta. Enlargement of the lymphatic ganglions of the neck is most common in young subjects, before the age of twenty, whereas aneurism of the carotid is rarely met with until after thirty; moreover, it is almost peculiar to scrofu- lous persons, while aneurism occurs in all classes of individuals, the strumous and the non-strumous. In aneurism the tumor is generally well-defined; its surface is smooth and uniform, and the swelling heaves and throbs, as if it were alive. In glandular enlargement, there is generally a chain of diseased ganglions, either scattered about in different parts of the neck, or stretched along the inner border of the sterno-cleido-mastoid muscle ; the tumors feel hard, and raay, with a little care, be easily separated, not only from each other, but from the carotid artery, so as to get entirely beyond the reach of its pulsation. Aneurism of the carotid artery has sometimes been mistaken for abscess; the tumor has been punctured, and the patient has speedily perished of he- morrhage. Such an error, of course, implies great carelessness, and could hardly happen at the present day when our means of diagnosis are so much more perfect than formerly. The discrimination must be determined on gene- ral principles. If there be an abscess, the history of the case, conjoined with the unnatural heat and redness of the part, the rapid progress of the swelling, the febrile disturbance, and the absence of the characteristic pulsa- tion, thrill, and bellows' sound, will be sufficient to distinguish it from aneu- rism of the carotid artery. Encysted tumors, usually containing a serous or sero-sanguinolent fluid, are liable to form at the front and sides of the neck, most generally in con- nection with the thyroid gland, but sometimes independently of it, in the cellular tissue beneath the muscles. They can usually readily be distin- guished by their slow growth and fluctuating feel, the absence of pain and pulsation, and, when they are attached to the thyroid gland, by their obey- ing the movements of the larynx in the act of deglutition. If, after a care- ful examination of their history, any doubt exists as to their real nature, the only resource will be the cautious introduction of the exploring needle. Goitre is liable to be mistaken for carotid aneurism only when it spreads laterally over the neck, so as to overlap the carotid, and receive its pulsation. It is certainly not possible to commit any error of diagnosis in the more ordi- nary and simple forms of the disease. Confusion is most apt to arise when ANEURISM OF THE COMMON CAROTID ARTERY. 775 aneurism and goitre co-exist, or when, as occasionally happens, the latter dis- ease is developed uncommonly rapidly, and is attended with considerable local distress. Ordinarily, goitre forms in early life, at a period when aneurism is extremely infrequent; its progress is generally tardy, several years elapsing before it attains any material bulk, and is subject to occa- sional interruptions, and even total suspension, whereas aneurism gene- rally advances rapidly and steadily, the symptoms proceeding from bad to worse, until it attains its crisis. Another important criterion is the fact that goitre is almost peculiar to females, whereas carotid aneurism occurs by far most frequently in men. But the most satisfactory diagnostic signs are, first, that, in goitre, the tumor obeys the movements of the larynx, whereas, in aneurism, it remains stationary, however strong the efforts at deglutition; secondly, that, in the former, the turaor may be drawn away from the vessel, raised up or pushed to one side, while in the latter the vessel follows it, form- ing, as it does, a part of it; and, lastly, that in goitre the general health rarely suffers, even when the tumor is of large bulk, whereas in aneurism it is always more or less impaired, especially when it has reached such a stage as to be likely to occasion embarrassment in regard to the discrimination between the two affections. A dilated condition of the internal jugular vein may simulate aneurism of the carotid artery. The deception will be more likely to happen if the vein receives a pulsatory movement from the heart or from the carotid, as when the artery is overlapped by the vein. The venous tumor may generally be distinguished by its softness and compressibility, by its situation, which is commonly just above the sternum, and rather behind than in front of the mastoid muscle, and by the circumstance that its motion is more of an undu- latory, wave-like, or tremulous character, than shock-like and vibratory, as in aneurism. Superadded to this is the fact that the venous swelling may be readily effaced by pressure applied to its distal extremity, whereas, in aneu- rism, the pressure, to produce any appreciable effect of this kind at all, must be applied to the cardiac extremity of the tumor, and then it will result only in a diminution, not in complete obliteration. Finally, a carotid aneurism may be confounded with aneurism of the bra- chio-cephalic artery or of the arch of the aorta, especially if it be situated low down in the neck. When this is the case, the difficulty may be very great, if not insurmountable. The best diagnostic sign with which I am acquainted, and one that will rarely fail us, in such an emergency, is afforded by our ability to insinuate the point of the forefinger between the top of the sternum and the lower extremity of the aneurism, while the head is being bent powerfully forwards, so as to relax as fully as possible the mastoid mus- cles. If this can be done, the probability is that the tumor is connected with the carotid ; otherwise we may conclude that it is formed by the innominate artery, or by the arch of the aorta. Progress.—The progress of carotid aneurism, although usually rapid, is not so always. The annals of surgery contain several cases where the disease remained almost stationary for a considerable number of years; in one in- stance as many as fourteen. A spontaneous cure sometimes occurs, but such an event must necessarily be extremely rare. The turaor, if allowed to go on unchecked, eventually—generally at a period varying from three to twelve months—destroys life either by excessive constitutional irritation, hemor- rhage, gangrene, pneumonia, or asphyxia. When seized by ulceration, it may burst either externally, or it may open into the pleura, the anterior me- diastinum, the trachea, or one of the bronchial tubes. Treatment.—The treatment of carotid aneurism is generally conducted according to the Hunterian principle of ligating the supplying vessel at the cardiac side of the tumor; and, fortunately, as the disease is ordinarily situ- ated rather high up, this may commonly be done without any very great 776 DISEASES AND INJURIES OF THE ARTERIES. difficulty, especially in the earlier stages of the affection, before the swelling has attained much bulk. When the turaor is of great size, or located at the inferior part of the neck, we may be compelled to adopt the method of Brasdor, and tie the carotid on the distal side of the aneurism, trusting that the blood in the tumor, no longer finding an outlet, will gradually coagulate, and so effect its obliteration. The fact is, this artery, owing to the total ab- sence of collateral branches, is peculiarly adapted to this operation, and it is well that it should be so, seeing that, if it were otherwise, we should be oh- liged to resign many of the more severe cases of carotid aneurism to their fate, without any attempt whatever at surgical interference. It is obvious, frora the relations of the vessels and nerves of the neck to the tumor, that compression, now so much employed in the treatment of aneurism of the lower extremity, cannot be brought in play here, the parts being intolerant of the requisite manipulation, to say nothing of the obstruction which it would oc- casion to the return of the blood in the internal jugular vein, which, being dammed up in the brain and the sinuses of the dura mater, might speedily induce apoplexy, and other serious cerebral symptoms, endangering the patient's life. When the tumor is of extraordinary bulk, rendering ligation of the carotid impracticable at any point, our only hope, faint though it be, is the success of general measures, particularly Valsalva's method, for expe- rience has conclusively proved that no benefit is to be expected from the ligation of the innominate artery, as originally proposed and practised by Dr. Mott. The deligation of the terminal branches of the carotid might be tried with a better prospect of success, but this also would be likely to fail, owing to the numerous offsets of the external carotid, which, unless included in separate ligatures, would continue to transmit the blood from the tumor with sufficient force and activity to maintain its circulation unimpaired, and so inevitably frustrate the intentions of the operation. When the tumor is unusually voluminous, or even of moderate size, bnt situated very low down, overlapping and compressing the trachea, the symp- toms may be so urgent as to demand the operation of laryngotomy, to save the patient frora impending asphyxia. Such an event must, however, be very uncommon. A very interesting case of carotid aneurism has been related by Dr. Robert- son, of Edinburgh, in which he performed an operation after the tumor had burst into the oesophagus. The swelling was situated so low down that he was compelled to ligate the vessel only half an inch above its origin from the innominate artery. Notwithstanding these unfavorable circumstances, the patient made an excellent recovery, the ligature coming away on the seven- teenth day. The operation of tying the carotid is easy enough in ordinary cases, but when the aneurism is large, or the neck very short and fat, it is one of the most difficult and trying undertakings in surgery. The principal accidents likely to attend it are the inclusion of the jugular vein and pneumogastric nerve in the ligature, and the wounding of some of the smaller vessels of the neck, which it is sometimes more difficult to find and secure than the carotid itself. Mortality and other Effects.—Of the mortality of the operation for carotid aneurism, a tolerably accurate estimate may be formed from the data now before the profession. Of 21 cases mentioned by Mr. Crisp, 10 were suc- cessful, and 11 fatal. In 5, the artery was ligated at the distal side of the tumor, and of these, 3 recovered, the other 2 being only somewhat bene- fited. Of the 11 fatal cases, 5 were lost by hemorrhage, 2 by inflammation of the sac and artery, and 1 by spasm of the glottis, the cause of death in the remaining 3 being doubtful. The table of Dr. Norris contains an analysis of 38 cases, in which the carotid was tied for aneurism, including 4, however, ANEURISM OF THE COMMON CAROTID ARTERY. 777 in which the disease was found, after the operation, not to have been con- nected with the artery. Of these cases, 22 recovered, and 16 died. The cause of death is mentioned in only 12 of the cases; in 5 it was hemorrhage, in 2 inflammation of the sac, in 2 apoplexy and congestion of the brain, in 1 cerebritis, in 1 spasm of the glottis, and in 1 exhaustion. In 6 of the 38 cases, the aneurism suppurated, and either burst or was laid open; of these, 4 died and 2 recovered. In one instance the opening in the sac occurred four months, and in another nearly eight months, after the ope- ration. In one fatal case the tumor burst into the pharynx fifteen days after the deligation of the artery, and in another case, which, however, recovered, it had discharged some of its contents into the mouth prior to the operation. Return of pulsation in the tumor, after the operation, was noted in nine of the thirty-eight cases; in one the pulsation never ceased entirely for two months, and in another it continued for upwards of four months. The detachment of the ligature occurred, in 13 cases, before the twentieth day; in 7, between the twentieth and thirtieth, and in 1 on the thirty-third day. The time, in the remaining cases, was not observed. In seven of the cases, analyzed by Dr. Norris, there was a mistake in the diagnosis, as was proved on the dissection, for all the patients died. In four, the disease consisted of different kinds of tumors ; in two, of aneurisms sup- posed to be abscesses ; and in one, of an aneurism of the vertebral artery. The examples of mistaken diagnosis include the celebrated case of Mr. Lis- ten, of a lad, nine years of age, who had a tumor on the right side of the neck of two months' stauding, which, although seated over the carotid, was en- tirely free from pulsation, except along the track of that vessel. Under the conviction that it was merely an abscess, a bistoury was introduced, the removal of which was followed by a gush of arterial blood to the amount of four ounces. The bleeding being arrested by closing the wound with the twisted suture, the common carotid was tied on the following day, October 21st, close to its origin from the innominate artery. On the 3d of Novem- ber, the arterial hemorrhage suddenly recurred, but was suppressed by plug- ging the wound with lint; it, however, again broke forth, and proved fatal on the 5th, that is, fifteen days after the operation. Although the ligature had retained its hold upon the artery, the proximal end of the vessel was found to be quite patulous, no attempt having been made at the formation of a coagulum. The probability is that, as Mr. Listen has suggested, the tumor, in this remarkable case, was originally a scrofulous abscess, a part of the wall of which was formed by the carotid; the latter, becoming ulcerated, finally gave way, and thus sent its contents into the cyst inclosing the matter. Injury to the internal jugular vein has been a cause of death in several cases of ligation of the carotid. In an instance in which Barovero included this vessel with the artery, the patient died on the sixty-ninth day of gastric fever. Mr. Crisp met with a case where a surgeon tied the internal jugular vein instead of the carotid; the patient was a child, and the error was not discovered until after death. Very serious cerebral and pulmonic symptoms occasionally follow the ligation of the carotid artery, and are among the principal sources of the mortality from this operation. The effects which the operation produces upon the brain have been elucidated both by experiments upon the inferior animals and by observations upon the human subject, and manifest themselves in various ways and at different intervals. Their full importance, however, was not known until after the publication of the researches of Mr. Chevers, of London, in 1845, to whom the profession is greatly indebted for the valuable light which he has thrown upon a subject which, up to that period, had been entirely overlooked. In the one hundred and twenty-five cases analyzed by Dr. Norris, in which the common carotid was tied either for 778 DISEASES AND INJURIES OF THE ARTERIES. aneurism, wounds, or erectile tumors, more or less severe cerebral disturb- ance occurred in thirty. Sorae of these cases recovered completely, some got well of the operation, but remained afterwards in a crippled condition, and some, perhaps the majority, died, the period of death varying frora a few hours to several months. There is no uniformity either in the character or in the manifestation of the cerebral symptoms. Sometiraes they come on immediately, or at all events, within a few hours after the deligation of the vessel; while at other times, and perhaps most generally, they do not appear until the end of several days, weeks, or even months. Their access is usually sudden, but occasionally so gradual and imperceptible as to keep the patient in ignorance of it until it is discovered accidentally. The most frequent symptoms, on the whole, are convulsions and paralysis. The former are sometimes general, but much oftener partial, affecting, for example, one arm, a leg, or one side of the face ; in some cases, there are merely spasmodic twitches, or irregular, involuntary movements. The paralysis occasionally exists on the side of the affected artery, but in most cases it occurs on the opposite side, when it sometimes pervades one-half of the body, as in hemiplegia, though generally it is only of limited extent, being confined, perhaps, to the face, tongue, throat, fauces, eyelid, hand, arm, leg, or thigh. Sometimes there is dimness of vision, with or without dilatation of the pupil; a feeling of drowsiness, somnolency, stupor, or coma; dizziness, vertigo, or headache; noise in the ears or partial deafness ; delirium, either alone or conjoined with paralysis or convulsions; difficulty of deglutition ; dyspnoea; a sense of coldness, or cold- ness and numbness ; and various other symptoms, mostly of an anomalous, nervous character. Occasionally these effects rapidly disappear, but in gene- ral they are more or less persistent, and in some cases they remain up to the moment of the death of the patient. In some instances, inflammation of the brain, or of the brain and its envelops, supervenes, either soon after the deligation of the vessel, or at a more or less remote period. How are these phenomena produced ? Are they caused merely by an inadequate supply of blood to the brain, or are they the consequence solely of a loss of equilibrium in the cerebral circulation ? To these questions it is of course impossible to return anything like a definite answer. It would seem probable, from the free anastomosis which exists between the branches of the internal carotid arteries, on the one hand, and between these arteries and the vertebral, on the other, that they could not be occasioned by a mere want of blood, inasmuch as these vessels are capable of furnishing the organ with an abundant supply of that material for the purpose of carrying on its healthy functions. Nevertheless, it is not unlikely that unpleasant effects may and do follow the sudden withdrawal of a certain quantity of blood from the brain, resembling those produced by copious bleeding at the arm, or by a smart concussion of the brain. In some instances, it is reasonable to con- clude that they are the result of the inclusion of an important nerve; while in another class of cases, as when several weeks or months elapse before their supervention, they would seem to be the direct consequence of inflaramation. Under the latter circumstances, dissection reveals softening of the cerebral substance and effusion of serum, or of serum and lymph, in the ventricles and upon the surface of the brain. The most constant pulmonary effects occasioned by the ligation of the carotid artery are cough, bronchitis, and inflammation of the pulmonary tissue. Cough is not only a very frequent occurrence, but often one of great severity, rendering it sometiraes extremely difficult to check it. It generally comes on soon after the operation, in fits of a violent spasmodic character, in which the patient is in the deepest distress, looking and acting as if he were about to be suffocated. Its duration is variable; sometimes lasting only a ANEURISM OF THE OPHTHALMIC ARTERY. 779 few hours, while at other times it continues, as a prominent symptom, for days together. When very severe, it may occasion hemorrhage in the wound, by reopening some of the vessels. It is not easy to determine how this cough is induced. From the fact that it often follows immediately upon the operation, it is not unlikely that it may arise from the inclusion in the ligature of some nervous filament, which thus sets up irritation in the mucous membrane of the air-passages, especially of the larynx and trachea, causing an effect not dissimilar from that awakened by the sudden intromission of a drop of water into the windpipe. That the effect must be somewhat of this character would seem probable, when we reflect upon the spasmodic and uncontrollable nature of the cough which generally characterizes the attack. At other times, the cough may be purely sympathetic, or, what is more likely, may be caused by the compression of the filaments of the tri-splanchnic nerve, which are so abundantly distributed through the coats of the arteries, especially those about the neck and chest. The effects which the ligation of the carotid exerts upon the bronchia and lungs set in at various periods after the operation, and are denoted by the usual rational and physical signs. On dissection, the mucous membrane of the former is found to be of a reddish color, either uniformly, or in patches, greatly engorged with blood, and covered with pus, or pus and lymph. The lungs are abnormally vascular, loaded with black blood, more or less hepa- tized, or solidified at one point and softened at another. Blood and pus are sometimes contained in the anterior mediastinum ; the pleura has been known to be the seat of extensive effusions; now and then there are traces of in- flammation of the larynx and trachea; and occasionally, though rarely, the examination reveals the existence of pericarditis and endocarditis. When the inflammation of the respiratory organs is at all considerable, the blood drawn during life generally evinces a buffed, if not also a cupped appearance. Such being the effects which are liable to follow, probably in one case out of every four or five, in the brain and lungs, in consequence of the deliga- tion of the carotid, it is obvious that they should be carefully looked for, in order that proper measures may be adopted for their prompt and efficient removal the moment they arise. Much may be done, in most instances, by way of prevention, by a judicious preparatory course, consisting of venesec- tion, purgatives, light diet, and repose of mind and body, which cannot fail to contribute materially to the protection both of the brain and lungs. The operation having been performed, these organs are most sedulously watched, the least indication that arises being met by appropriate means ; and in this way, the case is safely conducted to a favorable issue. If the patient be pale and faint, alcoholic stimulants, cautiously and judiciously administered, will be of service; cough and convulsive symptoms are treated with anodynes and antispasmodics, particularly morphia; and inflammation is controlled by the lancet, leeches, blisters, purgatives, aconite, and antimonials. ANEURISM OF THE EXTERNAL CAROTID. Spontaneous aneurism of the external carotid is perhaps still more uncom- mon than that of the internal carotid; its history, consequently, is involved in obscurity. The situation of the tumor just below the angle of the jaw, its throbbing, pulsatile character, and its gradually increasing volume, would serve to distinguish it from ordinary growths in this portion of the cervical region. ANEURISM OF THE OPHTHALMIC ARTERY. Aneurism of this artery is rare, both as a traumatic and as a spontaneous affection. The former is usually caused by severe injury, and is apt to be 780 DISEASES AND INJURIES OF THE ARTERIES. followed by excessive enlargement of the structures of the orbit with protru- sion of the eye. A number of cases of spontaneous aneurism of this artery are upon record, in only a few of which, however, the nature of the disease has been verified by dissection. Aneurism by anastomosis is also sometimes met with. The progress of aneurisra of the ophthalmic artery is usually slow, and the symptoms are always characteristic. The proper remedy is ligation of the common carotid artery as early in the disease as possible, before there is any serious structural change in the parts. Of four cases treated in this way, and recently reported by Mr. Thomas Nunneley, of London, three proved successful, the other having perished from hemorrhage on the sixteenth day. In anastomotic aneurism, a cure has occasionally been effected by in- jection of perchloride of iron ; and lately several cases have been success- fully treated by digital compression of the carotid. ANEURISM OF THE INTERNAL CAROTID. Aneurism of the internal carotid has been observed only in a few instances, its deep situation at the side of the neck and its exemption from ossific and fatty degeneration serving to protect it from this disease. The diagnosis must necessarily be obscure, and is generally only determined after death. The London and Edinburgh Monthly Journal of Medicine and Surgery, for 1842, contains the particulars of a remarkable case of aneurisra of this vessel observed by Mr. Syrae. The patient, a woman aged sixty, had had a tumor for about five months in the throat, in the usual situation of abscess of the tonsil. It had attained about the size of a large walnut, exhibited a diffused appearance when viewed through the mouth, and pulsated in a strong and characteristic manner in every portion of its extent. The ligation of the common carotid artery diminished, but did not completely arrest, the throb- bing. The woman died in thirty hours after the operation without any assignable cause. Had a less careful surgeon had the management of this case, he might probably have punctured the tumor under the supposition of its being an abscess, and thus instantly hurled his patient out of existence, much to his own discredit and that of the profession. ANEURISM OF THE VERTEBRAL ARTERY. Aneurism of this artery, both spontaneous and traumatic, is extremely uncomraon, a circumstance no doubt due to the deep situation of this vessel and to its freedom from ossification. In two very interesting cases of this disease, described by Ramaglia, of Naples, and South, of London, the diag- nosis was so obscure that the true nature of the disease was not detected until after death. In both the common carotid was tied, without, of course, any benefit. In the former, which was an example of traumatic aneurism, situated behind the left ear, the operator, finding that the deligation did not arrest the pulsation, removed the ligature and treated the case upon general principles, death occurring soon after. In the other instance, in which the carotid artery could be distinctly traced over the tumor, this vessel was also tied under the supposition that it was the seat of the swelling. The tumor, however, rapidly increased, and in a fortnight after caused death by bursting into the trachea. Dissection showed that it was an aneurism of the verte- bral artery, situated between the transverse processes of the fourth and fifth cervical vertebrae. Mobus, a German surgeon, has reported a case of aneurism of the verte- bral artery, the result of a wound of the neck, in which a cure was effected by compression and the use of ice. ANEURISM OF THE SUBCLAVIAN. 781 ANEURISM OF THE SUBCLAVIAN. Statistics prove that aneurism of the subclavian is nearly as frequent as that of the carotid. In Lisfranc's table the popliteal comes first, then the femoral, next the carotid, and then the subclavian, the latter having suffered in 16 cases out of 179. In the table of Mr. Crisp, comprising 295 cases of external aneurism, the subclavian was engaged in 23, and the carotid in 25. The disease is more frequent in the right artery than in the left, in men than in women, and in the laboring than in the higher classes. The period of life during which most of the cases occur is between the thirtieth and fiftieth years. The disease may affect any portion of the artery, but is most frequent beyond the scalene muscles, a short distance before it becomes merged in the axillary. The form of the aneurism is generally globular or ovoidal, but cases are observed in which it has a singularly compressed appearance; and, on the other hand, it may be remarkably lobulated, especially when it is very capacious, and extends deeply among the surrounding structures, which thus indent its surface. Its volume is seldom very large, unless it becomes diffuse, when it may attain an enormous magnitude, reaching nearly up to the angle of the jaw, pushing out the clavicle, overlapping the trachea, displacing the scapula, pressing backwards against the ribs and spine, and dipping into the cavity of the chest so as to force down the lung and impede respiration. As the tumor enlarges, it necessarily encroaches upon and compresses the neighboring parts, causing more or less pain, oedema, difficulty of respiration, dilatation of the veins of the neck, chest, and upper extremity, and a feeling of numbness and sometimes even partial paralysis. Originally small, deep seated, circumscribed, indolent, and movable, it generally steadily augments in volume, approaching, as it does so, nearer and nearer to the surface, loses its defined shape, becomes the seat of incessant pain, and at length contracts firm adhesions to the surrounding structures, identifying itself, as it were, with them. Examined with the ear and hand, it readily imparts to them the peculiar beat, thrill, and bellows' sound so characteristic of aneu/ism in other regions. Diagnosis.—The diagnosis of subclavian aneurism is sometimes extremely difficult, and several cases have been reported in which the vessel was ligated where no disease of the kind existed. The affections with which it is most liable to be confounded are aneurism of the innominate artery or arch of the aorta, abscesses, and various kinds of tumors, solid and encysted, benign and malignant. As these lesions are of frequent occurrence in this region, it is impossible for the surgeon to be too cautious in his examination of cases involving questions of diagnosis. The history of the tumor and its situation at the side of the neck, just above the clavicle, generally afford important data in regard to the diagnosis. If the patient is under thirty years of age, it may almost certainly be assumed that the disease is not spontaneous aneurism, as there are probably not three well-authenticated cases on record in which the subclavian was thus affected at this early period. Aneurism of the innominate is situated lower down, and approaches nearer to the middle line, than aneurism of its subclavian divi- sion ; and in aneurisra of the aorta, the tumor, although it may extend into the neck, rarely projects as far above the clavicle as in the lesion in question ; certainly not in its earlier stages, when alone a correct diagnosis can be of any avail in an operative point of view. If the case be seen soon after its commencement, before the tumor has attained any considerable bulk, a very good idea may often be formed as to the precise portion of the artery that is affected by it. Thus, for example, if the aneurism occupies the space imme- 782 DISEASES AND INJURIES OF THE ARTERIES. diately exterior to the sterno-cleido-mastoid muscle, and manifests a tendency to extend upwards into the neck, and downwards in the direction of the axilla, it may be assumed that it is seated upon the outer portion of the vessel, beyond the scalene muscles. On the other hand, it may be concluded that it is connected with the inner portion of the artery, if the tumor is placed under cover of the mastoid muscle, and is gradually making its way over towards the median line, thus leaving the inferior triangle of the neck clear. It may be added that in subclavian aneurism the tumor is less liable to en- croach upon the windpipe and oesophagus than in innominatal and aortic aneurism, and hence there is generally much less cough, dyspnoea, and dys- phagia in this than in the other affections. It is only, in fact, when the tumor is of great bulk, or when it happens, from the peculiarity of its posi- tion, to exert much pressure upon the pneumogastric, phrenic, and laryngeal nerves, that any serious symptoms of this kind will be likely to arise. Progress.—Subclavian aneurism is always a serious disease, a spontaneous cure, although possible, as several cases upon record testify, being an ex- tremely rare occurrence. In general, the disease progresses until it attains a certain point of development, when it terminates fatally, either by ulcera- tion and hemorrhage, or by the induction of constitutional irritation. The sac may open externally, a not uncommon event, especially when it is invaded by gangrene; or it may burst into the pleura, lungs, trachea, or oesophagus; in either case, death takes place either instantly or within a short time after the tumor has begun to give way. There are several cases on record in which the aneurism pointed in the axilla and on the shoulder, having com- pletely eroded some of the upper ribs and the body of the scapula, the latter being scooped out so as to form a kind of bed for the accommodation of the sac. Treatment.—The treatment of subclavian aneurism has hitherto been ex- ceedingly unsatisfactory, and there is no probability, judging from the deep situation and intricate relations of the tumor, that much benefit will ever accrue from any mode of management that may be devised for its relief. The plan of Valsalva, varied in every possible manner, has signally failed in every instance except a few, and no one seems now disposed to place any confidence whatever in its efficacy. Acupuncturation and electricity, from which so much benefit had at one time been anticipated, have likewise disappointed expectation. Some time ago a case was reported in which a cure was alleged to have been effected by galvano-puncture, but the example is a solitary one, and the procedure is of too problematical a character to merit serious atten- tion. Of what resource, then, can the surgeon avail himself in this unfortu- nate class of cases ? Ligation of the affected artery is not only difficult, under any circumstances, in consequence of the position of the tumor and the intri- cacy of its anatomical relations, but is frequently absolutely impracticable on account of the diseased state of the artery, rendering it unable to support the ligature. Shall be adopt the operation of Dr. Mott, and secure the innominate, of which the subclavian, on the right side, is one of the main divisions? Here, again, difficulties meet in every direction, for even if he should be so fortunate as to get his ligature around the vessel, which, how- ever, is by no means always the case, he will find, by consulting the history of the operation, that every instance in which it has been performed has had a fatal termination. Nothing, therefore, is to be gained from that procedure. In short, the Hunterian principle of operation is hardly applicable to any case of subclavian aneurism. On the right side, we are not only obliged to encounter, as just stated, great difficulties in reaching the innominate artery, but in throwing a ligature around the vessel we effectually cut off a large and important supply of blood to the brain, thus greatly enhancing the dangers of the case. LIGATION OF THE INNOMINATE ARTERY. 783 The innominate artery has been tied for the cure of subclavian aneurism in nine cases, the results of which are here subjoined in tabular form. Ligation of the Innominate Artery. Opera- tor. Mott Graefe Norman Arendt Hall Bland Lizars Hutin Cooper 1818 57 1822 1824 1824 1830 1832 1837 1842 1860 45 31 30 26 M. M. M. M M, M, M Disease. Result. Subclavian aneurism Subclavian aneurism Subclavian aneurism Subclavian aneurism Subclavian aneurism Subclavian aneurism Hemor- rhage after ligature of subclavian Subclavian aneurism Died on 26th day Died on 67th day Died Died on 8th day Died on 5th day Died on 18th day Died on 21st day Died in 12 hours Died on 41st day Remarks. Artery tied half an inch below its bifurcation ; liga- ture separated on the 14th day; hemorrhage on the 9th, and again on the 23d day; death on 26th day. Ulceration of the artery, and want of oc- clusion. Ligature came off on 14th day; death from hemor- rhage. Cause of death, inflammation of the aneurismal sac and of the pleura and lungs. Artery morbidly adherent; dilated, soft, and fria- ble ; torn, in the attempt to separate it, at two points, between which the ligature was applied ; copious hemorrhage during operation ; plugging of the wound ; participation of the aorta and ca- rotid in the disease. Ligature placed around artery near its bifurcation ; hemorrhage on the 17th day, proving fatal on the 18th ; innominate and carotid closed by solid clots; the subclavian still open. Ligature separated on 17th day; pleuritis ; death caused by repeated hemorrhages ; twenty ounces of coagulated blood at the root of the neck ; ar- teries imperfectly closed. Tied for secondary hemorrhage, after subclavian had been secured for wound of the axillary. Ligature, applied an inch from the aorta, detached on 18th day; patient did well for three weeks, when hemorrhage occurred, and finally caused death. All the cases in the above table, except one, proved fatal from hemorrhage of the wound, caused by the want of occlusion either of the ligated artery, or of the carotid and subclavian. It will be observed that Graefe's patient sur- vived upwards of two months. I purposely exclude from the table the cases which are usually referred to as having occurred in the practice of Dupuytren and Bujalski, not considering them as sufficiently well authenticated to entitle them to a place in it. I also reject from it several reported cases in which the operation of ligating the innominate artery was commenced but not com- pleted. Dr. Peixotto, of Portugal, tied the innominate artery in 1851, on account of secondary hemorrhage from the common carotid, which had been ligated three weeks previously. The ligature, however, which was a precautionary one, was not tightened, but applied merely so as to flatten the vessel. The patient made a good recovery. Such an operation can hardly be regarded as a true case of deligation of the innominate artery. The cure was doubtless effected by the ligation of the other vessel. Mr. Key, of London, in a case of aneurism of the subclavian, found it impracticable to apply a ligature to the innominate, in consequence of the volume of the turaor, and the diseased condition of the latter vessel. The patient was seized soon after the operation with symptoms of pulmonary distress and exhaustion, and died on the twenty-third day. The operation of ligating the innominate artery is one of no inconsiderable difficulty, even in the dead subject, but in the living the perplexity is greatly 784 DISEASES AND INJURIES OF THE ARTERIES. increased by the proximity of the aneurism, by the presence of glandular swellings, and, above all, by the manner in which the parts at the root of the neck are matted together by plastic deposits, rendering it thus exceedingly troublesome to separate them. These embarrassments were experienced in a striking degree by Dr. Hall, of Baltimore ; he had great difficulty in isolating the vessel, and, in attempting to do so, tore it at two points' ligating it after- wards between them. Hemorrhage occurred at the time, but was checked by plugging the wound. Another obstacle to successful deligation is disease of the vessel, consisting either in a morbid dilatation, or in a softened and lacerable condition of its coats. Unforeseen difficulties were present in more than one-fourth of the cases in which ligation of the artery has been attempted, compelling the operators to desist, notwithstanding their great dexterity and profound knowledge of the anatomy of the neck. Mr. Porter, of Dublin, in 1831 attempted to tie this artery on account of aneurism, but was obliged to desist in consequence of its diseased condition. The tumor, nevertheless, gradually disappeared, and the patient, a man forty- seven years of age, finally recovered. Dr. Hoffman, of New York, in a case of subclavian aneurism in a man, aged sixty-three, cut down upon the innominate artery with the design of applying a ligature to it, should he be unable to ligate the subclavian; but he found the vessel so much enlarged that it was deemed inexpedient to pro- ceed any further, and the patient was accordingly abandoned to his fate. The operation was performed on the 26th of October, 1839, and death occurred on the 19th of January, 1840. The proposal to ligate the innominate originated with Mr. Allan Burns, from a conviction that the circulation in the head and upper extremity could be maintained without the agency of this vessel, and that it could be easily enough exposed by tracing it downwards towards the aorta, by a careful and patient dissection, the head being at the time bent well back. It remained, however, for Dr. Mott, in 1818, to put the suggestion to the test of experi- ment upon the living subject; and, although the operation had an unfavor- able issue, the man dying, as has already been stated, on the twenty-sixth day, yet we cannot but admire the genius which could plau, and the intrepid skill which could execute, so daring and brilliant a feat. The case was one of subclavian aneurism above the clavicle, and the design had been to apply the thread to the latter vessel, but after exposing it on the tracheal side of the scalene muscle, it was found that its tunics were too much diseased to bear the pressure of the ligature, and he accordingly tied the innominate in its stead. In a case of subclavian aneurism, Dupuytren tied the axillary artery under the pectoral muscles. Hemorrhage, or, rather, oozing of blood commenced on the fifth day, and the patient died on the ninth. In another case the same operation was performed by Petrequin. The tumor continuing to pulsate, the sac was punctured, and eight or nine drops of a solution of the perchloride of iron were injected, the brachio-cephalic trunk being compressed during the injection, and for ten minutes afterwards. The next day all pulsation had ceased in the tumor, but the patient died of hemorrhage at the place of the ligature, twelve days after its application. Finally, benefit may occasionally arise in subclavian aneurism from mani- pulation of the tumor, as practised by Mr. Fergusson ; some of the clots detached in the operation may accidentally find their way into the distal extremity of the vessel, and thus occlude its caliber along with the interior of the aneurismal sac. In a disease so desperate as this is known to be, and in which every expedient hitherto devised has been tried in vain, any suggestion that holds out the least possible chance of relief is worthy of trial. ANEURISM OF THE AXILLARY ARTERY. 785 ANEURISM OF THE AXILLARY ARTERY. Aneurism of the axillary artery is less frequent than that of the subcla- vian. In 364 preparations of aneurism in the London museums, examined by Mr. Crisp, including 249 of the aorta, the axillary artery was affected only 8 times. In 551 cases analyzed by him from different sources, includ- ing 234 cases of aneurism of the aorta, 18 only were of the axillary artery. The disease is, out of all proportion, most common in men ; it follows upon different occupations, and is most frequently met with between the ages of thirty-five and fifty. In very many of the cases it is of traumatic origin. The volume of the tumor ranges from that of an egg to that of a child's head, the average being that of a goose-egg. Symptoms.—The symptoms of axillary aneurism are generally so well marked as to render it impossible to mistake their character. When the dis- ease arises spontaneously, or without any assignable cause, it may exist for seve- ral months without attracting any particular notice, and the same thing occa- sionally occurs when it results frora external violence, as a blow or strain. Generally, however, the tumor rapidly augments in bulk, and produces such a train of phenomena as to lead at once to its detection. Of these, one of the ear- liest, and at the same time most unpleasant, is the sense of fatigue or uneasiness in the affected part arising from the pressure on the axillary plexus of nerves. This symptom is usually succeeded in a few weeks, sometimes, indeed, in a few days, by a feeling of pain, which is always in direct ratio to the size of the aneurism, being comparatively slight when it is sraall, and more or less intense when large. Nor is the pain confined to the site of the disease; in most cases it radiates frora it, as from a common centre, in different direc- tions, outwards into the shoulder, downwards along the arm, and upwards into the neck. Pressure, severe coughing, the recumbent posture, and the weight of the limb greatly increase it. Numbness of the shoulder, chest, and arm, is another symptom which generally manifests itself at an early period of the disease, and is never absent when the tumor has acquired considerable magnitude. It is always very distressing to the patient, is greatly aggra- vated by pressure on the swelling, and commonly extends to the ends of the fingers. Indeed, it is at this point that the sensation in question is often most keenly felt. The pulsation of the tumor, at first faint and scarcely perceptible, becomes very distinct during the progress of the disease, so that it can not only be felt by the fingers, but seen at a considerable distance; sometimes, indeed, ten or twelve feet from the patient. On applying the ear or stethoscope to the tumor, the blood is found to rush into it with more or less violence, produc- ing a peculiar thrill, or whizzing noise, synchronous with the contraction of the left ventricle of the heart. In the early stage of the disease, the swelling is soft and elastic, and may be readily emptied by pressure; by degrees, however, it becomes firm, tense, and, in great measure, if not entirely, in- compressible. In some cases, especially in those attended with great enlarge- ment, there is considerable diminution of the temperature of the affected limb, with indistinctness, if not entire absence, of the pulse at the wrist, more or less cough, dyspnoea, and shortness of breathing. Occasionally the pulse is fully as strong as in the other arm, but irregular or intermittent, losing seve- ral strokes in a minute. In addition to these symptoms, there is always, when the swelling is large, so much displacement of the clavicle as to render it difficult, if not impossible, to distinguish the pulsation of the subclavian artery, the vessel being deeply buried behind and below the bone. In some instances the collar-bone has been found to be considerably imbedded in the tumor, or partially removed by vol. i.—50 786 DISEASES AND INJURIES OF THE ARTERIES. absorption. Another symptom, which, from its frequency, especially in the latter stages of the disease, requires mention here, is the swelling of the affected limb. This varies in degree in different cases, often extends from the shoulder to the ends of the fingers, and is usually of an cedematous cha- racter, pitting under pressure, and becoming aggravated by the dependent position of the part. When thus affected, the muscles lose their contractile power, and the motions of the extremity are proportionably impaired, or en- tirely annihilated. Sometimes, again, owing to the great magnitude of the tumor, the patient is unable to approximate the limb to the side of the chest. Finally, there is another phenomenon, which, as it is almost invariably pre- sent in the latter stages of axillary aneurism, I am disposed to regard as pathognomonic. I allude to the peculiar attitude of the patient, arising from the constant inclination of the head towards the affected side, and the manner in which he supports the corresponding arm ; the object of both being evi- dently to prevent the tension which would otherwise be caused in the tumor. Under these circumstances, too, the countenance wears an anxious and dis- tressed appearance, and, as the system sympathizes with the local affection, there is more or less derangement of the general health. When the tumor is unusually bulky, it will necessarily greatly encroach upon the clavicle, forcing it upwards into the neck, and at the same time exerting severe pressure upon the subclavian artery, perhaps so much as to render it difficult, if not impossible, to distinguish the pulse at the wrist. Diagnosis.—Notwithstanding that the symptoms of this disease are usu- ally well-marked, it has sometimes happened that tumors of this description have been opened by ignorant practitioners under the belief that they were abscesses. For such stupidity no apology can be offered. Still, cases occa- sionally present themselves, though very rarely, in which it is extremely diffi- cult, at first sight, to distinguish between this and other swellings in the armpit or subclavicular region. Enlarged lymphatic ganglions, adipose tumors, or encephaloid growths, for example, if they happen to lie along the course of the axillary artery, might have its pulsation imparted to them, and thus create some doubt in regard to their real character. Under such circum- stances, the facility with which the tumor can be elevated or removed from the vessel, the absence of the peculiar whizzing sound, previously alluded to, as being generally present in aneurismal disease, the slight pain and numbness in the part and in the corresponding limb, the continuance of the swelling on the application of pressure to the subclavian artery, and, above all, the history of the case, will generally be sufficient to enable the practitioner to arrive at a correct diagnosis. In this disease the tumor may be situated either immediately below the clavicle, or in the axilla, properly so called. In the former case, it may not only elevate the clavicle, but extend up into the neck, beneath the bone, as far as the acromial margin of the scalene muscles. In the latter, it has been known to reach some distance down the arm, so as to compress the brachial artery and nerves, and prevent the approximation of the limb to the side. Treatment.—Axillary aneurism occasionally undergoes spontaneous cure, as in the instances reported by S. Cooper and Breschet. Such an occurrence, however, is extremely uncommon. Most generally the disease, if left to itself, terminates fatally, either by rupture of the sac and exhausting hemorrhage, or by gangrene of the limb. In a few rare cases the tumor destroys life by inducing caries of the ribs and perforation of the pleura, followed by a dis- charge of its contents into the cavity of the chest. In a case narrated by Mr. Guthrie, it was ascertained, on dissection, that the aneurism had forced its way into the right side of the chest by the destruction of a portion of the first five ribs, and had contracted adhesions to the upper lobe of the lung, into which it had gradually opened and discharged its contents, the man having ANEURISM OF THE AXILLARY ARTERY.' 787 spat blood more or less profusely for several weeks prior to his death. In a similar case mentioned by Dr. Neret, of Nancy, an aneurism, about the size of a large chestnut, was seen to communicate with a cavity as large as the head of a new-born infant in the upper part of the left lung. The man had been admitted into the hospital on account of hemoptysis. The only remedy for axillary aneurism is ligation of the subclavian artery, and it need hardly be said that the sooner this is done the more likely will it be to effect a cure. The operation, however, should not be declined, even although gangrene of the sac has already commenced, provided there is nothing else to forbid it. I am not aware that aneurism of the axillary artery has ever been cured by compression, nor is this surprising when we reflect upon the difficulty of approaching the subclavian under such circum- stances, and also the proximity of the axillary plexus of nerves, which could hardly be induced to brook such an attempt for a sufficient length of time to produce any good effect. If the procedure is ever admissible, it will be in those cases where the turaor is uncommonly small, and the subclavian more than ordinarily superficial. The vessel might then be reached and success- fully compressed either by the finger, the handle of a key, or the instrument delineated at page 548, figure 165. If the parts were very tender, the pa- tient might be kept gently under the influence of chloroform while the neces- sary pressure is maintained, just as the obstetrician occasionally blunts the sensibility of the female for many hours together in protracted and painful labor. Mortality.—Of 27 cases of axillary aneurism, which I analyzed in 1841 in the Western Journal of Medicine and Surgery, including one of ray own, and for which the subclavian artery was tied, 17 recovered and 10 died, death occurring from the third to the thirtieth day, either from hemorrhage, gan- grene of the arm, ulceration of the artery, pericarditis, pleurisy, or pneu- monia. In one case it seemed to have been caused by effusion into the brain, and in one, ray own, it was consequent upon rupture of the aneurismal sac into the thoracic cavity. In the tables of Dr. Norris, showing the mortality in 69 cases in which the subclavian artery was tied for aneurism, including 9 of wound of the axillary artery and 2 of tumors not aneurismal, though supposed to be so at the time, 36 are stated to have recovered, and 33 to have died. In three of the cases mentioned in my paper, the subclavian was secured on the tracheal side of the tumor, and all proved fatal. In one of the cases, that of Mr. Colles, the ligature was not tightened till the fourth day after the operation, owing to the supervention of excessive dyspnoea and cardiac oppression. In my own case, the tumor burst at the end of the twenty-sixth day after the operation, discharging its contents into the right thoracic cavity, and thus causing fatal pleuritis. The patient, a man aged thirty-six years, was suddenly seized with intense pain in the chest, which was particularly severe at the base of the right lung, from which it extended over towards the sternum, on the one hand, and up towards the axilla, on the other. The respiration was hurried, laborious, and fifty-six in the minute; and the pulse, which was quick and tense, rose rapidly to one hundred and forty. Two days after the accident, the patient experienced a sensation near the upper part of the chest, as if a fluid were passing from the pleuritic cavity into that of the aneurismal sac, and, on carefully auscultating the spot, a plashing sound could be distinctly heard at every inspiration, the noise resembling that produced by shaking water in a closed vessel. The respiration in the right lung was now bronchial, and there was extensive dulness on percussion of that side of the chest. It is proper to add that the tumor prior to the operation was about the volume of a large fist, and that the ligature, which 788 DISEASES AND INJURIES OF THE ARTERIES. had been placed on the artery on the external side of the scalene muscle, came away on the fourteenth day. The dissection revealed the following facts, the arteries having previously been injected. The wound made in the operation was completely cicatrized, and the pec- toral muscles, although somewhat attenuated, retained their natural appear- ance. The subclavian artery terminated abruptly at the outer margin of the scalene muscle, where the ligature had been applied, its caliber being closed by a mass of solid fibrin, about one-third of an inch in length, which adhered firmly to the lining membrane, and thus afforded an effectual barrier to the passage of the blood. Between this and the thyroid axis the vessel was occupied by a dark coagulum of blood, which, as it was unadherent, was probably formed only a short time before death. Beyond the seat of the ligature the artery had a rough, ragged appearance, and was sufficiently per- vious to admit of the ready passage of a small probe into the aneurismal sac. Superiorly the tumor was overlapped by the brachial plexus of nerves, while in front, at its lower part, was the subclavian vein, which, besides being thrown out of its natural course, was considerably diminished in size. No pus was anywhere discoverable, the parts immediately involved in the operation being intimately consolidated by plastic lymph. The aneurismal tumor, placed immediately below the clavicle, was of a conical form, and about the volume of a moderate-sized orange, being two inches and a quarter in diameter at its base. Its walls varied in thickness at different points from half a line to the eighth of an inch, and its interior communicated by means of an oval aperture, one inch and three-quarters in length by an inch and a half in width, with the pleuritic cavity : it was situated between the first and second ribs, nearly equidistant between the sternum and spine, and was obviously the result of ulcerative absorption, induced by the pressure of the tumor. Both ribs were denuded of their periosteum immediately around the opening, and the serous membrane had a shreddy, ragged aspect. The aneurismal sac contained a few reddish clots arranged in a laminated manner, and closely adherent to its inner surface, especially at the part corresponding with the apex of the tumor. The right thoracic cavity contained nearly three quarts of bloody-looking serum, intermixed with flakes of lymph and laminated clots, the latter of which were of a reddish-brown color, and had evidently been originally lodged in the aneurismal sac. The pleura exhibited everywhere marks of high inflammation, while the right lung was greatly reduced in volume, from the corapression of the effused fluid. The left lung was considerably en- gorged, and at one or two points almost hepatized. The heart and peri- cardium were sound. The abdominal viscera presented nothing unusual. None of the arteries appeared to have been affected by disease. There can be no doubt, from the manner in which this case, which was one of a traumatic character, terminated, that the ulcerative absorption which gave rise to the opening above referred to, and which finally led to the escape of a portion of the contents of the aneurismal sac, commenced prior to the deligation of the artery, having been produced by the violent pulsative action of the tumor. Could such an accident have been foreseen, I should not have hesitated to empty the sac to relieve the parts of pressure, objectionable as such a procedure certainly would be in ordinary cases. An instance of a character similar to the above occurred in 1823, in the practice of Mr. Bullen, of England, and is related iu the twentieth volume of the London Medical Repository. The patient was a man, aged thirty-six years, and the aneurism, which was of nearly five months' standing, also occupied the right side. Eighteen days after the operation, the tumor began to increase in size and to become painful. Very soon evidence of suppura- tion appeared, and at the end of a week, from six to eight ounces of bloody pus were ejected during a violent paroxysm of coughing, the sac immediately ANEURISM OF THE AXILLARY ARTERY. 789 diminishing one-half in volume. A puncture being made into the swelling, five ounces of a similar fluid were discharged, to the great relief of the patient It was now apparent that there was a cavity between the first and second ribs, near their sternal extremities, through which the matter had found its way into the lung, and which now readily admitted air from the latter organ, whenever the man coughed, at which time a little also escaped at the artificial opening. By degrees, the discharge of matter ceased, the cough grew less and less, and at the end of three months the recovery was perfect. Mr. Erichsen, struck with the extraordinary mortality after ligation of the subclavian artery, in the third part of its course, for spontaneous aneurism in the axilla, determined, if possible, to ascertain the cause of death. For this purpose he analyzed 47 cases of the operation, of which 23 recovered, and 24 were fatal. Of the latter 10 perished from inflammation within the chest, 6 of suppuration of the sac, 3 of hemorrhage, 1 of gangrene of the hand and arm, and 1 of general gangrene, the cause of death in 3 not being mentioned. The ten cases in the first category died of pneumonia, or of this disease and of inflammation of the pleura and pericardium ; produced, as Mr. Erich- sen suggests, either by an extension of the inflammation of the deep cellular tissue of the neck to the contents of the chest, by the inward pressure of the aneurismal 6ac, or, lastly, by the injury inflicted during the operation upon the phrenic nerve. Suppuration of the sac was the immediate cause of death in six cases, and it occurred also in two of the cases that died of inflammation of the chest. Besides these fatal cases there were six of recovery, making thus an aggre- gate of 14 cases, or a ratio of nearly one in three. The period at which the suppuration set in varied, on an average, from eight days to four weeks. Hemorrhage proved fatal in three of the cases, and appears to be a fre- quent cause of death after suppuration of the sac. It may proceed from the distal orifice of the artery opening into the sac, or from one of the large branches in its immediate vicinity, as the subscapular or posterior circumflex. Gangrene of the hand and arm was the cause of death in one instance only, although the disease occurred also in two others. In Blizard's case, in which there was sloughing of the sac and pericarditis, the gangrene was con- fined to two fingers; while in Brodie's case it occurred both in the upper and lower extremities, thus showing that it depended, not upon a want of power in the collateral circulation, as in the other examples, but upon some peculiar state of the constitution. LIGATION OF THE SUBCLAVIAN ARTERY ON ITS TRACHEAL ASPECT. This vessel is sometiraes ligated on the inner side of the scalene muscles. The subjoined table, comprising ten cases, will serve to place the subject in its true light. _ Operator. g M 02 < Result. 1'Colles M. 33 Death 2Mott F. 21 Death 3 Hayden F. 57 Death 4 O'Reilly M. 39 Death SjPartridge M. 38 Death 6 Liston M.— Death 7 Liston M. 32 Death 8 Auvert _ _ Death 9 Auvert _______i— Death 10 J. K. Rodgers M. 42 Death Remarks. In this case there was only a space of three lines between the sac and the bifurcation of the innominate. The patient died of hemorrhage on the fourth day. The patient died on the eighteenth day of hemorrhage. The patient died on the twelfth day of hemorrhage. The patient died on the thirteenth day of hemorrhage. The patient died on the fourth day of pericarditis and pleurisy. Patient died of hemorrhage on the thirteenth day. The patient died on the thirty-sixth day of hemorrhage. Fatai hemorrhage on twenty-second day. Fatal hemorrhage on eleventh day. Fatal hemorrhage on the fifteenth day. 790 DISEASES AND INJURIES OF THE ARTERIES. The result in all the above cases, except one, has been death by hemor- rhage, notwithstanding the undoubted ability and skill of the operators, comprising some of the most illustrious names in surgery. Should this fact not be sufficient to deter practitioners from repeating the operation, or should they continue in their efforts to save life until some one, more fortunate than the rest, shall succeed in finding an exceptional case ? The case of the late Dr. J. Kearney Rodgers, of New York, in which the artery was secured on the left side on account of an aneurism, is full of the deepest interest in this respect, as showing that, although the patient finally perished from hemorrhage, yet the ligated vessel was completely closed by an adherent coagulum. Until the operation of Dr. Rodgers, it was universally regarded as imprac- ticable to ligate the left subclavian artery on the inside of the scalene muscles, such being the intimate relation of the vessel in this situation to the sac of the pleura, the carotid artery, internal jugular vein, pneumogastric nerve, and thoracic duct. It had been thought that, from the severe injury which would necessarily be inflicted upon the surrounding structures during the operation, violent and fatal inflammation must be the speedy and inevitable consequence. At all events, no one had yet been found ingenious enough to devise, and bold enough to execute, such an enterprise. Although it is not likely that the operation will soon be repeated, yet the case in question de- serves brief notice here as a matter of surgical history, if nothing more. The patient was a man, aged forty-two, who, in consequence of lifting a heavy weight, upwards of a month previously, suddenly became the subject of aneurism of the left subclavian artery. At the time of his admission into the New York Hospital, the tumor could be seen above the clavicle, about the size of a small hen's egg, extending outwards towards the shoulder, and inwards towards the sterno-cleido-mastoid muscle, by the outer border of which it was considerably overlapped. The signs of aneurism were well marked in every particular. The operation was performed on the 14th of October, 1845. Two incisions were made; one, three inches and a half in length, along the inner border of the sterno-cleido-mastoid muscle, terminating at the sternum, and dividing the integuments and platysma-myoid muscle; and the other, two inches and a half in length, extending horizontally over the inner extremity of the clavicle, the two meeting at a right angle near the trachea. Several small veins having been ligated, and the flap thus formed dissected up, the sternal portion with half of the clavicular of the mastoid muscle was divided upon a grooved director, a procedure which fully brought into view the sterno-hyoid and omo-hyoid muscles and the deep-seated jugular vein, all covered by the cervical fascia. A part of the aneurismal sac was also in sight, overlapping a considerable portion of the anterior surface of the scalene muscle, upon which the operator could distinctly feel the phrenic nerve. By digging with the handle of the knife and fingers, the deep cervi- cal fascia was now divided close to the inner edge of the scalene muscle, when, after a little search, the subclavian artery was easily discovered as it passed over the first rib, pressure upon this portion readily arresting the pul- sation of the tumor. The next step of the operation consisted in passing the ligature around the vessel without injury to the pleura and thoracic duct, but this proved to be one of extreme difficulty, owing to the great narrow- ness and depth of the wound, the latter nearly equalling the length of the forefinger. This, however, was at length successfully accomplished by means of an aneurismal needle with a movable point, carried from below upwards. The moment the ligature was tied all pulsation in the tumor ceased, and the patient, if not entirely comfortable, made no complaint of any kind. The wound became somewhat erysipelatous after the operation, but, on the whole, the patient got on well until the 26th of October, when, on changing ANEURISM OF BRACHIAL ARTERY AND BRANCHES. 791 his position in bed, hemorrhage supervened, and, continuing to recur at vari- ous intervals, destroyed him on the fifteenth day. On dissection, the wound was found to be filled with clotted blood, beneath which the artery had been completely divided by the ligature, which lay loose close by. The stump of the subclavian, between the aorta and the point of ligation, was about an inch and a quarter in length, and thoroughly impervious to air and liquids, its caliber being occupied by a solid and firmly adherent coagulum. The distal extremity of the subclavian contained a soft, imperfect clot, while the vertebral artery, which was given off immediately at the site of the ligature, was almost patulous, and had evidently been the seat of the hemorrhage which caused the patient's death. The aneurismal sac, the size of a small orange, was completely blocked up with coagula. The thoracic duct was uninjured, but the pleura at the bottom of the wound was found to be ex- tensively lacerated, and through the opening thus formed a large quantity of blood had passed into the left cavity of the chest. In reflecting upon this interesting case, Dr. Rodgers regretted that he had not secured the vertebral artery and also the thyroid axis, believing that this would have effectually prevented the fatal hemorrhage. ANEURISM OF THE BRACHIAL ARTERY AND ITS BRANCHES. Spontaneous aneurism of the brachial artery and of its terminal branches, the radial and ulnar, is extremely uncommon, for the reason, adverted to in a previous section, that ossification and fatty degeneration of the coats of these vessels are of such great rarity compared with the same lesions of the femoral and its principal divisions. I have, in fact, never witnessed a single example of the disease, and I am not aware that it has ever been noticed by any one in this country. Cases of the disease, however, are mentioned by foreign authorities, among others by Desault, Palletta, Flajani, Pelletan, and Scarpa. Spontaneous aneurism of the ulnar and radial arteries are spoken of by several writers, but in so vague a manner as to render it difficult to determine whether the disease depended upon degeneration of the coats of the vessels, or merely upon laceration by external injury. All these arteries are subject to traumatic aneurism ; the brachial, how- ever, is much more frequently involved than the radial and ulnar, and one of the raost common causes of the occurrence is venesection at the bend of the arm, the puncture of the lancet establishing a communication between the vein and the artery, thus giving rise to what is called an arterio-venous aneurism. Or, instead of this, the instrument may almost completely sever the artery, and so induce a diffused aneurism, not opening into the vein, but diffusing its contents, up and down, over a large portion of the inner and fore part of the lirab. Some of these latter cases are occasionally very for- midable, requiring great judgment and skill for their successful management. Arterio-venous aneurism may sometimes be cured by systematic compres- sion of the brachial artery, at a distance of five or six inches from the seat of the disease ; but in general the most expeditious plan is to lay open the sac, turn out its contents, and tie the artery above and below, the inferior ligature being necessary to prevent hemorrhage from the recurrent branches. Wound of the brachial artery, without communication with a vein, should be treated, if the case can be reached soon after its occurrence, by compres- sion ; but if there be extensive extravasation of blood, constituting what is usually, but improperly, called a diffuse aneurism, the vessel must be exposed at the site of injury, and ligated at its cardiac and distal extremities. Aneurisms and wounds of the ulnar and radial arteries must be treated upon the same general principles as those of the brachial artery, and do not, therefore, require any special mention. Compression can rarely be rendered 792 DISEASES AND INJURIES OF THE ARTERIES. available, except at the wrist, and even here it will usually be found to be unsatisfactory, on account of the difficulty of maintaining it in a firm and steady manner. Hence, the proper way is always to ligate the affected vessel at once, not waiting until the parts have become obscured by the extravasated blood. As both arteries are very deep-seated in the upper and middle portions of their extent, rendering it very difficult to expose them, it has been proposed, when they are wounded in these situations, to ligate the brachial; but the objection to this procedure is that, while the cardiac extremity of the affected vessel will thus be closed, the distal one will remain patent, and thus admit of a continuance of the hemorrhage by the recurrent circulation. Wounds of the arteries of the hand, especially of the palmar arch, are best managed by free incisions and the application of two ligatures. It is great folly, under such circumstances, nay, it is positively worse than folly, to tamper with the comfort and welfare of the patient by the use of compression, either direct or indirect, if the vessel be of any considerable size. Only pre- cious time is wasted; the bleeding will return whenever the mechanical sup- port is taken off, and in this way the patient may lose quarts of blood before the hemorrhage is finally arrested, as I have known to happen in more instances than one. The ligation of the radial and ulnar arteries will be equally unavailing, for blood will still be sent to the wound by the interos- seous branch, and, even if this also were secured, still the probability is that the bleeding would go on, especially if some time had elapsed since the occurrence of the accident, owing to the communication of the anastomosing vessels. We now and then read of cases in which the brachial artery has been tied for the arrest of hemorrhage of the palmar arch. Can there be anything more absurd than such a procedure, or that shows a greater degree of ignorance of the anatomy of the hand? The advice of John Bell, in his Principles of Surgery, in regard to the treatment of wounded arteries in general, cannot be too strongly enforced here : " Meet the danger boldly, and don't be afraid to look your enemy in the face." A curious case of aneurism under the ball of the right thumb has been related by Mr. Pilcher, as having occurred in a goldsmith from the repeated though slight blows inflicted with his hammer in the exercise of his trade. The disease speedily disappeared after ligatiou of the radial and ulnar arteries at the wrist. ANEURISM OF THE COMMON ILIAC ARTERY. The history of aneurism of this vessel remains to be developed. Nothing short, in fact, of a careful analysis of the various recorded cases of it can place it in its true light. That the disease is extremely uncommon in its occurrence is a circumstance which has long been familiar to surgeons. The table of Mr. Crisp supplies only two cases of aneurism of this artery in 551 cases of the lesion as it shows itself in different portions of the arterial sys- tem. Both occurred in males. In one, the tumor was seated on the right side; the patient was a sailor, exposed to hard labor in whale-fishing; the aorta was tied by Dr. Murray, of the Cape of Good Hope, but the man died twenty-three hours after the operation. In the other case, the aneurism, also seated on the right side, was of a fusiform shape, and communicated with the common iliac vein. No operation was performed. The following table exhibits the results of five cases in which the abdominal aorta has been tied for aneurism of the common iliac. ANEURISM OF THE COMMON ILIAC ARTERY. 793 Operator. Cooper James 3, Murray Monteiro South 1317 1829 1834 1842 M. M. M, M. 1856 M, 38 44 33 28 Result. Remarks. Died in 40 hours Died in 3^ hours Died 23 hours Died in 10 days Died in 43 hours The operation was performed for aneurism of the left iliac artery. The tumor being of enormous size, extending four inches above and four inches below Poupart's liga- ment ; the thread was applied three-quarters of an inch above the bifurcation of the aorta. The sac contained an immense quantity of clotted blood. There was an external iliac aneurism, for which the femoral was ligated. Increasing in size, 33 days afterwards the aorta was tied. The ligature was applied eleven lines above the bifurcation of the vessel, and five below the mesenteric artery. There was an extensive aneurism of the right external iliac, the tumor reaching as high as the umbilicus, and more than half way across the lower part of the abdomen. Mortification of the limb was rapidly approaching when the operation was performed. The aorta was tied about four lines above its bifurcation. A large tumor occupied the lower part of the abdomen and upper part of the thigh. It was a spurious aneurism of the femoral artery, caused by the bursting of that vessel. The patient died, at the expiration of ten days, of second- ary hemorrhage, from a small opening in the vessel cor- responding with the knot of the ligature, which had been applied four lines above the point of bifurcation. The aneurism occupied the external and common iliac, and was of immense size. The ligature was applied a little above the bifurcation of the aorta. It will be perceived from the above table that the five cases in which the abdominal aorta has been tied, all terminated fatally; a result which might assuredly have been foreseen by the distinguished surgeons who performed the operation. Questionable as the propriety of such an operation is, I should, I confess, be strongly tempted to perform it if my patient were placed in circumstances precluding all hope of relief from any other source. That this was the feeling which prompted Sir Astley Cooper, in 1817, to under- take it, and which has since induced others to imitate his example, is more than probable, and our only regret is that their efforts have not been crowned with success. What the effect might have been if the cases had been of a more favorable nature prior to surgical interference is, of course, merely a matter of conjecture, but it is perfectly evident, from their history, that they were all in as desperate a condition as they could well have been at the time. The tumor, in every instance, was of enormous volume, almost, in fact, ready to burst; in Mr. Murray's patient there was, besides, incipient gangrene of the lower extremity. In the case of Mr. James, an error of diagnosis had been committed, which led, improperly, as was afterwards proved, to ligation of the femoral artery, thereby causing the patient not only much suffering but the loss of much valuable time, upwards of four weeks having elapsed between the two operations. In performing the operation, the peritoneum was divided in two of the cases, and left intact in three; in one instance, it was opened to the extent of nearly four inches. Such a procedure would probably of itself have been a cause of death, had the patient survived the immediate effects of the deli- gation of the vessel. The case of Dr. Monteiro, the most successful of all, is replete with in- terest, as it establishes the fact that the circulation may go on in the lower extremities, after the flow of blood in the abdominal aorta has been com- pletely arrested by the ligature. The patient survived the deligation ten days, when he died of secondary hemorrhage, caused by a small aperture in 794 DISEASES AND INJURIES OF THE ARTERIES. the side of the vessel corresponding with the knot in the thread. The dis- section showed that the peritoneum, which had not been cut in the operation, was perfectly free from inflammation. The aorta had been ligated four lines above its bifurcation, and an inch below the inferior mesenteric artery. The aneurisra, which was a false one, had originated in a rupture of the upper extremity of the femoral artery, from which the blood had made its way up- wards, underneath Poupart's ligament, through the intermuscular cellular tissue, into the iliac fossa, and thence on behind the peritoneum along the posterior part of the abdomen, as high up as the diaphragm and liver. The common and external iliac arteries were involved in the tumor, and were in an inflamed and friable condition. The external wound had nearly healed. It is worthy of remark that the pulsation in the tumor ceased immediately on tying the ligature, but returned slightly on the third day, and became more marked on the fourth. Hemorrhage supervened the day before death. The operation was followed by coldness of the lower extremities, but in four hours afterwards this had passed off, and the temperature was now a little above the natural point. No paralysis was present at any time in the limbs. ANEURISM OF THE INTERNAL ILIAC. Aneurism of the internal iliac, gluteal, and sciatic arteries is very uncom- mon, and their history has not been studied with sufficient care to enable us to present anything like a satisfactory account of them. Owing to the deep situation of the former of these vessels, the diagnosis of aneurism occupying its course would necessarily be attended with considerable difficulty, and should not be declared without a good deal of reserve and circumspection. Aneurism of the sciatic and gluteal arteries is more frequently traumatic than spontaneous. In fat, muscular subjects the disease is generally difficult of recognition, and hence it is not surprising that solid growths have sometimes been mistaken for it. Mr. Guthrie once tied the internal iliac artery for a tumor which he had taken to be aneurismal, but which, after death, was found to be of an encephaloid character, the deception having been caused by the circumstance of the tumor having received a distinct impulse from the artery. I have not met with aneurism of the pudic artery, and am not aware that the disease has ever been observed in this country. Mr. Erichsen states that the only instance of the kind with which he is acquainted is exhibited in a pre- paration in the Museum of the College of Surgeons at London. Aneurism of the gluteal and sciatic arteries may be treated by ligating the internal iliac, or exposing the sac by a free incision, turning out its con- tents, and tying the vessel above and below. Such a proceeding would, un- questionably, be very bloody, but by far less hazardous in the end than deligation of the internal iliac. The gluteal artery has been tied at least twice in this country for the cure of aneurism ; once by Dr. Davidge, of Baltimore, and once by Dr. George McClellan. The tumors being of great bulk, the incisions were obliged to be unusually large, and the loss of blood was very profuse. Notwithstanding this, however, both patients made an excellent recovery. ANEURISM OF THE EXTERNAL ILIAC. Aneurism of the external iliac is a rare affection. In the table of Mr. Crisp, the most elaborate hitherto furnished, it occurs only 9 times in 551 cases, while the femoral is mentioned 66 times, and the popliteal 137 times. In 364 specimens of aneurism contained in the London museums, the same writer found the external iliac affected in 7 cases, the femoral in 12, and the popliteal in 50. The nine cases analyzed by Mr. Crisp all occurred in males: ANEURISM OF THE EXTERNAL ILIAC. 795 two, between twenty and thirty ; four, between thirty and forty ; one, at forty, and one at fifty-six, the age of the other not being given. The disease is most comraon in hard working persons. One of the worst cases of it that I have ever seen occurred in a priest. The turaor in this disease may be seated at any part of the artery, but in general it will be found rather low down, and, as it progresses, it manifests a tendency to pass underneath Poupart's ligament into the upper part of the thigh. It usually rapidly augments in size, and is capable of attaining a large bulk, encroaching upon the iliac fossa and the pelvic cavity, lifting up the peritoneum, and pressing forward the structures in the inguino-femoral region, so as to give rise to great deformity in this situation. The pulsation, thrill, and bellows' sound are usually very distinct. If the patient be very thin, compression of the abdominal aorta will arrest the movements of the tumor, and diminish its volume, thus serving to distinguish it from other affections. The diagnosis is, nevertheless, not always so easy as might at first appear. Several cases have been reported where the common iliac artery was ligated on account of morbid growths, supposed to be aneurismal, which afterwards proved to be of a malignant character. On the other hand, a tumor really aneurismal has occasionally been confounded with one alto- gether of a different character. Such a mistake is most likely to happen when the aneurisra is partially solidified by the coagulation of its contents, thereby preventing the perception of pulsation. It is only necessary to allude to the possibility of such an occurrence in order to put the practitioner upon his guard in the investigation of his cases. When an aneurism of the external iliac artery has attained a considerable bulk, the patient walks with extreme difficulty, and is unable to flex the thigh upon the pelvis. The whole limb is enlarged and cedematous from the ob- struction to the return of the venous blood, while the pressure of the tumor upon the femoral nerves keeps up constant pain, with a sense of numbness and stiffness in the parts below, generally extending as far down as the foot and toes. Aneurism of the external iliac artery, if left to itself, proves fatal in one of three ways, by rupture and hemorrhage, gangrene of the sac or limb, or constitutional irritation. A spontaneous cure now and then occurs, but the circumstance is extremely rare, and, therefore, does not deserve to be taken into the account in our therapeutic considerations. The only remedy hitherto employed in the treatment of this disease was deligation of the artery leading to the turaor; the external iliac, when the aneurism was situated low down, so as to leave a sufficiency of the superior portion of the vessel intact, and therefore in a suitable condition for the re- ception of the ligature ; or, when the reverse was the case, the common iliac, one of the most formidable operations in surgery. I believe, however, that it will be found that the tumor may generally be promptly obliterated, espe- cially in its earlier stages, by compression of the iliac as it passes over the brim of the pelvis ; and, although I am not aware that this practice has ever been adopted, yet I am the more inclined to regard it as feasible, from the fact that the external iliac does not give off any branches, in any portion of its course, so as to offer any barrier to the process of solidification of the contents of the sac. The epigastric and circumflex iliac arise just above Poupart's ligament, and could not, therefore, in any wise interfere with the cure. If a case of aneurism of the external iliac should be presented to me, I should certainly give this mode of treatment a fair trial, and should feel very sanguine of success. Digital compression would of course be preferable to any other, on account of the greater facility of its application. The result of the ligation of the artery leading to and feeding the tumor, has, on the whole, been rather encouraging. Iu the nine cases mentioned in 796 DISEASES AND INJURIES OF THE ARTERIES. Mr. Crisp's table, the common iliac was tied in two, one recovering, and the other perishing of hemorrhage on the eighth day. In four cases the external iliac was ligated, and all got well. In one instance both the femoral artery and the abdominal aorta were tied, but the man died a few hours after the last operation. One case was cured spontaneously, and another recovered under compression. Within the last few years the treatment of inguinal aneurism by digital compression has been tried. Of four cases thus managed, only one—a patient of Dr. Nichols, of New Orleans—was cured. The thumb was pressed against the neck of the sac for thirty hours, by which time the pulsation had stopped, but, as a matter of precaution, it was continued for ten hours longer. ANEURISM OF THE FEMORAL ARTERY. Aneurism of the femoral artery is very common, although less so than that of the popliteal. In Mr. Crisp's cases, 551 in number, 66 relate to the femoral artery, of which 61 occurred in males, thus showing that the disease is very rare in women. The period of life at which it is most frequently met with is from thirty to fifty. As in the other arteries, aneurism of the femoral is most common in the laboring classes, particularly in those persons who are subject to severe muscular exertion of the lower extremities, causing a sudden strain upon the vessel. Instances have been observed in which each femoral artery was simultaneously affected with aneurism, and it occasionally happens that the same vessel has two such tumors connected with it. The femoral artery is not equally subject to aneurisra in all parts of its extent. The superior third suffers more frequently than the rest of the ves- sel, and external aneurism occurs here much oftener than in any other artery, except the popliteal. Sailors are said to be particularly liable to the disease in this situation, owing, as Mr. Crisp supposes, to the violent flexion and extension of the thigh which they are obliged to make in mounting the rig- ging and performing other labors on ship-board. I have never seen an in- stance of spontaneous aneurism in the lower third of the thigh, and general experience concurs in declaring that such an occurrence is extremely uncom- mon. In sorae of the published cases, the disease is described as having been femoro-popliteal, a term evidently intended to convey the idea that the lesion involved both the terminal portion of the femoral and the incipient portion of the popliteal. Diagnosis.—The diagnosis of femoral aneurisra, although generally easy, is sometimes involved in so much obscurity as to cause not a little perplexity. This is more especially the case when the tumor is seated along the middle or lower third of the thigh, where the artery is tightly bound down by the muscles and aponeuroses. Abscesses and various morbid growths, solid, semi-solid, or fluid, and malignant and non-malignant, are the affections with which it is most liable to be confounded ; and it behooves the surgeon, in every case of doubt, to institute the most careful and thorough examination before he expresses an opinion in regard to its character, or permits himself to engage in any operative procedures for its relief. The best diagnostic, unquestionably, is the effect which compression of the femoral artery exerts upon the tumor, when it is situated some distance below Poupart's ligament, or of the ileo-femoral, when it occupies the superior part of the thigh. If the tumor be aneurismal, the compression will not only arrest its pulsation, thrill, and bellows' sound, but, while it is being kept up, it will enable the surgeon to squeeze out its contents, and thus greatly diminish its volume, circumstances which cannot possibly occur when the swelling is of a non- aneurismal character, whatever may be its structure or consistence. The exploring needle is only to be used in cases not admitting of discrimination ANEURISM OF THE FEMORAL ARTERY. 797 by the method here suggested, and then it should be so fine as not to cause hemorrhage or excite inflammation. The femoral artery, in the upper portion of its extent, is sometimes pro- truded forward by a synovial burse, situated behind the psoas muscle, just below Poupart's ligament, especially when the pouch is inflamed and much distended, in which case it will probably receive an impulse from the vessel, so as to cause the swelling to simulate aneurism. The proper way to deter- mine the diagnosis is to flex the thigh upon the pelvis, a procedure which, by taking off the tension of the muscle, puts a stop to the pulsation of the tumor, and thus reveals the true nature of the disease. A number of lymphatic ganglions lie in the upper part of the thigh, imme- diately upon and around the femoral artery. Enlargement of these glands has been mistaken for aneurism, and, conversely, aneurism for enlargement of the glands; but the history of the case and a careful examination of the parts will generally promptly clear up the diagnosis. Psoas abscess occasionally points below Poupart's ligament, and might be mistaken, by a careless observer, for aneurism of this vessel, or of the ex- ternal iliac. The best diagnostic signs are the want of pulsation, the soft and fluctuating character of the swelling, the absence of discoloration of the skin, and our ability to efface the swelling almost entirely, when the patient lies on his back with the thigh and pelvis a good deal elevated. Moreover, if there is pus, a drop will be sure to follow the withdrawal of the exploring needle. Progress.—The course of the aneurisra is variable. When it is situated high up, it is liable, in its progress, to extend upwards, and to project at length beneath Poupart's ligament into the pelvic cavity. When, on the other hand, it involves the inferior portion of the artery, it may pass down into the ham, and so simulate popliteal aneurism. The swelling usually in- creases rather rapidly, and, in time, often spreads over a large space, diffus- ing itself, in fact, widely, in consequence of the giving way of the two inner tunics of the artery. When this is the case, the limb below the seat of the turaor becomes greatly enlarged and cedematous, from obstruction to the return of the venous blood, and the patient constantly complains of stiff- ness, pain, and numbness in it, extending generally as low down as the feet and toes. In the more advanced stages of the disease, progression becomes difficult and finally impracticable, the whole limb feeling like a dead, heavy mass. A spontaneous cure occasionally occurs; but most commonly the disease goes on from bad to worse, until life is destroyed by gangrene, exces- sive suppuration, hemorrhage, or constitutional irritation. Treatment.—The treatment of aneurism of the femoral artery may, I think, generally be successfully conducted by compression, especially now that our means of applying and regulating it are so much better understood than formerly. The compression may be made either with the finger or by means of one of the numerous mechanical contrivances now before the profession. In the case of a negress, aged thirty-two, who was under the joint care of my son and myself, last summer, on account of a large aneurism of the upper third of the femoral artery, the assistants succeeded in effecting complete solidifica- tion of the contents of the sac in forty-six hours, by digital compression alone. The tumor progressed most favorably, and in less than three weeks after the operation, the woman was able to walk about the house. In this case, re- ferred to in a previous section, there was not more than an inch of space between the aneurismal sac and Poupart's ligament, in consequence of which the corapression was obliged to be applied to the iliac artery as it passed over the brim of the pelvis. Several instances of an equally gratifying termination have followed this treatment in the hands of other surgeons. When compression is inapplicable, the only resource of course is deligation 798 DISEASES AND INJURIES OF THE ARTERIES. of the artery which supplies the tumor with blood. The operation is easily done at Scarpa's triangle when the aneurism occupies the middle or lower third of the femoral artery, or even when it extends up to the inferior portion of this space, provided the coats of the vessel are sufficiently sound to bear the pressure of the ligature. When this is not the case, or when the tumor is situated high up, near Poupart's ligament, or projects beneath it partly into the pelvic cavity, the proper remedy will be ligation of the external iliac, an operation which, although not devoid of risk, has now been performed so often and so successfully as to be justly ranked among the established resources of surgery. Mortality.—In Mr. Crisp's 66 cases, above referred to, the external iliac alone was tied in 43, and in two others both this artery and the femoral; 36 of the patients recovering, and 10 dying. Of the latter, three perished from hemorrhage, four from gangrene of the sac or limb, one from tetanus, one from exhaustion, and one without any apparent cause. In 12 of the cases the femoral artery alone was tied, with a result of 9 cures to 3 deaths. Am- putation was successfully employed in five cases; in two, the tumor was obliterated by compression, and in one the disease spontaneously disap- peared. In the table of Dr. Norris, comprising 118 cases of ligation of the external iliac artery, of which, however, 97 only relate to aneurism, 85 recovered, and 33 died, three of the former having undergone amputation of the limb in consequence of gangrene. In 4 of the 97 cases of aneurisra, the disease ex- isted simultaneously both in the thigh and in the ham, and in 3 of these the operation succeeded in curing both tumors. A return of pulsation in the sac took place in 9 cases, and hemorrhage in 14, of which 7 proved fatal, and 7 recovered. In 10 cases the tumor suppurated after the operation, although they all ultimately did well. Gangrene of the limb occurred in 16 cases out of the 118, of which 12 died. In two instances the peritoneum was wounded, but both patients recovered. Finally, a number of cases of femoral aneurism have been recorded in which a cure was effected simply by refrigerant applications to the tumor, aided by steady compression with the bandage, strict recumbency, and an abstemious regimen. This treatment has occasionally succeeded both in the spontaneous and traumatic form of the disease. ANEURISM OF THE POPLITEAL ARTERY. The extraordinary frequency of aneurism of the popliteal artery has long been familiar to pathologists and surgeons. With the exception of the thoracic portion of the aorta, there is no artery in the body which is so often the subject of this disease. The table of Mr. Crisp, already so fre- quently referred to, comprises an analysis of 551 cases of spontaneous aneu- rism, of which 137 occurred in the vessel under consideration, the thoracic aorta suffering 175 times. Three circumstances seem to serve to establish this extraordinary liability to aneurism on the part of this artery; one is its extreme proneness to ossific and fatty degeneration, another, the curve which it forms behind the knee, and the third, the frequent, sudden, and forcible extension to which it is so constantly exposed in the various movements of the lower extremity. Age and Sex.—Popliteal aneurism occasionally occurs at a comparatively early age, a number of cases having been observed in which it took place before the twenty-fifth year. Mr. Syme has related one in a child of seven years. The great majority of instances, however, are met with between thirty and fifty. Both sides seem to suffer nearly in an equal degree, and both are occasionally affected simultaneously, or successively, as I have myself wit- ANEURISM OF THE POPLITEAL ARTERY. 799 nessed in several individuals. The disease is almost peculiar to men. In Mr. Crisp's cases, 137 in number, 133 occurred in males, and only 4 in females. No occupation is exempt from aneurism of the popliteal artery, but the statistics which have been published upon the subject conclusively show that the laboring classes, especially soldiers, sailors, bargemen, and porters, who are in the constant habit of making long-continued and violent exertions of the muscles of the lower extremities, are more obnoxious to it than any other. The idea, first broached by Morgagni, that postilions and coachmen are particularly prone to popliteal aneurism, has been proved to be erroneous. Diagnosis.—Aneurism of the popliteal artery is probably produced in most cases by a sudden and violent sprain or twist of this vessel while its coats are in a state of osseous degeneration, and consequently deprived of their elas- ticity, by which they are prevented from following the various movements of the leg with their accustomed freedom, a sudden rupture being thus induced, of which the patient is himself often made conscious, either by his feeling, or by a kind of snapping noise. The tumor, being at first quite small, generally escapes attention until it has acquired a considerable bulk, as, from the great depth at which the artery is situated, and the unyielding nature of the parts iu the ham, it takes some time for it to reach the level of the surrounding surface, or to exhibit to the eye the characters of a distinct swelling. A careful examination, however, will always enable us, even at an early period, to arrive at a satisfactory conclusion respecting the nature of the case, except, perhaps, in very fat subjects. The tumor will be found to throb synchron- ously with the artery in the groin, and, by grasping it firmly between the thumb and finger, it may readily be pushed about in the hollow between the tendons of the flexor muscles, feeling like an elastic, circumscribed knob, which is easily diminished by pressure, but immediately regains its former size when the pressure is removed. As the disease progresses, the sac in- creases in volume, and encroaches more and more upon the popliteal space, pushing aside the soft parts, compressing the popliteal vein and nerve, and interfering seriously with the movements of the limb. The leg is habitually bent at an obtuse angle with the thigh, and all efforts to straighten it prove abortive; it is the seat of constant aching pains, with a sense of numbness or tingling ; its temperature is notably diminished, and its subcutaneous cellular tissue, owing to the obstruction to the return of the venous blood, is loaded with serum, or serum and lymph, giving the surface a glossy, shining appear- ance, and causing it to pit under pressure. The ear and the hand readily detect the characteristic thrill and bellows' sound. Aneurism of the popliteal region is liable to be confounded with other tumors, and we read of cases in which the sac was laid open under the impression that the disease was not arterial. The lesions for which it is most apt to be mistaken are abscesses, solid and fatty growths, and synovial burses. Abscess of the ham is of very uncommon occurrence, and is in general easily distinguished by the history of the case, its inflammatory character, by the absence of pulsation, by the presence of fluctuation, especially when the matter is considerable in quantity, and by our inability to produce any change in the volume of the swelling by compression of the femoral artery high up in the thigh. When any doubt exists, a small exploring-needle, carefully inserted into the tumor, will readily determine the diagnosis. Solid growths, of various kinds, benign and malignant, are liable to form in the popliteal region, and might be mistaken for aneurism, especially by a careless and inexperienced surgeon. The fact that such tumors are usually stealthy in their origin, tardy in their development, firm in their consistence, 800 DISEASES AND INJURIES OF THE ARTERIES. and free from pulsation, will always readily distinguish them from aneurism of the popliteal artery. A synovial burse is occasionally developed in this space, but the occur- rence is rare, and it would be difficult to imagine how such a growth as this should ever be confounded with an aneurism in this region. In the Louis- ville Medical Review, a case of this affection is reported by Dr. S. W. Gross, in which the largest tumor of this description that I have ever seen, occur- ring in a man, aged twenty-nine years, was readily diagnosticated by the exploring-needle, although its history—especially the absence of pain and pulsation, its non-interference with the patient's occupation, and the pre- servation of the natural appearance of the leg below the knee—had been sufficiently denotive of its true nature without any expedient of this sort. Progress.—Aneurism of the popliteal artery may reraain circumscribed for a considerable length of time; but, in general, it becomes soon diffused, and by its pressure upon the surrounding structures causes not only great pain and swelling in the leg below the knee, but a tendency to mortification by cutting off the nervous and vascular supplies. Such a termination, in fact, is almost inevitable if the case be permitted to proceed unchecked. Sorae- times a spontaneous cure occurs, probably in consequence of the pressure of the tumor upon the artery, thereby arresting the circulation in the sac. Professor Pancoast, some years ago, had a case of popliteal aneurisra upon which he had intended to operate the next day; but when he got to his patient's room, he found that all pulsation in the tumor had ceased, and the man gradually recovered without any farther trouble. Occasionally the tumor opens into the knee-joint. Treatment.—The treatment of popliteal aneurism was, until recently, usually conducted by deligation of the femoral artery in the superior third of the thigh, according to the method of Hunter, first practised in 1785. Since 1840 numerous instances have been cured by compression, and so gratifying has been the result of this procedure that the old operation is likely, before long, to become almost obsolete. In a case recently communicated to me by Professor Blackman, of Cincinnati, that gentleman succeeded in arresting completely the pulsation in a popliteal aneurism by digital compression for two hours, after the failure of various other methods. Forced flexion, described at page 754, is particularly applicable to aneu- rism of the ham, and always deserves a fair trial provided the tumor is not so large as to encroach seriously upon the structures of the joint or to threaten to burst into its interior. Mortality.—The mortality from the operation for popliteal aneurism by the Hunterian method would seem to be variable. In the table of Dr. Norris, comprising a list of 188 cases of aneurism for which the femoral artery was tied, 142 were cured, and 46 died. It is proper, however, to add that the ligation in 33 of the cases was performed for other purposes than aneurism of the popliteal artery. The table of Mr. Crisp furnishes 110 cases, operated upon by the Hunterian method, of which 91 recovered completely, 7 required amputation after the use of the ligature, and 12 died. Of the 11 cases of double popliteal aneurism comprised in it, all were cured; 10 by ligature, and one by compression. The greatest cause of the mortality after the ligation of the femoral artery is gangrene of the leg. Traumatic aneurism of the ham is unusual. Cases have occurred where it was occasioned by a sabre wound, a musket ball, or the sharp end of a piece of bone in fracture of the femur above the condyles. A few cases are also recorded of arterio-venous aneurism in this situation, in consequence of ulceration establishing an interchange of blood between the popliteal artery and vein. ANEURISM OF THE ARTERIES OF THE LEG AND FOOT. 801 ANEURISM OF THE ARTERIES OF THE LEG AND FOOT. Spontaneous aneurism of the arteries of the leg is almost unknown. The traumatic form of the disease, however, is occasionally met with, and there are few cases in surgery more difficult to manage, especially wheu the lesion involves the posterior tibial artery, owing to the great depth at which this vessel is situated, and the confused condition of the parts in consequence of the extravasated blood. The proper remedy, of course, is free exposure of the affected vessel, removal of the coagula, and ligation of both ends. To accomplish this to the best advantage, often involves great coolness on the part of the operator, and an unusual amount of anatomical knowledge and dexterity. During the operation, the iliac artery should be compressed at the brim of the pelvis, or a tourniquet be applied round the upper part of the thigh. Without such precaution, the hemorrhage might be frightfully profuse. Injuries of the arteries of the foot are often followed by troublesome hemorrhage, which may eventually become quite exhausting. Cases of this kind are, more than almost any other in surgery, a stumbling-block to men ignorant of surgical anatomy, and it is not going too far to say that they are also, at times, exceedingly perplexing to the educated practitioner, annoying, fretting, and worrying him until his patience is nearly exhausted. The ar- rangement of the arteries in the sole of the foot is very similar to that of the palm of the hand ; the anastomosis between the plantar arteries is very exten- sive, and hence when these vessels are wounded it often becomes extremely difficult to arrest the flow of blood permanently without the use of the knife and ligature. It might be supposed, at first sight, that well-regulated, syste- matic compression would put an effectual stop, in most cases, to the hemor- rhage, but this, it is well known, is not the fact. It arrests the bleeding temporarily, and that is all. If an occasional exception occurs, it is an exception merely, nothing more. The rule is that the plantar arteries, when divided, will continue to bleed until they are secured by ligature. Why, then, not ligate them at once, without waiting until the patient is blanched and exhausted by the loss of blood, in the vain hope that compression may eventually stop it ? That this is the proper course of procedure, is unques- tionable ; the only objection to it is the extensive wound which we may be obliged to make in order to bring the bleeding vessel fully into view, so as to enable us to apply the ligature. Still, as this must generally be done, sooner or later, in every case, we cannot too strongly insist upon its being done as early as possible after the infliction of the injury. In making the necessary incisions, care must, of course, be taken not to disturb any import- ant structures; and in every instance the golden rule must be observed, to tie each end of the bleeding vessel, lest the hemorrhage should continue through the recurrent branches. It has been proposed in these cases to cut down upon and tie the principal arteries of the leg, and we read of instances in which even the great trunk of the thigh was ligated for such a purpose. Such a procedure cannot be too strongly condemned, as being contrary both to common sense, anatomical knowledge, and sound experience. The experiment of tying both the tibial arteries has been tried again and again under such circumstances, and the almost invariable effect has been complete failure; as might, indeed, have been anticipated from a careful study of the disposition of the arteries of the foot. Notwithstanding the somewhat pointed manner in which I have here spoken against compression in hemorrhage of the plantar arteries, it is but proper to add that I have seen this very method occasionally put a most prompt and vol. i.—51 802 DISEASES AND INJURIES OF THE ARTERIES. effectual stop to the flow of blood. I recollect distinctly the case of a little girl, which came under my observation many years ago, where I succeeded, by a single dressing, in arresting an exhausting and daily recurring hemor- rhage of upwards of a month's duration. A graduated compress placed over the orifice of the bleeding vessel, and confined by a roller extending from the toes upwards, aided by elevation of the leg and cold applications, constituted, as it always should when such a procedure is adopted, the means employed on the occasion. Sometimes we may advantageously resort to the expedient of compressing the anterior and posterior tibial arteries by means of two corks, placed directly over the vessels, opposite the malleoli, and bound down firmly by a suitable bandage, passed around the foot and leg in the form of a figure 8. The corks should each be wrapped up in a bit of patent lint, and should be at least three-quarters of an inch in length, and of proportionate thickness and breadth, otherwise it will be difficult to make them retain their proper posi- tion. When the compression is obliged to be made with great firmness, it may be well, in order to defend the soft parts, to extend a piece of sheet-lead across the limb under the bandage. SECT. VIII.—OPERATIONS ON THE ARTERIES. LIGATION OF THE INNOMINATE OR BRACHIO-CEPHALIC. Although the innominate may easily be exposed on the dead subject, as was shown by Dr. George McClellan as early as 1820, by a linear incision carried vertically down in front of the trachea, without dividing any of the cervical muscles, yet I believe that such a plan would be ill suited to the pur- pose when there is a large tumor pressing upon and displacing the parts which environ this vessel. The operator must have ample room, and it will not, I presume, materially affect the issue of the case whether a little more or a little less tissue is cut. The plan suggested by Dr. Mott, in his cele- brated case, is, on the whole, it seems to me, the one best adapted for obtain- ing ready access to this artery, and is that which I should myself follow if I were called upon to secure the innominate for the cure of aneurism. The incision resembles, in outline, the shape of the letter 1_> the horizontal limb corresponding with the upper border of the clavicle and sternum, and the vertical with the inner margin of the sterno-cleido-mastoid muscle, each being about three inches in length. The lower incision extends as far in- wards as the centre of the trachea. The triangular flap thus mapped off, embracing the skin and platysma-myoid, being dissected up, the sterno- cleido-mastoid, sterno-hyoid, and sterno-thyroid muscles are respectively separated upon a director frora their inferior connections and turned out of the way. A layer of the deep cervical fascia is now cautiously pinched up and divided, when, by a little scratching with the finger-nail, the handle of the scalpel, or the end of a probe, the carotid will be brought into view a few lines above the top of the sternum, accompanied by the jugular vein and pneumogastric nerve. Taking this vessel as his guide, the surgeon can easily trace the course of the innominate downwards towards the heart, and isolate it frora its associate vein. The ligature, when the case admits of it, should be applied about the middle of the vessel, the needle being carried around it from left to right and from behind forwards. In performing this operation, it should be remembered that this artery is only about sixteen lines in length; that it rests upon the trachea, which it crosses somewhat obliquely at the base of the neck; that the middle thyroid veins, and sometimes the middle thyroid artery, run along its inner side; LIGATION OF THE COMMON CAROTID. 803 and that on the right side, and on a plane anterior to it, is the innominate vein, the two vessels being intimately united together by cellular substance, and in close relation behind with the pneumogastric and phrenic nerves, the latter lying external to the former. The top of the pleura is a little inferior and external to the artery, and might, unless great caution is used, be easily wounded. The middle thyroid artery is sometimes given off by the innomi- nate on its tracheal aspect, and should be looked for in isolating the vessel, as its division might be followed by annoying hemorrhage. LIGATION OF THE COMMON CAROTID. To Mr. Abernethy is usually, but erroneously, ascribed the merit of having first tied the common carotid. From some remarks of Hebenstreit, it ap- pears pretty certain that the operation had been performed some time pre- viously by a surgeon during the extirpation of a scirrhous tumor of the neck, in which he accidentally divided this vessel, and immediately surrounded it with a ligature, the patient soon recovering. The English surgeon did not ligate the artery until 1798; the case was one of wound of the internal carotid, and the man died in thirty hours. The first operation that was per- formed upon it for carotid aneurism was by Sir Astley Cooper, in 1805, and was unsuccessful, the case terminating fatally on the nineteenth day. Three years subsequently, he ligated the vessel again, and now with a happy result. There are two points of the neck at which the comraon carotid may be tied, the place of election being regulated by the circumstances of the particular case. These are the upper and inferior cervical regions, and it will be well, in every instance before the operation is begun, to recall to mind the more important anatomical relations of the parts, otherwise serious blunders may arise, such, for example, as tying the omo-hyoid muscle or jugular vein instead of the artery, or including along with the artery the vessel just named, or some important nerve, as the pneumogastric, sympathetic, or laryngeal. As the artery proceeds upwards, it is overlapped by the sterno-mastoid, sterno-hyoid, and sterno-thyroid muscles, and crossed by the omo-hyoid towards its superior extremity. Running down in front of its sheath is the descending branch of the ninth pair of nerves, a little, thread-like filament, easily recognized by its whitish appearance, while within the sheath are, on the external side of the artery, the internal jugular vein, and behind and be- tween them the pneumogastric nerve, the sympathetic and recurrent nerves being posterior to the sheath. These relations are very intimate, and hence the most cautious procedure is necessary in isolating the parts previously to the application of the ligature. The embarrassment is often immensely increased by the manner in which the artery is overlapped by the jugular vein, which occasionally, though less frequently than is generally supposed, swells out enormously during every effort at expiration, so as to obscure the vessel and render its ligation extremely difficult. The best way of remedying this is to request an assistant to compress the vein both at the upper and lower angle of the wound, the blood having been previously pressed out of it. The common carotid, on the right side, is sometimes absent, its place being supplied by two trunks, which, arising separately from the arch of the aorta, ascend along the neck, assuming the office of the external and internal carotid. When this arrangement exists, which, however, is extremely rare, the order of origin of the branches of the aorta is as follows: the right subclavian, right external carotid, right internal carotid, left common carotid, and left subclavian. It should also be borne in mind that the common carotid may, on the one hand, bifurcate very low down, not perhaps reaching as high up as the inferior border of the thyroid cartilage, and, on the other hand, it may not separate into its terminal divisions until it gets to the angle of the jaw. 804 DISEASES AND INJURIES OF THE ARTERIES. Lastly, it raay be crossed in front by the inferior thyroid artery, lie upon the vertebral artery as this vessel passes along the spine, and include in its sheath the descending branch of the ninth pair of nerves. In ligating the carotid, the patient should be recumbent, with the head inclined to the opposite side, and well supported by pillows, the shoulders being at the same time somewhat raised, in order to place the neck in a proper horizontal position. If he do not desire to take chloroform, he may sit on a chair, the head resting against the breast of an assistant. In the lower part of the neck the artery may be exposed by making an incision, from two and a half to three inches in length, along the inner border of the sterno-cleido-mastoid muscle, commencing just above the clavicle. The skin and platysma-myoid muscle being divided, a portion of the cervical fascia is pinched up with the forceps, and opened transversely to an extent large enough to admit a grooved director, upon which the membrane is then slit up and down nearly to the length of the outer incision. Two retractors are now inserted into the wound, one being used to draw the sterno-cleido- mastoid muscle outward, and the other to draw the sterno-thyroid inwards towards the trachea. The sheath of the artery being thus exposed, a little piece of it is now raised with the forceps, and divided horizontally, when, the director being introduced, it is slit open so as to denude the artery to a small extent, and enable the operator to isolate it from the jugular vein and the pneumogastric nerve, the ligature being passed from without inwards. Gene- rally a small subcutaneous vein will be found passing along the line of inci- sion, communicating above with the facial vein, and below with the thyroid plexus. This must, of course, be carefully avoided. The artery being more easy of access in the superior part of the neck than the inferior, this point should always be selected, when this is in our power, for ligating it. To expose the vessel in this situation, an incision should be carried along the inner margin of the sterno-cleido-mastoid muscle, com- mencing a little below the cricoid cartilage, and reaching nearly as high up as the angle of the jaw. Embracing the integuments, platysma-myoid mus- cle, and cervical fascia, it will thus conduct the operator at once down to the sheath of the vessel, which is Fig. 260. then to be opened in the same cautious manner as in the pre- vious case; and the artery be- ing separated gently from the accompanying structures is li- gated by passing the needle round it from without inwards, so as effectually to exclude the jugular vein. The omo-hyoid muscle which crosses this part of the carotid must be held aside with a hook. The annexed cut, fig. 260, represents the common carotid as being exposed by a long in- cision, with a view of showing where it is crossed by the omo- hyoid muscle. When access to the common carotid, in the inferior part of the neck, is rendered diffi- Ligation of the common carotid. Cult On aCCOUnt of the low LIGATION OF THE COMMON CAROTID. 805 situation of the tumor, the best plan is to divide the sterno-hyoid and sterno- thyroid muscles, either alone, or jointly with the inner portion of the sterno- mastoid, so as to enlarge the space between the aneurism and the sternum. By observing this precaution, Mr. Porter, of Dublin, was enabled, in one case, to ligate the vessel successfully within the eighth of an inch of the innominate; and examples of a similar character have occurred in the practice of other surgeons. The carotid is sometimes tied at a very early age. I recollect a case in which I assisted Dr. McClellan, where that excellent and brilliant operator secured this vessel in a child only five months old, on account of an immense nevus of the upper part of the face. I remember, also, that the descending branch of the ninth pair of nerves was divided on the occasion, as it inter- fered with the passage of the ligature. No untoward symptoms of any kind occurred; the tumor diminished somewhat after the operation, but in less than a month it was larger than ever. Ligation of the common carotid is occasionally required on account of wounds of the neck involving the external carotid or some of its branches. The operation is often embarrassing in consequence of the confused condition of the parts from the extravasation of blood, and is, moreover, not always successful, owing to the establishment of a return current through the internal carotid into the external carotid. Hence secondary hemorrhage, sometimes of a very profuse character, is liable to ensue, necessitating further proceed- ing, and that, perhaps, at a time when the wound is in a high state of in- flammation. In order to avoid all this, Dr. Gurdon Buck has proposed the simultaneous ligation of the common and internal carotid arteries, and, in the New York Medical Times for November, 1855, he has given the particulars of a case in which the operation was followed by the most gratifying results. The common carotid artery has been repeatedly secured for wounds, epi- lepsy, and erectile and other tumors, as well as for the purpose of restraining hemorrhage in operations upon and about the jaw, face, and neck. The statistics of these operations present points of much interest, and they have been placed in a very clear light by the tables of Dr. Norris. In 30 cases in which the artery was tied on account of wounds, 15 recovered, and 15 died; in 16 cases in which it was ligated previously to, or at the time of the extirpation of tumors of the jaw, face, or neck, 8 died; in 6 in which it was tied for the cure of epilepsy, all recovered from the effects of the deligation, although in 2 both vessels were secured; and in 42 cases in which it was tied for the cure of erectile tumors and various growths of the diploe, orbit, neck, jaw, and maxillary sinus, 20 were cured, 13 died, and 9 recovered from the effects of the operation without being materially benefited. In upwards of 20 of the 94 cases, more or less severe cerebral symptoms followed the ope- ration. Dr. James R. Wood, in 1857, published the details of 39 cases in which the primitive carotid was secured by different surgeons of the city of New York for various affections, as secondary hemorrhage, malignant growths, benign tumors, epilepsy, and aneurism of the branches of the carotid, with a loss of only six. Of these six cases, only five were dissected. The cause of death in two was found to be softening of the brain, in one inflammation of the jugular vein, in one pericarditis with abscess in the lung and liver, and in one exhaustion. A number of cases have been reported in which both these vessels have been tied, either simultaneously or after a variable interval. The following table affords a summary view of nearly all the examples of this kind that have yet occurred. S06 DISEASES AND INJURIES OF THE ARTERIES. o • ■ . Inter- Operator. a to S Disease. ft < 02 val. Result. 1 Remarks. Macgill 1823 ~ F. Tumors of Im- Vision destroyed before operation, and ~ both orbits proved eyes presenting a mass of disease. Mussey 1827 < M. Anastomo- 12 days Failed Pulsation returned in tumor, which was tic aneurism excised three weeks after second ope- of scalp ration. Mussey 28 Ditto 28 days Re-covered Miiller 1831 4J Erectile tu- 4} mo. Re- ! mor covered Preston 1831 51 M. Epilepsy 84 days Failed Fits had existed for six years, and had latterly been attended with palsy on one side. Preston Epilepsy 1 mo. Failed Convulsions the day after each opera-tion. No material relief. Kuhl 1834 53 M. Aneurism of 72 days The second operation was performed the occiput during a profuse hemorrhage of the scalp. The first operation was fol-lowed by syncope and convulsions. Mott Disease of parotid 15 min. Died in 48 hrs. Mott Malignant polypi Several months Reco-vered ? Ellis 1844 Secondary hemorrhage 4£ days Re-covered J. M. War- 1845 23 Erectile 33 days Failed Tumor occupied the mouth, face, and ren tumor neck. Subsequent excision of the diseased structures, followed by cure. Hamilton 18 Epilepsy 6 mo. Re-covered Robert F. Aneurism 8 mo. Re-covered Blackman M. Disease of antrum 21 days Re-covered W. Parker 1854 42 M. Malignant disease of nose & orbit 32 days Died G. C.E.We- 1857 20 M. Epilepsy 17 days Im- Disease had existed five years ; had no ber proved but not cured attack for seven days after first ope-ration. No cerebral disturbance after either operation. Of the above cases, 16 in number, 14 recovered from the effects of the operation, and 2 died. In Dr. Mott's case, where both vessels were tied almost simultaneously, coma soon supervened, and the man died in forty-eight hours. In the case of Dr. Ellis, of Michigan, the second deligation was per- formed at an interval of four days and a half, on account of secondary he- morrhage consequent upon a gunshot wound, and no unpleasant symptoms followed, the patient making an excellent recovery. In Dr. Mussey's case twelve days intervened between the two operations, neither of which was suc- ceeded by any accident. To Dr. Macgill, of Maryland, belongs the credit of being the first to tie both carotid arteries on the same subject. LIGATION OF THE EXTERNAL CAROTID AND ITS BRANCHES. The external carotid, extending from the superior border of the thyroid cartilage to the neck of the lower jaw, is situated just above its origin, in the triangular space formed by the omo-hyoid muscle below, the digastric above, and the sterno-mastoid externally, immediately beneath the integuments and platysma-myoid; but it soon sinks deeper in, passing up under cover of the stylo-hyoid and digastric muscles, and is finally buried in the substance of the parotid gland. It is accompanied by two veins, and is crossed near its commencement by the hypoglossal nerve," and, in various parts of its course, by branches of the external jugular and other veins. The glosso-pharyngeal LIGATION OF EXTERNAL CAROTID AND ITS BRANCHES. 807 nerve is interposed between this artery and the internal carotid, while the superior laryngeal nerve lies under both. Deligation of the external carotid is seldom required for anything else than wounds and vascular growths about the face and head. The vessel is often opened in attempts at suicide, though less frequently than is generally imagine*; for persons intent upon self-destruction usually bend the neck so far back as to place the artery beyond the reach of the knife. Some of its branches are, however, comraonly injured under such circumstances, especially the superior thyroid and lingual, and the hemorrhage thus produced may be promptly fatal. A ligature may be readily placed round the external caro- tid, in the first part of its course, by carrying an incision, about two inches and a half in length, along the inner edge of the sterno-mastoid muscle, com- mencing opposite the middle of the thyroid cartilage, and terminating at the angle of the jaw. The trunk of the common carotid will guide the finger to its external division. The incision should be made with great care, lest vio- lence be done to some of the numerous offsets of the vessel. The artery, as it lies beneath the digastric and stylo-hyoid, is exposed with difficulty; the incision must be proportionably large, and the muscles just mentioned must be well depressed with the retractor. The principal branches of this artery, requiring surgical consideration, are the superior thyroid, lingual, facial, occipital, and temporal. The superior thyroid artery is, as already stated, much exposed to injury in attempts at suicide, and may, under such circumstances, be easily traced simply by following the wound. If it becomes necessary to ligate it, as is sometimes the case in hypertrophy of the thyroid gland, with a view to dimi- nish the supply of blood, it may be laid bare by making an incision across the upper part of the neck, obliquely downwards and outwards from the side of the hyoid bone to the edge of the sterno-mastoid muscle. The lingual artery may be exposed in the same manner as the thyroid, near which it takes its origin; its situation, however, is very deep, and its rela- tions are so complicated that it is generally better to secure the external or common carotid. If the operation should be deemed necessary, it may be performed as fol- lows, according to the plan laid down by Mr. Skey. " The head of the patient being placed horizontally, and the neck length- ened by raising the chin, an incision of about twelve lines in length should be made immediately behind the cor- ner of this bone, the outline of which should be distinctly ascertained be- fore proceeding to the operation: the incision should be directed down- wards and forwards. The skin and platysma being divided, the fascia is exposed, which should be also di- vided to the length of the external wound. The facial vein, often of considerable size, may be brought into view at the upper part of the wound, in its course downwards to the internal jugular, and should be drawn outwards. The remaining parts should be torn, rather than cut asunder, passing transversely in- wards, nearly parallel to the upper edge of the cornu of the os hyoides, when the artery will be exposed. In Fig. 261. Ligation of the lingual artery. 808 DISEASES AND INJURIES OF THE ARTERIES. passing the needle behind it, care must be taken to avoid the superior laryngeal nerve, which descends nearly at right angles behind the artery." The facial artery is frequently concerned in operations about the neck, face, and lips, and may be easily compressed with the finger as it passes over the jaw. If divided, it should immedi- ately be secured. When its ligation be- comes necessary, in case there is no wound, its pulsation will point out the proper situation for the incision. When it is de- sired to secure it just above its origin, the incision should be made as in the opera- tion upon the lingual, its approach being facilitated by drawing the digastric strong- ly upwards. The vessel is most easily exposed and tied where it lies over the jaw, as in fig. 262. The occipital artery sometiraes requires ligating on account of wounds, but its depth in the lower part of its extent is such as to protect it generally frora injury involving the cervical region. On the back of the head, however, it is not unfre- quently laid open, and usually bleeds very freely. It may be exposed just above its origin by carrying an incision along the inner border of the sterno-mastoid muscle, in the angle formed by it and the digastric, the latter of which must be well drawn down. It is in intimate relation here with the hypoglossal nerve, which hooks round it as it passes forwards towards its destination. The artery, after emerging from the sple- nius muscle, on the back of the head, fig. 263, is superficial, its course be- neath the scalp being denoted by its pulsation. \W Ligation of the facial artery. Fig. 263. Fig. 264. Ligation of the occipital artery. Ligation of the temporal artery. The temporal artery is occasionally wounded, and may be secured immedi- ately above the zygoma, by a short vertical incision, fig. 264, embracing the temporal aponeurosis, immediately beneath which it is situated. Lower down, the depth at which it lies is too great to justify an attempt at ligation. Should it be divided in this portion of its extent, the best plan is to tie the external carotid. The anterior branch of this vessel is the one always selected in arterio- tomy, when it is wished to practise depletion on account of affections of the LIGATION OF THE SUBCLAVIAN ARTERY. 809 brain or the brain and its membranes. After a sufficient amount of blood has escaped, the artery is cut across, and a graduated compress applied. If this precaution be neglected, a false aneurism will form. The internal maxillary artery is sometimes wounded in consequence of a thrust with a sharp knife or dirk. The necessary result, of course, is a co- pious hemorrhage, for the arrest of which the only remedy is ligation of the external carotid; compression, it is true, now and then succeeds, but the only reliable means is the ligature. When the vessel is wounded in the ex- tirpation of the jaw, it may sometiraes be seized and tied; when this is im- practicable, the bleeding may generally be stopped with the hot iron, or with the tampon, wet with a saturated solution of alum and tannin, or covered with persulphate of iron. LIGATION OF THE VERTEBRAL ARTERY. The vertebral artery is the largest branch of the subclavian, and, of course, bleeds profusely when divided, as it occasionally is in wounds of the neck. Taking the opening as the guide, the vessel should be traced to the seat of injury, and a ligature applied to each extremity. The dissection necessary for its exposure should be conducted with the greatest caution, on account of the important and complex relations which the vertebral sustains to the surrounding parts. LIGATION OF THE SUBCLAVIAN ARTERY. The point which is usually selected for tyiug the subclavian artery is just external to the scalene muscle, in what is considered as the third course of the vessel. One single incision will generally be found to be sufficient for the free exposure of the artery, and this may be strictly horizontal or more or less curvilinear, according to the fancy of the operator. It is only when the tumor is so bulky as to cause great malposition of the shoulder, forcing the collar-bone high up into the neck, that two incisions can really be re- quired, the one extending along the upper border of the clavicle and the other vertically upwards, parallel with the outer edge of the sterno-cleido- mastoid muscle. Previously to commencing the ope- ration, the patient should be placed in the horizontal position upon a narrow table, with his head and chest moder- ately elevated, and the face slightly inclined towards the sound side. An assistant taking hold of the hand, keeps the affected limb close to the trunk, at the same time that he pulls down the shoulder as much as possi- ble, in order to draw the clavicle away, as it were, from the subclavian artery as it passes from the scalene muscle towards the first rib. The surgeon, standing by the side of the patient, above the shoulder, stretches the integuments of the neck upon the upper part of the chest with the fingers of the left hand, while with the other he makes an incision, about two inches and a half in length, di- Fig. 265. Ligation of the subclavian artery, in its outer third. 810 DISEASES AND INJURIES OF THE ARTERIES. rectly along the middle of the clavicle, commencing at the sternal origin of the mastoid muscle and terminating near the anterior margin of the trapezius. In this manner he divides the skin, the superficial fascia, and the platysma-myoid. Letting go his hold with his left hand, the parts will be found instantly to resume their natural situation, leaving thus the incision on a level with the superior border of the clavicle. The next step of the opera- tion consists in detaching from this bone the deep cervical fascia, or rather aponeurosis, which may readily be accomplished by a few gentle strokes of the handle of the scalpel instead of the point of the instrument, which would greatly endanger the surrounding vessels and nerves. The external jugular vein will be found close to the outer edge of the mastoid muscle, and should be held out of the way with a blunt hook. The supra-scapular artery will also generally appear, at this stage of the proceeding, just above and behind^, the clavicle, or partially covered by it, and should be treated in a similar manner; or, if it be divided, it should immediately be tied. The omo-hyoid lies at the outside of the incision, bound down by a process of the cervical aponeurosis, which should next be torn through with the knife. Taking the anterior scalene muscle for his guide, the operator feels for the tubercle of the first rib, a little to the outside of which the artery will be found pulsat- ing, more or less distinctly, and where it may in general be easily secured by passing the needle from before backwards and from below upwards. Before tightening the ligature, it should be ascertained that it controls the circula- tion of the aneurismal sac, and, above all, that it does not include any of the cords of the axillary plexus of nerves, a circumstance which has happened in several of the cases in which this.operation has been performed. It should be stated that whenever the clavicular origin of the mastoid muscle is unusu- ally broad, as it not unfrequently is, it should be divided upon a grooved di- rector. By pursuing this course, I am convinced that our approach to the vessel will, in the majority of cases, be greatly facilitated. Particularly will this be the case when the design is to apply the ligature behind the scalene muscle. In this manner, the subclavian may, in the generality of cases, be easily reached without much waste of blood or loss of time. In some instances, however, the operation is rendered extremely difficult, tedious, and embar- rassing, owing either to the magnitude of the tumor and the consequent ele- vation of the clavicle, the diseased state of the artery, an unusual course of the vessels of the neck, or, even when these follow their natural direction, the swollen and distended condition of the subclavian vein, some irregularity on the part of the omo-hyoid, an enlarged condition of the cervical lympha- tic ganglions, or, finally, the great condensation of the parts from the effusion of plastic lymph. A few remarks on each of these topics must suffice. 1. The elevation of the clavicle is generally in direct proportion to the size of the tumor. Sometimes, however, even when the swelling is comparatively diminutive, this bone is situated much higher up than usual, owing to the peculiar conformation of the individual. In either case, the difficulty of finding the vessel will be much increased. In one instance, where the eleva- tion was produced by the enormous development of the disease, Sir Astley Cooper was forced to abandon the operation altogether. When such a con- tingency arises, which, on the whole, must be extremely rare, instead of giv- ing up the case in despair, as was done by the English surgeon, the best plan, it seems to me, would be to divide the anterior scalene muscle, so as to en- able us to apply the ligature somewhat nearer the heart, or even on the tracheal side of that muscle. 2. The operation is occasionally rendered more or less intricate and embar- rassing by the diseased state of the artery. In this case, although the vessel may be easily enough approached, it is impossible to apply the ligature at LIGATION OF THE SUBCLAVIAN ARTERY. 811 the usual situation. To divide the scalene muscle, or to cut down along its inner margin, for the purpose of securing the vessel at one or other of these points, is here our only resource. The brachial plexus of nerves may also be so much in the way of the operator as to render this course necessary, as happened on one occasion to Dupuytren. 3. The cervical vessels, both arterial and venous, are almost constantly in the way of the operator, even when they follow their usual route. This is particularly true of the external jugular vein and of the supra-scapular artery. The former of these vessels, commencing at the angle of the jaw, passes ver- tically down the neck under cover of the platysma-myoid. In the early stage of its course, it rests upon the sterno-mastoid ; afterwards it gets to the outer border of this muscle, and finally, at the inferior part of the neck, sinks behind it, to terminate in the subclavian vein near its junction with the internal jugular. Just before it disembogues, which it soraetimes does by several dis- tinct trunks, it receives two pretty large branches, the supra-scapular and transverse cervical, which traverse the neck in a horizontal direction from without inwards, parallel with the arteries of that name. These arteries, as well as their accompanying veins, lie deeply at the root of the neck, espe- cially the supra-scapular, which is frequently concealed for some distance by the clavicle, on a line with which it runs to reach the root of the coracoid process; it is generally a branch of the thyroid axis, and rests at first upon the anterior scalene muscle, crossing as it passes outwards the subclavian artery. The course of the transverse cervical artery is nearly similar, but it is usually situated somewhat higher up; it is also considerably smaller, and is most frequently derived immediately from the subclavian. Now, in attempting to reach the subclavian, it is almost impossible to avoid wounding some of the vessels above mentioned. The external jugular vein is particularly in danger, and can scarcely escape without the utmost coolness and dexterity on the part of the operator. As soon as it is recognized it should be separated from the surrounding structures by a few gentle strokes with the handle of the scalpel, and drawn to the outer side of the wound. This plan is undoubtedly always the best and safest when it can be adopted; however, it sometimes happens that the vessel is so much in our way as not only greatly to embarrass our progress, but absolutely put a stop to it. In this case, it must be cut across, or, what is preferable, tied with two fine ligatures, and divided between them. By pursuing this method, we not only avoid a troublesome hemorrhage, but effectually prevent the introduction of air into the lower portion of the vessel, an occurrence which should always be guarded against. The supra-scapular artery, if in the way, should be carefully drawn aside, or, if it be wounded, immediately secured. Any bleeding vessels, indeed, no matter whether arterial or venous, provided they pour out a sufficient amount of blood to interfere with the operation, should at once be tied, though no more ligatures should be retained than are abso- lutely necessary. 4. The inordinate swelling of the subclavian vein is another source of em- barrassment which is occasionally experienced in operations of this kind. This vessel is usually situated somewhat below and superficially to the artery, being separated from it by the anterior scalene muscle, upon which it lies. Commencing at the inferior margin of the first rib, where it is continuous with the axillary, it passes horizontally inwards until it joins the internal jugular vein, within a few lines of the sterno-clavicular articulation. In this course, in which it is almost entirely concealed by the clavicle, it receives the small branches which accompany the different offsets of the artery as well as the external jugular, which last enters it, as before stated, nearly opposite the centre of the bone, but sometimes more internally. After the division of the cervical aponeurosis in the lower part of the neck, the operator will occa- 812 DISEASES AND INJURIES OF THE ARTERIES. sionally observe this vessel alternately to swell and subside, owing not so much, as some have supposed, to the natural flow of the current within it as to the reflux caused by the action of the right auricle, aided by the hurried and agitated state of the respiratory movements. The difficulty thus occa- sioned is not only annoying, but sometimes so embarrassing as to render it almost impossible even to see the artery, much less to separate and tie it. To remedy this, it has been suggested that the operation should be suspended for a moment, and the patient placed in the semi-erect posture to allow him to make several full and easy inspirations, after which, it is said, the tension of the vein will be diminished, and the regurgitation of the blood cease. The surest and most expeditious plan, however, is to hold the vessel out of the way by means of a broad blunt hook, or copper spatula, carried down behind the clavicle. In this manner the vein may be effectually compressed to the extent of half an inch, or more, if necessary, and the artery fairly brought into view. 5. The omo-hyoid muscle, instead of forming a triangular space, as it usu- ally does, with the scalene muscle and the clavicle, may run parallel with, and just above, that bone, or even entirely below it. In either case, should it be productive of inconvenience to the operator, he should pass a director under and divide it. Such a proceeding, however, can seldom be called for, as, by laying open its sheath, the muscle may generally be drawn out of our reach. 6. The lymphatic ganglions, at the inferior part of the neck, raay be so much enlarged as to interfere seriously with the different stages of the opera- tion. When this is found to be the case, instead of trying to save these bodies, they should be carefully dissected out, as we shall thus not only expe- dite our arrival at the artery, but, what is a matter of no little importance, greatly facilitate the healing of the parts after the vessel is tied. 7. Finally, considerable embarrassment may arise from the condensed and indurated state of the parts, caused by the effusion of plastic lymph. This may always be looked for when the disease is of long standing, or when the tumor is so large as to excite severe inflammation in the deep-seated struc- tures immediately above the clavicle, thereby obscuring the nerves and vessels. If, from the above causes, it be sometimes difficult to denude the artery, to convey a ligature around it will often be found to be much more so. Indeed, this generally constitutes the most annoying and embarrassing step of the operation. To facilitate this procedure, various mechanical contrivances have been resorted to, some of them so complicated in their character as to be well calculated to enhance instead of diminishing the difficulty. Under ordinary circumstances, every indication may be fulfilled with the common aneurismal-needle, or even with a common eyed-probe. Whatever mecha- nical contrivance be employed, the ligature, as a general rule, should be passed from before backwards and from below upwards, as it will be found much easier in this way to prevent injury to the subclavian vein, while there will be no danger whatever of including any of the cords of the brachial plexus of nerves. Owing to the great depth of the wound, not a little diffi- culty is sometimes experienced in tightening the knot. In this case the ingenious instrument invented by Dr. Hosack, of New York, will be found very useful. By holding the first knot firm it enables the surgeon to tie a second or third with the utmost facility. Notwithstanding the assistance to be derived from the different instruments that have been invented for that purpose, such has been the difficulty, in some instances, of conveying the ligature around the artery as to lead not only to great delay, but almost to an abandonment of the operation. It has been suggested, under these circumstances, to saw through the clavicle, and to this proposal I can see no objection, provided the shoulder is so much elevated as to offer an almost insurmountable barrier to the passage of the LIGATION OF THE AXILLARY. 813 ligature. By this practice, although a compound fracture of the clavicle would be superadded, yet this would be of the most simple kind, while the operation, instead of occupying from one to two hours, as has repeatedly happened heretofore, could be completed in a comparatively short time; the vessel could be much more effectually secured, the risk of wounding the sub- clavian vein and other parts would be greatly diminished, and the patient would have a much better chance for recovery. The arteries which are more particularly concerned in maintaining the collateral circulation after the ligation of this vessel, are the supra-scapular, transverse cervical, internal mammary, long thoracic, circumflex, and sub- scapular, the first three being branches of the subclavian, the other three of the axillary. The thoracic artery frequently arises from the aneurismal sac, and is therefore liable to be obliterated for some distance in the progress of the disease. The subclavian artery has been tied several times in the second course of its extent, but the procedure is very difficult, as well as replete with danger, owing to the proximity of numerous important structures, especially the phrenic nerve, jugular vein, pleura, and thyroid axis. The external incisions are similar to those employed for exposing the artery in the other parts of its extent; as soon as the anterior scalene muscle is fully brought into view, a grooved director is carried behind it, and its lower attachment carefully severed from the clavicle, the phrenic nerve having previously been placed beyond the reach of the knife. The top of the pleura, lying close by, must not be wounded in passing the needle. It will thus be perceived that the operation is one of excessive delicacy, requiring consummate anatomical knowledge and skill for its successful execution. The greatest objection, however, to its performance is that the subclavian is obliged to be tied so close to the superior intercostal and deep cervical branches; a circumstance which must necessarily materially interfere with, if not wholly prevent, the formation of a firm and adherent clot. The subclavian is occasionally tied for wounds of the axillary artery. In the table of Dr. Norris, comprising 69 cases of operations upon this vessel, 9 were performed for this purpose, and of these, 6 proved fatal. Mr. Guthrie, in his Treatise on the Diseases and Injuries of the Arteries, refers to 22 cases in which the subclavian was ligated for a similar object, 11 times above the clavicle, and 11 times below. Of the former cases, 9 recovered, and 2 died; death in one being caused by the bursting of an internal aneurism, and in the other, by gangrene after amputation at the shoulder-joint. Of the 11 cases in which the artery was tied below the clavicle, 6 recovered, and 5 perished, three frora gangrene'of the limb, one from exhaustion, and one from hemorrhage. LIGATION OF THE AXILLARY. The axillary artery requires ligation chiefly on account of penetrating wounds, or its accidental laceration during the reduction of ancient disloca- tions. Of the latter occurrence, quite a number of cases have been reported by surgical writers. There are two regions where the vessel may be secured, either just below the clavicle, or in the hollow of the axilla. In the inter- mediate point, the vessel is so deeply situated, and in such intricate relations, as to render its approach a task of much difficulty. The artery in the first of these regions is very deep seated, and hence it has been advised, instead of tying it, to ligate the subclavian in the third stage of its course. Cases, however, occur, in which it is desirable to secure it soon after its origin, and this can generally be done without any difficulty, pro- vided the surgeon is sufficiently cool and deliberate, and has a thorough knowledge of the anatomy of the parts. The patient being placed in a half- 814 DISEASES AND INJURIES OF THE ARTERIES. sitting posture, with the arm slightly abducted, an incision is carried along the inferior border of the clavicle, through the skin and platysma-myoid, com- mencing one inch from the sternura, and extending to within a short distance of the deltoid muscle, care being taken to avoid the cephalic vein, as it lies in the groove between the latter and the great pectoral. The next step con- sists in dividing the fibres of the great pectoral to the full extent of the ex- ternal wound. The small pectoral is now seen at the lower portion of the wound, and should be relaxed by bringing the arm close to the trunk. A retractor being inserted, and the divided structures well depressed, the artery will be found at a short distance below the clavicle invested by a dense fascia, which must be carefully scraped through before the vessel can be fairly ex- posed to view. The accompanying vein, which often swells suddenly out during expiration, lies below and in front of it, while the brachial plexus is behind, except one of its branches, which is above and in contact with it. The anterior thoracic artery, one of the offsets of the axillary, is also on its anterior surface. The needle is passed from within outwards, in order to exclude the vein. As difficulty is sometimes experienced in distinguishing the artery frora the cords of the axillary plexus of nerves, it will be well, be- fore tightening the thread, to ascertain what effect its application has upon the pulse at the wrist, Fig. 266. or in the aneurismal sac. The costo-coracoid liga- ment sometiraes requires division in this operation. To expose the artery in its inferior section, fig. 266, the arm should be abducted and supinated, and an incision, nearly three inches in length, made through the axilla, close to the border of the broad dorsal muscle. The cellular and aponeurotic structures being next di- vided, the median nerve Ligation of the axillary, in its inferior division. and axillary Vein will be brought into view, the two roots of the former embracing the artery on each side, and the latter run- ning along its anterior surface. Cautiously separating these parts with the finger, or the forceps and director, and turning them in opposite directions, the artery is exposed, and tied by passing the ligature from within outwards. LIGATION OF THE BRACHIAL. The brachial artery, in consequence of wounds and various kinds of trau- matic aneurisms, requires to be ligated more frequently than any other artery in the body. Extending from the lower border of the axilla, on a level with the tendon of the teres muscle, to nearly one inch below the bend of the elbow, it is overlapped above by the coraco-brachial muscle, and in the mid- dle by the two-headed flexor, while inferiorly it is completely covered by a reflexion of the brachial aponeurosis. Its whole course, however, is com- paratively superficial, so that it is easy to feel its pulsations in the greater portion of its extent. In attempting to secure the artery high up, near its origin, an incision, two inches and a half in length, should be made along LIGATION OF THE BRACHIAL. 815 the inner margin of the coraco-brachial muscle, the arm being extended and supinated. The artery, accom- panied by its two veins, will be Fig. 267. found lying here between the me- dian and ulnar nerves, the former being on its outer side, and the latter on the inner. If the artery be sought for at the middle of the arm, the best guide to its seat will be the internal edge of the two- headed flexor muscle. The median nerve, in this part of the course of the artery, usually lies on the inside aud in front of the vessel. At the bend of the arm, the brachial is readily exposed by dividing the brachial aponeurosis in a line with the ulnar border of the tendon of the two-headed flexor muscle. In none of these operations is it neces- sary to divide any muscular fibres. Schemes for tying the brachial, radial, and ulnar arteries, are de- picted in fig. 267. In operating upon the brachial artery, it should be borne in mind that this vessel is subject to certain varieties, which may serve both to perplex the surgeon, and mar the result of the undertaking. The most frequent of these anomalies is the high division of the artery into the radial and ulnar, which, on reaching the elbow, either pursue their usual course, or, as is more generally the case, the former pro- ceeds superficially down the forearm, while the latter becomes deep seated ; or their course may be reversed, the radial following its ordinary route while the ulnar descends immediately under the skin. Several instances have been Fig. 268. Ligation of the brachial, radial, and ulnar arteries; also of the palmar vessels. Double brachial artery. met with in which the brachial divided high up into two branches, which sub- sequently united again into a single trunk, as in fig. 268, which afterwards bifurcated regularly into the radial and ulnar. 816 DISEASES AND INJURIES OF THE ARTERIES. LIGATION OF THE RADIAL AND ULNAR. The radial artery, whose course along the forearm is indicated by a line drawn from the middle of the bend of the elbow to the forepart of the styloid process of the radius, may be tied near its origin, at its middle, and at its inferior extremity. When the design is to ligate it above, or in the first of these situations, it may be approached by an incision, about three inches in length, parallel to the inner border of the long supinator muscle, between which and the round pronator the vessel will be found, accompanied by its two veins, the radial branch of the musculo-spiral nerve lying at its outer side and some distance from it. Care is taken not to wound the basilic vein. In the middle third of the forearm, the artery lies between the long supinator and flexor muscle of the carpus, the spiral nerve descending close along its radial border. In the inferior portion of its extent, the artery is compara- tively superficial; its pulsation is very distinct in the greater part of its length, and therefore serves as a ready guide to its course. The ulnar artery is sometimes divided in the upper part of its extent by a knife or ball, and in this event it may generally be easily found by taking the wound as our guide, enlarging it, if necessary, and tying the vessel at each extremity. When a false aneurism exists in this situation, it is usually re- commended to ligate the brachial, but I am satisfied that it would be more safe, in every instance, to tie the ulnar soon after its origin, by cutting boldly through the thick muscular mass at the upper third of the forearm, as we could thus effectually guard against hemorrhage from the recurrent circula- tion. In the middle of the limb the artery lies along the radial border of the ulnar flexor of the carpus, which should therefore be taken as a guide to the knife, and be carefully separated from the common flexor of the fingers. The ulnar nerve here lies on the inner side of the vessel. Near the wrist the artery is generally found with facility, its situation being indicated by its pulsation. LIGATION OF THE ABDOMINAL AORTA. Ligation of the abdominal aorta may be required on account of a wound, either of itself or of the common iliac, and in that event the best plan would probably be to enlarge the external opening to an extent sufficient to encircle the vessel with the thread. In ligating the vessel for aneurism, the patient should lie on his right side, and care should be taken to avoid injury to the peritoneum, which can be easily done by adopting the procedure of Dr. Murray, since followed by Monteiro and South, of making a curvilinear in- cision, with the convexity towards the vertebrae, from an inch above the anterior superior spinous process of the ilium to the cartilage of the tenth rib. It should be fully six inches in length, and should extend, in the first instance, merely through the common integuments. The various underlying structures should then be severally divided until the peritoneum is brought into view, which is cautiously peeled off from the iliac and psoas muscles with the hand a short distance beyond the contemplated point of ligation. The separation of the aorta from its accompanying vein on the right side, and the filaments of the sympathetic nerve in front, constitutes one of the greatest difficulties of the operation, but is generally best effected with a long director, slightly sharp at the extremity, and the nail of the index finger. The liga- ture should be passed round the artery frora left to right, and from behind forwards, about one inch above its bifurcation into the common iliacs. LIGATION OF THE COMMON ILIAC. 817 LIGATION OF THE COMMON ILIAC. The common iliac artery was first ligated by Dr. William Gibson, of this city, in 1812, in a case of gunshot wound, his patient surviving the operation thirteen days, death being caused by peritoneal inflammation and secondary hemorrhage. Subsequently to this, namely, in 1827, it was tied, for the first time under such circumstances, for aneurism of the external iliac, by Dr. Mott; the ligature came away on the nineteenth day, and in less than two months the man was entirely well, and is, I believe, still living. This artery has probably been secured altogether nearly forty times. The most extended and reliable statistics of the operation that have yet appeared are those of Dr. Stephen Smith, of New York, who has arranged his cases under four distinct heads, as they relate, first, to the arrest of hemorrhage ; secondly, to the cure of aneurism; thirdly, to the starvation of pulsating tumors; and lastly, to the ligation of the vessels, as a means of avoiding hemorrhage during the removal of morbid growths. Two of the tables of Dr. Smith are so interesting and instructive that I shall take the liberty of transcribing them. His paper will be found at length, in the American Journal of the Medical Sciences for July, 1860. Group I.—Eleven Cases of Ligation for the Arrest of Hemorrhage. 6 Operator. " sJ-S Disease or accident. Result. Date of death. Cause of death. % OQ -SJ ,OQ 1 Gibson M. 38 L- Gunshot wound of external iliac artery Died 15th day Hemorrhage 2 Liston M. 8 R- Hemorrhage after amputation of thigh:Died 24 hoursjExhaustion 3 Garviso ... Hemorrhage from bursting of aneu- Died 4 hours Exhaustion 4 Pirogoff M. | rism R. Hemorrhage after ligature of external 1 iliac Died 14th day Hemorrhage 5 Deguise M. 42 R. Hemorrhage after ligature of the ex-1 | | ternal iliac Cured 6 Post M. 20,L. Hemorrhage from an incision into an | aneurism Died 24 hours Exhaustion 7iUhde M. 26ili. Rupture of internal iliac in applying 1 | ligature Died 4th day Peritonitis 8: Edwards M. 27 R. Rupture of an aneurism of external | | iliac Died 25th day Hemorrhage 9 Holt M. 24 R. Hemorrhage from opening a gluteal | aneurism Died 3d day Exhaustion 10 Parker M. 20'R. Hemorrhage from a stab in the groin Died 10 hours Exhaustion lliBuck M. 40iL. Hemorrhage after ligature of external Died 17th day Hemorrhage iliac Of the above cases, 10 were fatal, and 1 recovered, being a mortality of nearly 91 per cent. The average period of death was eight days, the cause in 5 being immediate exhaustion, in 4 secondary hemorrhage, and in 1 peri- tonitis. vol. i.—52 818 DISEASES AND INJURIES OF THE ARTERIES. Group II.—Fifteen Cases of Ligation for the Cure of Aneurism. 6 Operator. H 6 to Seat of aneurism. Result. Date of death. Cause of death. £ OQ . \ 868 DISEASES OF THE BONES AND THEIR APPENDAGES. answers an excellent purpose, promptly arresting the excessive pain, and promoting the absorption of effused fluids. As soon as evident fluctuation exists, or even before, if there be inordinate tension and throbbing, a free incision should be made, extending, if possible, into the very depths of the bone, so as to admit of the most thorough drainage. To allow the matter to be pent up for days and even weeks, as often happens in the hands of timid practitioners, must always prove excessively injurious, from the tendency which the fluid, under such circumstances, has to burrow among the surround- ing structures, detaching them from each other, and leading, in the end, to the formation of numerous sinuses. Besides, the early evacuation of the matter greatly abridges the suffering, constitutional as well as local, and thus prepares the system better for the future struggle. I have never seen a case where the retention of pus, whether among the soft parts, in the osseous tissue, or within a joint, has been productive of benefit; it always acts as a foreign substance, maintaining local and constitutional irritation, and hence I never hesitate to get rid of it as promptly aud effectually as possible. These re- marks are applicable to caries both of the superficial and deep-seated pieces of the skeleton. When the matter is pent up in the interior of a bone, as, for instance, in the articular end of the femur or tibia, evacuation should be attempted with the trephine. The means now described are all merely of a palliative nature ; they relieve pain, swelling, and constitutional disturbance, but are entirely incapable of curing the disease, however slight. To fulfil this indication other remedies are necessary, and these may be arranged under two heads, those, namely, which are used with a view of modifying the affected tissues, so as to afford them an opportunity of regaining their normal characters, and those which are resorted to for effecting riddance of the diseased bone, either in part or in whole. Under the first of these heads are to be mentioned various detergent and acidulated preparations, as the solutions of the chlorides, creasote, nitrate of silver, and acetic, nitric, and hydrochloric acid, their strength varying with the age and constitution of the patient, and the state of the parts, the con- tact being effected by means of a large glass syringe, two operations being sufficient in the twenty-four hours. The chlorides are particularly service- able iu these cases on account of their cleansing and deodorant effects, while the acids act more directly upon the osseous tissue, stimulating the capillary and absorbent vessels, and thereby promoting a more healthy tone, at the same time that they produce disintegration of the earthy matter of the dis- eased bone. These remedies, aud all others of a kindred nature, are certainly not without some benefit in the milder and more accessible cases of caries, but they all have the disadvantage of being difficult of application, as well as uncertain in their results, and can rarely be relied upon for a cure. I have, therefore, of late years, entirely abandoned their use with this intention, and now employ them only with a view to their detergent and deodorant effect, preferring, of course, the chlorides to any of the other articles for this pur- pose. The actual cautery, formerly so much vaunted in the treatment of certain forms of caries, especially in that of the carpal and tarsal bones, is obnoxious to the same objections as the remedies just mentioned. In applying it, it is necessary not only to divest the affected bone pretty thoroughly of its soft parts, but to employ the greatest circumspection, otherwise a much larger amount of tissue may be destroyed than is desirable. Moreover, the eschar is always a long time in coming away, and the iron has generally to be used again and again before a cure is finally effected. Under the second head are included the operations necessary for scraping or cutting away the diseased structure, excising the affected bone, either in CARIES OR ULCERATION. 869 part or in whole, and amputnting the affected limb, when the case is unman- ageable by other means. As a general rule, all operative interference, having for its object the re- moval of the carious matter, is carefully abstained from until the disease has become strictly chronic, or, in some degree, ceased to spread. If this injunc- tion be disregarded, injury, and not benefit, will be certain to follow our efforts, the irritation excited by them giving new impetus to the morbid action. The precise time for interference cannot, of course, be specified, but it is evident that no attempt should be made to scrape or cut the bone so long as the superimposed parts are in a highly tender, tumid, and inflamed condition. The proper treatment, under such circumstances, consists in the use of leeches, medicated fomentations, and other antiphlogistic measures calculated to soothe the irritated structures, and preveut the spread of the disease. When the caries is of small extent, it may generally be got rid of by means of a burr-head drill, similar to that used by the dentist for removing caries from decayed teeth previously to plugging. With such an instrument, of which the adjoining sketch, fig. 288, affords a good idea, the whole of the dis- eased substance may often be cut away in a few minutes, with little pain to the patient, and no detriment whatever to the neighboring parts, which should always be turned aside immediately prior to the operation, care being taken in doing so not to interfere with any important structures. Every bone-case should have from three to six drills, of varying size and shape, so as to meet every contingency that may arise in practice. Several trephines, pliers, gouges, chisels, and scrapers, should also be at baud, and, when this is the Fig. 288. Fig. 289. Bone-drill. Scraper. case, it is difficult to conceive how any surgeon can fail in accomplishing his object. In operating upon the tarsal and carpal bones, I have generally derived material service from the use of a short, stout scalpel, with a semi- sharp convex extremity, and a large handle. Such an instrument is pecu- liarly advantageous in paring the surface of deep-seated cavities. When the ligaments and cartilages are involved, the operation can hardly be completed in a satisfactory manner without a pair of blunt-pointed scissors, with long, thick, narrow blades. The raspatory is useful in smoothing carious cavi- ties after the removal of the disorganized substance. During the operation the diseased cavity is kept free frora blood by means of sponge mops. When all the diseased structure has been removed, free use should be made of the syringe in order to effect thorough clearance of the affected cavity. Unless this be done, more or less of the bony matter will be left, thus keep- ing up irritation and discharge, and interfering with the reparative process. 870 DISEASES OF THE BONES AND THEIR APPENDAGES. Considerable hemorrhage often attends these operations, the blood some- times proceeding frora small arteries, but more generally from uumeroua points, as if it came from the pores of a sponge. In the former case, the ligature will usually be required, more particularly as the vessels are unable to retract on account of the indurated condition of the surrounding parts, while in the latter the temporary application of the sponge, wrung out of cold water, will commonly speedily arrest the flow. Should this, however, not answer the purpose, the bleeding cavity should be stuffed with lint, soaked in a strong solution of alum, or of persulphate of iron, the plug being retained no longer than may be absolutely necessary. Doubt is often experienced, in these operations, as to the amount of sub- stance to be removed, the precise line of demarcation between the sound and diseased structures not being always easy of determination. A good diag- nostic, under such circumstances, is to wash the fragments in water, when, if they be carious, they will exhibit a whitish, grayish, greenish, or blackish appearance; whereas, if they are healthy, they will be found to be vascular aud red, and to retain their normal consistence, presenting none of the fragile and porous characters which distinguish them in the former case. Bleeding having been arrested, the edges of the wound are loosely approxi- mated by suture, and the limb, placed in a favorable position for drainage, is wrapped up in a bandage, extending from the distal extremity upwards beyond the seat of operation. Water-dressing is afterwards used, either cold or warm, as the case raay seem to demand, and strict attention is given to antiphlogistics generally. Occasionally it is found requisite to insert a tent, to conduct off the matter, and prevent premature closure; and for some time the bony cavity should be injected twice or thrice daily with tepid water and Castile soap, or sorae gently detergent lotion. The great dangers after the operation are erysipelas and pyemia, which it is only necessary to mention in order to put the practitioner upon his guard respecting their occurrence. The healing process, after such an operation, exhibits itself by the develop- ment of granulations, which, under the microscope, display very much the same appearance as those of the soft Fig. 291. parts. The vessels, as shown in fig. 291, from a drawing made for me by Dr. Packard, have a remarkably looped and varicose arrangement. It was taken from an ulcerated patella, which was covered with an immense number of the most beautiful scarlet granula- tions, not as large as the smallest pin's head, closely grouped together, and ex- ceedingly tolerant of rude manipulation. The section was magnified sixty dia- meters. Excision of an entire bone is sorae- times necessary for the relief of this disease. Such a procedure is most fre- stmcture of a granulation in a bone. quently required on account of caries of the carpal and tarsal bones, upon which it may frequently be performed with great advantage, a useful limb being generally left even after the removal of several of these pieces. In the long bones, the operation is usually limited to the articular end, or to this and a portion of the shaft. Respecting the manner of executing this opera- tion, and the estimate to be placed upon it, in a curative point of view, special mention has been made in the chapter on excision, so that any further dis- cussion of the subject here will be unnecessary. NECROSIS OR MORTIFICATION. 871 When the disease is so extensive as to be uncontrollable by the means now described, and the attendant discharges are so copious as to give rise to pro- fuse night-sweats, marasmus, and colliquative diarrhoea, amputation of the limb, comprising the carious bone, will afford the only chance of safety, and should be performed without delay. It is surprising how the system usually rallies after such an operation. The patient, in the course of a few days, generally looks like a new being; his sweats and diarrhoea soon leave him, and he rapidly improves in health and spirits, making often an excellent re- covery. SECT. VI.—NECROSIS OR MORTIFICATION. The word necrosis denotes the death of a bone, and is strictly synonymous with mortification, gangrene, or sphacelus, used to designate the death of a soft structure. The immediate cause of the occurrence is inflammation, eventuating in an arrest of the circulation and innervation of the osseous tissue. Necrosis is most common in those bones which are most superficial, or which lie immediately beneath the integuments, as the tibia, ulna, lower jaw, clavicle, the inferior portion of the femur, and the phalanges of the fingers. The long bones suffer more frequently than the short, and the short than the flat, the reverse being the case in caries, for the reason that, in the former, the compact tissue is most commonly affected, and in the latter, the spongy. Children under fifteen years of age, particularly such as are of a strumous diathesis or habit of body, are the most common subjects of this disease. This is more especially true of the idiopathic form ; for traumatic necrosis probably occurs as readily in adults and old persons as in young. Of the influence of sex, climate, and occupation, upon the production of the disease, nothing very satisfactory is known. If it be more comraon in boys than in girls, a circumstance, however, which has not been established, it is, probably, simply because the former are more exposed to the exciting causes of necrosis than the latter, and uot because of any sexual peculiarity. It has been gene- rally supposed, and not without reason, that the occurrence is most common in cold, damp, and variable regions; and the explanation of this seems to be that the inhabitants of these countries are particularly prone to suppression of the cutaneous perspiration, which, in individuals predisposed to disease, may, it is alleged, readily cause death of the more superficial bones. It has been ascertained that persons engaged in the manufacture of lucifer matches are liable to necrosis of the jaw, from the contact of the fumes of phosphorus with the interior of decayed teeth; and it is not improbable that there are other pursuits which may conduce to destructive inflamraation of the osseous tissue, although of their precise nature and mode of action we are not in- formed. Causes.__If we inquire into the idiopathic form of necrosis, we shall find, as has just been intimated, that it is most common in young strumous sub- jects, having well marked evidence of scrofula in other parts of the body, or, at all events, signs of a strumous predisposition, as evinced by the delicacy of the skin, the languid circulation, the tumid belly, and the deficient tem- perature of the extremities. I am certain that this has been the case in the great majority of the instances that have come under my own observation, and I believe that this, in the main, agrees with that of other writers. It is in persons of this description, more particularly, that we so frequently meet with the worst species of necrosis of the tibia, femur, and humerus, telling so fearfully upon the constitution, and so often requiring amputation in order to save the patient's life. The most common cause of the disease, in this class of subjects, is exposure to cold, as when a boy, overheated by play, sits 872 DISEASES OF THE BONES AND THEIR APPENDAGES. down in a current of air, and thus suddenly repels his perspiration; or when, under similar circumstances, he strips himself, and plunges into cold water. He is not made aware, perhaps, for several days that he has received any in- jury; but, all of a sudden, he is seized with violent pain in one of his limbs, attended with severe rigors alternating with flushes of heat, and, upon exa- mining the affected part, he observes that it is exquisitely tender on press- ure, more or less swollen, and covered with an erysipelatous blush. The local and constitutional symptoms progressing, matter soon forms deep be- neath the muscles, the swelling becomes more and more circumscribed, and, ulceration taking place, the contents of the abscess thus gradually find their way to the surface, leaving the bone dead below. Such is the manner in which necrosis is generally produced in weakly, scrofulous subjects, and it is hardly necessary to add that all the attendant phenomena are indicative of a rapidly destructive osteitis. Tertiary syphilis is another cause of necrosis, and the history of this dis- ease has shown that the osteitis growing out of it is more apt to occasion death of the bone when the patient has been subjected to free courses of mercury for its cure, than when the malady has been treated on general anti- phlogistic principles. The two poisons coming together, and mingling their baneful influence, induce a form of ossific inflammation which is extremely prone, especially in persons of a worn-out, debilitated constitution, to termi- nate in gangrene of the bones—those of the nose, palate, upper jaw, leg, and arm in particular. Protracted courses of mercury, especially in young subjects of a strumous diathesis, or exhausted by diarrh/Ea, cholera, or eruptive diseases, often cause necrosis of a frightful character, generally of the jaw-bones, but sometimes, also, of other pieces of the skeleton. What is termed dry salivation is fre- quently more destructive to the gums, teeth, and jaw-bones than salivation accompanied by profuse discharge. The debility produced by the injudicious use of drastic purgatives and tartar emetic has occasionally caused necrosis of the bones of the extremities, head, and trunk. Scurvy has been known to produce similar effects, although more commonly it causes caries. In short, there is reason to believe that idiopathic necrosis may be induced by whatever has a tendency to bring about an impoverished condition of the blood and solids. Among the local causes of necrosis may be enumerated wounds, contusions, fractures, and chemical irritants; in the tibia, the probability is that mere concussion, as happens when a person falls from a considerable height and alights upon his foot, is often sufficient to produce a destructive form of osteitis. Gunshot injuries are a common source of the occurrence, whether the bone be merely grazed by the passage of the projectile, or whether the ball lodges in its substance and acts as a foreign body. Mere denudation of a bone, however occasioned, is frequently followed by its death, especially when the loss of periosteum is very considerable, or if, even when it is com- paratively trivial, it is accompanied by the laceration of the nutrient artery, or extensive destruction of the soft parts generally. Under such circum- stances, the necrosis is usually limited to the outer compact structure, the part ultimately coming away in the form of an exfoliation. Such an event, however, is by no means inevitable. The periosteum may be stripped off to a considerable extent, and yet, if the bone be in other respects healthy, or enjoy a tolerably active circulation, granulations will spring up, and thus gradually repair the breach. It is only when the vascular connection be- tween the two structures has been materially impaired, or totally destroyed, that necrosis will be likely to ensue, the bone becoming white and dry, and eventually dark and even black. These appearances are well illustrated in what so often happens in compound fractures, attended with protrusion of NECROSIS OR MORTIFICATION. 873 the end of the bone divested of its fibrous covering, and in the phalanges of the fingers in whitlow. It will thus be perceived, without going into further details, that death of the osseous tissue may be produced by constitutional or local causes, and that these causes differ in no respect whatever from those which induce mor- tification of the soft parts. Furthermore, it will be observed that they are such as usually give rise to inflammation generally in all structures without exception. Extent.—Necrosis may be partial or complete, simple or complicated, su- perficial or deep ; that is, it may affect merely a portion of a bone, or it may pervade its entire structure ; it is said to be simple when it is limited to a single piece, and complicated when it attacks several, either simultaneously or consecutively. It is seldom that an entire bone perishes. Such an occur- rence is sometimes observed in the pieces of the carpus and tarsus, iu conse- quence of external injury, but it is extremely uncommon in the long bones; in these the shaft alone generally suffers, the articular ends retaining their vitality. Necrosis of the whole lower jaw has been repeatedly noticed as a result of the action of phosphorus, and some interesting cases in which the entire bone was successfully removed on account of this disease have been related by Dr. Carnochan and Dr. James R. Wood. Finally, necrosis may be limited to the outer surface of a bone, involving merely its superficial laminae, the dead portion being ultimately detached in the form of a thin scale or plate; or it may invade its entire thickness, and then not unfre- quently begins in the very depths of the cancellated tissue, in consequence generally of injury or disease of the medullary membrane. The occurrence of necrosis, the elimination of the dead bone, usually called the sequester, and the formation of new bone as a substitute for the old, or that which has died, involve some very curious pathological and physio- logical processes, and therefore deserve attentive consideration. The symp- toms which immediately precede, and those which accompany the death of the bone, are such, generally, as are denotive of violent inflamraation, deep- seated, attended with excruciating pain, and rapidly tending to the suppu- rative crisis, the mischief being often done in a few days, and sometimes even in a few hours. Action, general as well as local, is excessive, and both the part and system occasionally fall a prey to its devastating influence, especi- ally when there is involvement of a large neighboring joint, as now and then occurs when the necrosis attacks the inferior extremity of the femur, and extends into the knee. Progress, however, is not always so swift and over- whelming ; often it is quite the reverse, the part and system suffering but little, and the malady pursuing apparently a chronic course. A very common way in which the occurrence of gangrene of a long bone is announced is as follows. The patient, usually a lad from six to ten years of age, after having been overheated or exposed to severe cold, retires at night apparently perfectly well, but towards morning he is aroused by pain in the thigh or leg, deep-seated, circumscribed, of a sharp, aching character, and so excessively severe as to deprive him of further sleep and rest. The soft parts over the seat of the disease soon become exquisitely tender to the touch, swollen, and discolored, the surface having a glazed, dusky, reddish, or purplish tint, and pitting under pressure, in consequence of the infiltra- tion of the subcutaneous cellular tissue. These local phenomena are always attended by severe constitutional disturbance. There is high raging fever, with a tendency to delirium, and excessive restlessness ; the pulse is full, hard, and frequent; the skin is hot and dry ; the thirst incessant; and the urine, thick and scanty, is surcharged with urates. By and by, violent rigors set in, succeeded by flushes of heat, the pain assumes a tensive, throbbing cha- racter, the swelling becomes raore diffuse, extending often to a great distance 874 DISEASES OF THE BONES AND THEIR APPENDAGES. up and down the lirab, as well as widely circumferentially, the discoloration acquires an erysipelatous blush, and a careful examination soon detects, what, indeed, the existing symptoms sufficiently declare, the presence of pus, deep seated, lying partly between the affected bone and the periosteum, and partly on the outside of the membrane, in the cellular tissue of the muscles and aponeuroses, which it often extensively dissects and separates frora each other, forraing large pouches from wdiich it is frequently difficult to dislodge it. Sometimes the abscess opens into a neighboring joint, and thus becomes a source of additional mischief, exciting inflammation in the synovial mera- brane, perhaps ultimately followed by destructive softening of the cartilage, and caries or necrosis of the end of the bone. The quantity and quality of the matter found at this stage of the disease are very various. In the more severe cases it often amounts to several pints, whereas, under ordinary circumstances, it may not exceed that many ounces. The quantity furnished by the bone itself, or, rather, by the bone and perios- teum, is always comparatively small, most of it being supplied by the soft structures over and around the seat of the disease. In most cases of spon- taneous necrosis, it is found to be of a decidedly strumous character, being of a yellowish color, verging upon greenish, and of a thick cream-like con- sistence, interspersed with tough curdy matter, or flakes of lymph. In gene- ral it is raore or less fetid—sometiraes excessively so, particularly when long retained—and mixed with shreds of dead cellular tissue. Cases are met with where the matter is thin, ichorous, or sanious, but such an occurrence is unusual until after the bursting of the abscess, and the evacuation of its contents. When the matter has been discharged, whether spontaneously or artifi- cially, there is always a material improvement in the symptoms, both local and general, and an opportunity is now afforded for a thorough exaraination of the parts. The best instrument for this is the finger, or, when the open- ing is not sufficient or too devious, the probe. With either of these it is generally easy to determine the extent of destruction of the periosteura, or, at all events, of its separation, and the amount of injury sustained by the osseous tissue, the surface of the bone feeling rough, and having a whitish, grayish, or ashy hue, without any appearance whatever of vascularity. Such is a succinct account of the circumstances which immediately pre- cede, accompany, and immediately succeed the occurrence of necrosis as it is usually met with at the bedside. The first stage of the disease is over; the matter consequent upon the inflammation has been discharged; and the in- flammation itself has measurably subsided, the soft parts, however, being still swollen, indurated, tender, and painful, as well as entirely disqualified for the performance of their normal functions. Nature, never idle, now begins the double work of elimination and repair, both usually very tardy, often imperfect, and sometimes altogether unsatisfactory, the powers both of the part and system being inadequate to accomplish the object. In gangrene of the soft structures, the separation of the eschar is generally an easy mat- ter compared with that of a bone, provided the patient's strength holds out; the process, once fairly commenced, proceeds rapidly and energetically, the surgeon each day seeing decisive evidence of the fact; soon the line of de- marcation between the dead and living parts is perceived; then granulations are observed to spring up in the intervening chasm ; and, finally, the repara- tive efforts still advancing, the breach is gradually closed over with new skin, a circumstance clearly denotive of the completion of the cure. But it is altogether different in necrosis; here the detachment of the slough is a matter of time, commonly requiring many weeks, and sometimes even a number of months, for its satisfactory conclusion, and even then generally demanding the interference of art before it can finally be effected. The cause NECROSIS OR MORTIFICATION. 875 1 >*' of the difference is sufficiently obvious. In the one case there is an active circulation and an energetic system of absorbents, the former furnishing an abundance of plastic material for the repair of the lost tissues, and the latter exerting themselves to cast off the dead substance; in the other, on the con- trary, everything is the reverse, and the parts labor under the additional disadvantage of being loaded with earthy matter, which is obliged to be softened and disintegrated before it can be removed by the vessels whose duty it is to get rid of it. The necrosed substance may, as already seen, embrace merely a portion of the periphery of a bone, as, for example, its outer layer; or it may include its entire thickness, and also the greater part of its length. In the former case it constitutes, when detached, what is called an Fig. 292. exfoliation, and in the latter a sequester, a distinction of con- siderable importance, not so much on account of the extent of the dead substance, as of the manner in which the breach of continuity is repaired, or a new bone formed. An exfoliation is commonly merely a thin scale, plate, or lamella of the outer, peripheral portion of a long bone, of varia- ble color and consistence. In general, it is either whitish, gray- ish, or of a light brownish hue, rough, raore or less porous, and so brittle as to break under very slight pressure. No vessels are perceptible in it, and in most cases the animal matter seems to be almost completely abstracted. Maceration deprives it of its dark color, while immersion in dilute nitric acid for a few days completely destroys its proper texture, converting it into a soft, gristly substance. The sequester, properly so called, varies much in size and shape, consisting, at one time, of a part only of the circumfer- ence or length of a bone, and, at another, of its entire shaft, with perhaps a portion of its articular ends. A rather common form is that represented in the adjoining sketch, fig. 292, from a pre- paration in my collection ; it was a part of the body of the tibia, iu which all the spongy structure was completely destroyed, while the compact was remarkably hard and firm. The dead bone is always rough, pitted, excavated, or spiculated ; it is of a grayish, brownish, or blackish color, and emits, when struck with a probe or piece of metal, a peculiar hollow sound, by which it is usually readily distinguished from sound bone. In the cylindrical pieces, as in the femur and tibia, it is generally dense and dry; in the short and flat, on the contrary, it is porous, moist, brittle, and easily crumbled. The analyses of Von Bibra have shown that there is a very great reduction of organic matter in necrosis with a corresponding increase of earthy, the latter being as much as eighty per cent, of the entire mass. The same experimenter has proved that the difference is considerably less in the traumatic variety of the lesion than in the idiopathic. Reparation.— While the absorbents are engaged in detaching the dead bone, with a view to its ultimate expulsion, the capillaries take upon them- selves the duty of throwing out material for the formation of the substitute, or new bone. The process by which this is accomplished is the same as that which presides over the creation of the original structure. The first step consists in a deposit of plasma, the result of the incited action of the vessels caused by the irritation of the necrosed bone, and this substance, becoming organized is gradually converted into fibro-cartilage, which, in turn, gives way to cartilage as this ultimately does to osseous matter, the period required for the completion of the development varying, according to the age and Necrosis of the tibia. 876 DISEASES OF THE BONES AND THEIR APPENDAGES. Fig. 294. vigor of the patient, and the character and amount of the local disease, from a few weeks to several months. The new bone is at first a mere shell encas- ing the old, and thus serving to separate it from the surrounding parts, which ill brook its presence. In time, however, it increases in thickness, being often from three to six lines in depth, and occasionally, though not generally, it is fully as large as the original piece. Its surface is usually somewhat rough, and it is not uncommon to observe upon it considerable eminences and depressions, owing evidently to the irregularity of the deve- lopmental process. The new substance, too, has comparatively little areolar tissue, and hence, if some time have elapsed since its formation, it always cuts with great difficulty, the resistance offered by it being much greater than that of the pre-existing structure. In cases of long standing, indeed, it often acquires the solidity and density of ivory, so that it requires great patience and perseverance to penetrate it with the saw and pliers. The vessels, under such circumstances, are always very small and sparse, and the Haversian tubes are traced with difficulty. In the long pieces, after the death and removal of the shaft, there is never a complete reproduction of the medullary canal and its lining membrane, or of the endosteum. In fact, the new bone, although it possesses all the essential attributes of the osseous tissue, is, nevertheless, a very imperfect type of the original, and hence much less capable of resisting the effects of disease and accident. The appearances of the new bone, encasing the old or dead, are admirably depicted in fig. 293, taken from a specimen in the collection of Professor Pancoast. Owing to the ravages of the disease, am- putation became necessary. In viewing the new bone as it surrounds the old, its surface is found to be pierced by several apertures, to which, from their fancied resemblance to the rectal pouch of a bird, the term cloacce, fig. 294, is usually l;l»fl \ Bfrl'tfh l applied. These openings, which play an important part in the expulsion of the dead bone, owe their existence to a de- ficiency of periosteum, or of secreting structure, as is proved by the fact that, when the formation of new osseous tissue goes on uniformly round every portion of the periphery, the old bone will be com- pletely imprisoned, thus not only obscur- ing the diagnosis but rendering the re- moval of the sequester a matter of great difficulty and perplexity. The size of these cloaca? varies in different cases, frora that of a three cent piece to that of a quarter of a dollar, their shape being generally rounded, or somewhat oval. Not unfrequently, however, they present themselves in the form of long, irregular fissures, or slits. Their number is inde- finite ; sometimes there is but one, while at other times there are as many as half a dozen, the latter number being by no means uncommon in necrosis of the shaft of the tibia. Whatever may be the size, form, or number of these apertures, they always communicate with the surface of the limb in which the affected bone is situated, the passages Fig. V J Necrosed tibia, the dead bone lying loose within the new. Cloacae in a ne- crosed tibia. NECROSIS OR MORTIFICATION. 877 between them constituting so many channels for the discharge of matter and the ultimate elimination of the sequester, although this, owing to the inade- quate dimensions of the cloacae, is seldom effected without the intervention of art. It is an interesting fact, and one of no little practical value, that these openings are always situated in that portion of the new bone which is least covered by soft parts. There has been much dispute among pathologists, as to the agents by which the new bone is produced, and the question can hardly be said to be even yet definitively settled. Without entering into any details, I may state, as the result of personal observation, that the perfection of the new bone will generally be found to be in proportion to the integrity and activity of the periosteura. I have always found that, when this membrane has suffered much during the inflammation which precedes and accompanies the necrosis, the reproductive process, or new osseous epigenesis, is tedious and difficult, and often extremely inadequate, the new bone being comparatively small and stunted, and, therefore, ill adapted to the purpose of a substitute bone. The part which the periosteum plays in the development of the new bone is well shown in the formation of cloaca?, which, as already stated, is clearly dependent upon the partial destruction of that membrane. If the periosteum everywhere retained its integrity, the new bone would be without a solitary opening, and the consequence would be that the sequester, or slough, would always be an encysted or imprisoned body. When this membrane has perished along with the bone, as occasionally happens in the shaft of the tibia or femur, the new bone will be formed by the surrounding structures, whatever these may be, but under such circumstances it is so imperfect, short, and thin, as hardly to deserve the name of substitute, to which, in general, it is so well entitled. When the eschar presents itself as an exfoliation, or thin superficial scale, the breach is repaired through the medium of granulations, which, being de- rived from the old bone, are extremely vascular and sensitive, and soon assume the ossific process, throwing out an abundance of proper material for the accomplishment of the object. A similar process appears to be set up when the central portion of a bone perishes; for here the endosteum being also destroyed, it can have no agency in the reproductive act. When this merabrane retains its vitality, it must necessarily exert an important influence as an epigenetic agent. The idea has been broached, and warmly defended, that when the shaft of a bone is necrosed, so as to leave merely its articular ends, the new bone is formed exclusively by these ends, the osseous matter extending gradually towards the middle of the chasm, and ultimately coalescing there. Such a theory, however, is altogether untenable, being contrary to what occurs in the growth of the original bone, which always takes place by several distinct points, one of which is invariably central. However well the surviving ex- tremities might perform their duty, yet, as there is no central nucleus, serving as a point of departure for the ossific matter, it is easy to conceive that the bone would always necessarily be so deficient at that particular spot as to disqualify it materially for the performance of any useful functions.' Symptoms.—The symptoms which attend necrosis, in its earlier stages, have already been pointed out; those which accompany the separation of the old bone and the formation of the new, are, in general, sufficiently character- istic. The most important of these are, little ulcers, surrounded by large unhealthy granulations, arranged in a papilla-like manner; sinuses leading frora these ulcers down to the dead bone; and a discharge, more or less constant and copious, of thin, fetid, sanious matter, or of thick, white, ino- dorous pus; accompanied, in all cases, by a certain amount of hardness and swelling, pain* and tenderness on pressure, wasting of the soft parts above and below the seat of the disease, aud marked impairment of the functions of 878 DISEASES OF THE BONES AND THEIR APPENDAGES. the neighboring joints. The general health always suffers; the patient is wan and emaciated; and, if the irritation is at all extensive, he will usually have hectic fever. In sorae cases the end of the sequester sticks out at one of the cloacae, thus at once declaring the real nature of the complaint; but more commonly the dead bone is completely imprisoned by the new, and can only be reached by the probe or finger, carried along the sinuses leading from the surface to the cloaca?. In order to ascertain whether the separation has been effected, or whether the dead bone still maintains its relations, in some degree, with the living, the surgeon may often advantageously use two probes, introducing one at each extremity of the eschar, and moving thera alternately in different directions, as may frequently be easily done when the detachment is complete. In general also useful information, in this respect, may be ob- tained from a consideration of the history of the case, as the size of the affected bone, the age of the patient, and the commencement of the attack. Thus, other things being equal, it will usually be found that a small bone will be more readily separated than a large one, and the bone of a young subject than that of an old one, while in every instance the process may be supposed to be more advanced in proportion to the period that has elapsed since the death of the bone. Prognosis.—The prognosis of this disorder is variable. In general, it may be considered to be favorable when it is owing to external or local causes; when it is confined to the outer portion of a bone, the necrosis occurring in the form of an exfoliation; when it is simple and of moderate extent; and when the patient is young, robust, and of a good constitution. On the other hand, the cure is difficult, and the issue doubtful, when the disease is exten- sive and complicated with other affections; when it attacks pieces which are of high importance on account of their functions or situation ; when it oc- cupies the interior of a bone, and involves several parts of it; when it arises from an internal or constitutional cause, as struma or syphilis; when it ex- tends into the adjacent joints, especially when these joints are of large size; and, lastly, when the patient is enfeebled by age, long suffering, or previous disease. The time required for the development of the substitute bone will depend, as already stated, in great measure, upon the situation and extent of the dis- ease, the age, health, and condition of the patient, and various other circum- stances which will readily suggest themselves to the reader. That the whole of a necrosed bone may be regenerated, is a fact so well established as uo longer to admit of any doubt. The new bone, however, as intimated else- where, is always, at best, only an imperfect copy, although, as it respects its functions, it usually answers the purpose well enough. Treatment.—The treatment of necrosis must of necessity depend very much upon the circumstances of each particular case. There are three indications, however, which deserve special attention, the first of which is to limit and moderate the inflammation which is the immediate cause of the mischief, the second, to watch nature during the separation of the old bone and the for- mation of the new, and the third, to promote the removal of the sequester, slough, or eschar. The first of these objects, which should always be kept clearly in view by the practitioner, is to be attained, of course, by the proper employment of antiphlogistic remedies; by the lancet, if the patient be plethoric, purgatives, the antimonial and saline mixture, light diet, repose, and the free use of opi- ates to allay pain and induce sleep. The affected parts, placed in an easy, elevated position, are leeched and fomented, or, what is particularly service- able, painted with a strong solution of iodine at least three times in the twenty-four hours, the surface being protected in the intervals" with an emol- lient anodyne cataplasm, or medicated water-dressing. In some instances, NECROSIS OR MORTIFICATION. 879 great benefit is derived from the application of a blister large enough to encircle nearly the whole of the affected limb, and kept on sufficiently long to produce thorough vesication. By these means, the surgeon not only limits the inflaramation, but promotes the absorption of effused fluids, and hastens the suppurative crisis, which is always inevitable, to a greater or less degree, in every case of this kind. As soon as fluctuation is perceived, or even before, if there be inordinate pain and tension, or deep-seated matter, a large incision is made at one or more points, in the direction of the long axis of the bone, in the hope of saving osseous as well as soft tissue, especially the periosteum, the integrity of which is so essential to the development and formation of the substitute bone. In making the opening, due attention is, of course, had to drainage, and to the prevention of its premature closure. The second indication is to watch the part and system during the slough- ing process and the stage of reparation, in order that they may be enabled to perform with facility the arduous and important duties before them. The case requires active vigilance rather than active treatment; care, on the one hand, that the disease do not spread, and, on the other, that the debility consequent upon the drainage and irritation do not obtain the mastery, and so bring on fatal exhaustion. A certain amount of inflammation must neces- sarily attend both processes, a,nd, therefore, action must not be too much repressed, lest nature be thwarted, or, at all events, embarrassed in her opera- tions, operations which are both salutary and needful. A nutritious diet will generally be required, and the patient will often be immensely benefited by animal food and milk punch, ale, porter, or wine, and the use of quinine, iron, and aromatic sulphuric acid, especially if he have hectic fever and night- sweats. If he can move about on crutches, he should take gentle exercise daily in the open air; or, if this be impracticable, he should be pulled about in a hand-car, or be swung upon a hammock. Attention is, of course, paid to the bowels and secretions. Pain is allayed by anodynes. The principal local remedies are leeches, provided there is any disposition to over-action, the daily application of iodine, and the use of the bandage to support not merely the affected parts but also the distal portion of the limb, which, when this precaution is neglected, has usually a tendency to become cedematous. Fetor is allayed, and discharge moderated, by the chlorides, introduced by the syringe and sprinkled upon the dressings. Much has been said about the employment of solvents, thrown through the principal sinuses upon the dead bone, in the vain hope of promoting its gradual disintegration and elimination. Special stress used to be laid upon various acid solutions, par- ticularly the nitric, hydrochloric, and pyroligneous; but experience has proved that they are always productive of harm, from their irritating effects upon the new bone and the soft parts, whilst, unless they are intolerably strong, they can exert no destructive influence whatever upon the sequester itself. If such lotions be employed at all, they should, therefore, be em- ployed in the mildest possible form, simply with a view to their detergent and alterant effects, which are often very salutary, expediting the sloughing and restorative processes. In general, however, all the good that can be ex- pected to result from such remedies may be accomplished by injections of tepid water, impregnated with Castile soap, a little potassa, or common salt, followed, if there be much fetor, by a weak solution of chlorinated soda. If new abscesses form, as occasionally happens, they must meet with prompt attention. During this stage, a stage, I repeat, of comparative inactivity, inquiry is made into special diatheses, or states of the system. The patient may be strumous, and, therefore, be in need of anti-strumous remedies; or his system may be impregnated with the syphilitic posion, and a course of mercury, or of iodide of potassium, may be required. It must be obvious that no satis- 880 DISEASES OF THE BONES AND THEIR APPENDAGES. factory progress can be made, in any case, towards a cure so long as the system is borne down by the pressure of a vitiated state of the solids and fluids. The third indication is to get rid of the sequester, for so long as this remains it must necessarily act as an irritant, keeping up inflaramation and discharge in the parts with which it lies in contact. It was generally sup- posed, until recently, that the dead bone, during its sojourn among the living tissues, was acted upon by the absorbent vessels, so as to diminish, raore or less, its size and weight, the idea having apparently derived support from the altered and pitted condition of the surface of the affected piece. The notion, however, has been completely dispelled by the experiments of Mr. Gulliver, who ascertained, as might, indeed, have been anticipated, that such an occur- rence is altogether impossible. Pieces of necrosed bone, carefully weighed before and after exposure, were confined on suppurating surfaces, in the me- dullary canal, and in the subcutaneous cellular substance for months, and in one instance for upwards of a year, without undergoing the slightest altera- tion whatever. A paper, detailing nineteen experiments of this kind, may be found in the twenty-first volume of the Transactions of the Medico-Chi- rurgical Society of London. Seeing, then, that the dead bone acts as an extraneous body, and that it is in nowise amenable to the agency of the absorbents, the indication plainly is to remove it by operation. Such a step is the more imperative because of the manner in which it is imprisoned, the substitute bone forming a firm and solid case around it, and thus effectually preventing its extrusion. The only circumstance which should make the practitioner at all hesitate, is the doubt which may arise in his mind respecting the probability of the dead bone being completely detached, and the new one sufficiently advanced to enable it, after the removal of the sequester, to raaintain its position without bending under the weight of the limb, in turning in bed, walking, or sitting. If he is satis- fied of this, as he usually may be after a careful examination of all the facts of the case, he should at once proceed to adopt measures for the accomplish- ment of his object. The instruments which will be required for this purpose are various; but, in general, it will be necessary to have several scalpels, a trephine, a Hey's saw, an elevator, pliers, chisels, and stout forceps, with a good syringe for washing away the osseous debris after the operation is over. The adjoining cuts represent some of the more important of these instru- ments. The incisions should always be made in the direction of the long axis of the bone, out of the way of the great vessels and nerves. , The best plan usually is to select one of the principal cloaca?, or, when two or three are close together, especially if they be on the same plane, to connect them, thereby affording more room to work in. When the soft structures are much diseased, they may be included in an elliptical incision, as, in this event, it may be best to get rid of them. AVhen it is deemed advisable to connect two or more cloacae, the object may be easily attained by a Hey's saw, or, if the new bone is not very thick and firm, by the pliers. The trephine is chiefly of use when the openings in the substitute bone are very small, or when this bone possesses unusual density and thickness, rendering its division extremely difficult by the raore ordinary instruments. Access having thus been obtained, the sequester is to be seized by one of its extremities, with a pair of forceps having long, thin blades, serrated on their inner surface, and from a third of an inch to half an inch in width, the handles being well curved, so as to facilitate prehension and maintenance. When the sequester is unusually long, it may be necessary to divide it at the middle, and extract each piece separately; au operation which is always easily performed with the pliers or chisel. r^ NECROSIS OR MORTIFICATION. 881 The dead bone having been extracted, the next step is to wash out the canal left by its removal with a few syringefuls of cold water to clear away any little pieces, fragments, or debris that may have been left. Attention to this injunction, although generally neglected, will greatly expedite recovery by facilitating the growth of healthy granulations. The hemorrhage attend- ing the operation is often quite free, the blood oozing out at every point, in consequence of the great vascularity of the parts, both osseous and soft, and occasionally requires plugging of the cavern with lint steeped in some styptic lotion, as a saturated solution of alum, or alum and tannin. It is not often that any artery requires to be tied. Fig. 295. Fig. 296. Fig. 297. Fig. 298. Fig. 299. Instruments for removing dead bone. The operation being completed, the edges of the wound are drawn lightly together with adhesive strips, and the limb, placed in an easy position, is bandaged from the distal end upwards, the parts more immediately affected being kept constantly wet with cold water, or a weak spirituous lotion. The dressings are removed in forty-eight hours, when the wound is well syringed, and covered with an emollient poultice, to favor the granulating process. The only general means usually required are light diet and a little attention to the bowels, with a full anodyne after the patient is put to bed. If the new bone is not sufficiently strong to prevent the limb from bending or break- ing, it must be supported by appropriate splints, or, what is better, a case made of sole-leather, gutta-percha, or trunk-maker's board. vol. I.—56 882 DISEASES OF THE BONES AND THEIR APPENDAGES. Soon after the sequester has been removed, whether by nature or art, the new osseous shell begins to contract, and by degrees assumes the shape of the old bone, which it is designed to replace. While this change is going on externally, osseous matter is deposited upon the inner surface of the shell, as well as upon the articular ends of the surviving portions, thereby gradually filling up the cavity, the period required for this being generally in propor- tion to the size of the eschar. The medullary canal, in case of there having been one, is, as already stated, seldom re-established. It is not often, at the present day, that, with proper management, the practitioner is not able to effect a cure in necrosis; in general even with little deformity or loss of function. Cases do, however, occur, where, in conse- quence of neglect or injudicious treatment, the neighboring structures are so extensively and ruinously involved as to render it difficult, if not impossible, to save the patient without sacrificing the limb. Such an event will be par- ticularly liable to happen when a large joint is implicated, as, for instance, that of the knee in necrosis of the thigh, or of the ankle in necrosis of the tibia. Under such circumstances, hardly anything short of amputation will be likely to answer; and a similar procedure raay become necessary when the patient's constitution is so much shattered by previous or concomitant disease as to preclude the possibility of its holding out during the time which may be required for the separation of the dead bone from the living. In other cases, again, amputation may be demanded on account of hemorrhage from some large sinus, presenting itself either as a general oozing, or as a flow from an artery of considerable size, opened by ulcerative action, under circumstances when the loss of a few more ounces of blood might prove fatal. It is impos- sible, however, to exercise too much caution in attempting to decide so grave a question. In weighing the several points involved in its consideration, we must not lose sight of the fact that cases, apparently of the most forlorn character, where life literally hangs, as it were, by a thread, will sometimes promptly recover upon the removal of the dead bone. Finally, it must not be forgotten that excision of an entire bone has often been advantageously performed, especially of late years, recovery taking place with comparatively little deformity. SECT. VII.—SOFTENING. The essential characteristic of osteomalacia, mollifies ossium, or softening of the bones, is a diminution of the firmness and solidity of the osseous tissue, depending upon the gradual removal of its earthy constituents, and the depo- sition of a reddish sero-albuminous, oily, Fig. 300. or greasy substance. The malady is often confounded with rachitis, but differs from it in the circumstance, first, of its being a disorder of adult life; and secondly, in being always attended with severe pain; whereas rickets is peculiar to infancy, and free from local suffering. Extent.—Softening of the osseous tis- sue varies in degree and extent, occurring at one time as a very slight affection, with hardly any appreciable change of struc- ture, and at another as a most serious lesion, in which it is difficult to distin- guish any trace of the normal substance. Madame Supiot, in a posture quite practicable In regard to its extent, it may be general in the advanced stage of the disease. or partial, in the one case pervading the SOFTENING. 883 eutire skeleton, while in the other it is limited to particular bones, or portions of bone. Of general osteomalacia, the case of Madame Supiot, which has long since become classical, and which has been so minutely described by Morand, the younger, in the Memoirs of the Academy of Sciences of Paris, for 1710, affords a characteristic, as well as a most extraordinary example, as shown in fig. 300. This female, who was thirty-seven years of age at the time of her death, had her bones so completely softened that they could be bent like wax, and put in alraost any position, although she herself had lost all control over them, her head and left arm being the only parts she could move. Most generally the disorder is confined to particular bones, especially the ribs, sternum, vertebra?, and pelvic pieces. Morbid Anatomy.—The osseous tissue in this disease gradually loses its firmness and solidity, becoming ultimately so soft and pliant that it may be easily bent, if not cut. It is of a pale reddish color, often inclining to yel- low, is specifically lighter than the healthy structure, and is infiltrated with a turbid, viscid serum, removable by pressure. Occasionally the osseous fibres are widely separated from each other, so as to leave large cells, which are filled with a bloody-looking, adipose substance. When this is the case, the bone is sometimes remarkably pliant, bending like semi-concrete wax. Boil- ing completely dissolves it; and exposure to the air, by abstracting its moist- ure, sensibly diminishes its weight. Such are the principal changes observable in the osseous tissue. The periosteum over the affected part is abnormally thick, rough, and but feebly adherent; it is of a grayish hue, deeply injected, and, like the bone, infiltrated with sanguinolent matter. Upon being macer- ated, however, it is found to retain its fibrous structure. The marrow is converted into a reddish, greasy sanies; and the medullary membrane is wasted away to a few soft, cellular shreds. The cartilages sometimes partici- pate in the softening, while the muscles are pale, atrophied, and infiltrated with a reddish fluid. The softening generally involves the whole thickness of the bone; but cases occur in which the outer table remains unchanged, consisting of a thin, brittle shell. The disorder obviously consists either in an inordinate absorp- tion of the phosphate of lime, upon which the solidity of the osseous struc- ture naturally depends, or in a deficient deposition of this matter into its meshes. It has already been mentioned that the bones become specifically lighter in this disease; and Dr. Bostock has ascertained the additional fact that they contain nearly eighty parts of animal substance in the hundred. The experiments of this gentleman were afterwards confirmed by those of Dr. G. 0. Rees, of London, who, from a careful analysis of three diseased specimens, taken from the same adult subject, obtained the following results, which he has compared with those furnished by healthy bone :— Diseased. Healthy. Earths. Animal matter. Earths. Animal matter. Fibula . . 32.50 67.50 60.02 • 39.98 Rib . 30.00 70.00 57.49 42.51 Vertebra. . 26.13 73.87 57.42 42.58 On examining this table, it will be observed that, in the diseased as well as in the sound state, the fibula contains more earthy matter than the rib, and the rib more than the vertebra. In health, the vertebra and rib approach very nearly in their proportions of animal and saline ingredients, whereas, in softening, a considerable difference obtains. Causes.__What are the causes of this remarkable disease, or the circum- stances which influence its origin and development? Upon this subject, unfortunately, science is alraost completely silent. A great variety of causes have been accused as being capable of producing it, more especially a gouty, 884 DISEASES OF THE BONES AND THEIR APPENDAGES. rheumatic, syphilitic, or scorbutic state of the system ; but, in admitting such an agency, it should not be forgotten that vast numbers of persons labor under such a taint, and yet are never the subjects of osteomalacia. That it may occasionally induce softening of the osseous tissue is extremely probable; but that this occurrence is frequent all experience plainly contradicts. The whole course of the disease shows it to be essentially connected with a vitiated and depraved condition both of the solids and fluids; but whether the dis- order of the one precedes that of the other, or whether they have a simul- taneous origin, and afterwards keep steady and regular pace with each other, are questions which our knowledge is inadequate to solve. However pro- voked, it is sufficiently apparent that the structures which are its seat are in a state of inflammation, and that this inflammation plays an important part in the production of the changes which characterize it. We cannot, as rational pathologists, assume any other ground ; for, how else can we account for the excessive vascularity of the affected tissue, the sanguinolent nature of the infiltrated fluids, the thickened, spongy, and congested condition of the periosteum, and, finally, the atrocious and constant pains which form so nota- ble a feature in the history of osteomalacia ? All these circumstances unerringly point to inflammation as the great agent in the production of these changes; changes which, when existing in the soft structures, are in- variably referred to this cause, and to none other. The morbid action, what- ever it may be, is always of a chronic character, and is attended with important lesion of nutrition, leading to the removal of the earthy matter of the bones, and the excretion of it from the system, or its deposition among parts where it does not naturally occur. Or, what is more probable, there is both absorp- tion of the original solid structure and a want of secretion of new, thus causing a complete disintegration, or decomposition, of the osseous tissue. All these circumstances are sufficiently obvious and tangible; but if we attempt to go beyond them, we involve ourselves at once in difficulties, from which it is found impossible to extricate ourselves. Age and Sex.—Osteomalacia is rarely seen before the age of puberty; its favorite period of attack is between the thirtieth and fiftieth year. Another singular feature in its history is that it takes place much more frequently in women than in men, in the proportion, it has been said, of ten to three, but upon this subject it is obviously impossible to give any definite information. It is most comraon in females who have borne several children, and in a num- ber of instances it has seemed to commence within a short time after parturi- tion. Several cases have been reported where it was hereditary, having been distinctly traced through three generations, but in none of the offspring did it show itself until after puberty. Symptoms.—The invasion and progress of this disease are generally very insidious. The earliest, and, for a long time, the most prominent, symptom is pain in the limbs, spine, and pelvis, of a wandering, shifting character, which the patient usually supposes to be of a rheumatic nature, and which is often so severe as to cause immense distress, especially at night, and in damp, chilly states of the atmosphere. By and by, dyspnoea sets in, with palpita- tion of the heart, and a sense of constriction across the chest, and the patient is seized with an overwhelming feeling of prostration, which utterly unfits him for business, and usually compels him to keep his bed. If he attempts to walk his limbs bend under him, and if the effort be often repeated, they soon become badly curved; should his toe catch in the folds of the carpet, or should he be so unfortunate as to trip, or fall, or give his body a sudden twist, he will probably hear some of his bones crack, and yield under the superincum- bent weight. Emaciation gradually takes place, the appetite is deranged, the skin is bathed with clammy perspiration, the tongue is foul, the bowels are irregular, being either costive or too loose, and the urine, surcharged SOFTENING. 885 with earthy phosphates, is very thick, heavy, of a whitish aspect, and fre- quently also albuminous. In the latter stages of the malady the saliva, tears, and sweat often contain similar ingredients. Great distortion frequently occurs, the bones bending in every direction, and thus effectually disqualify- ing them for the performance of their functions. The chest projects like that of a pigeon, the spine is bent laterally, as well as backwards, the pelvis is twisted, or rotated upon its axis, and the whole stature of the individual is sensibly diminished, the head being thrust down between the shoulders, which are unnaturally arched and prominent. Amidst all this disturbance, how- ever, the intellect is unclouded, menstruation is perfect, and even conception is still possible. The period at which death occurs varies from a few months to several years, its approaches being usually very gradual, and the conse- quence of sheer exhaustion. Diagnosis.—Osteomalacia is liable, as already stated, to be mistaken for rachitis. While it cannot be denied that the two diseases have several fea- tures in common with each other, it is equally certain that they possess suffi- cient points of dissimilarity to justify us in considering them as separate affections. The chief differences are the following: Osteomalacia is rarely seen before the age of twenty-five or thirty, while rachitis is altogether pecu- liar to infancy and childhood, the disease in the former attacking the bones after the completion of ossification, whereas, in the latter, it assails them before they are fully developed. In softening, the patient is harassed with excessive pain and an overwhelming sense of exhaustion ; in rickets, on the contrary, there is a total absence of pain, and the little patient generally retains a good share of strength. In osteomalacia there is more deformity than in rachitis; the disease is also of a more fatal character, few persons getting well, whereas in rachitis recovery is the rule, death the exception. Softening is much more common in women than in men, especially in such as have had several children ; rachitis, on the contrary, is nearly equally frequent in both sexes. In softening the urine always contains a large quantity of earthy matter, whereas in rickets this excretion is usually lateritious. Finally, the two affections are signalized by marked differences in their anatomical character. In osteomalacia the osseous structure is completely disintegrated and decomposed; in rachitis, on the other hand, it is merely modified, and therefore susceptible of restoration. Prognosis___Osteomalacia is generally a fatal disease. Hence Solly and sorae other authors are inclined to regard it as of a truly malignant character. Such an opinion is, of course, untenable, but it serves to show how exceed- ingly unmanageable the disease has hitherto proved to be in the hands even of the best practitioners. The period at which death occurs is very variable, sorae patients dying in a few months, others not under several years. Treatment.—The progress of osteomalacia can be arrested only by causing a change in the action of the secernent vessels, but as we know of no means that are capable of doing this, all that can be done, in the present state of the science, is to endeavor to improve the general health by a well regulated diet and the employment of tonics, as iron and quinine, the shower bath, and change of air. Mercury has occasionally been administered, and carried to the extent of ptyalism, but, instead of proving beneficial, it has generally been productive of injury by still further exhausting the powers of life. Phosphate of lime, as having a tendency to supply the deficiency of osseous matter, has also been tried, but apparently with no better effect. If we adopt the idea that the disease is of an inflammatory nature, antiphlogistics ought to be advantageous, but thus far their employment has yielded no good results, but rather the reverse. When the disease is fully established, confinement in the bed or upon a soft elastic mattress will be necessary, and every pre- 886 DISEASES OF THE BONES AND THEIR APPENDAGES. caution should be taken to avoid the occurrence of curvature and fracture of the affected bones. Pain must be relieved by the liberal use of anodynes. SECT. VIII.—RACHITIS. Rachitis, or rickets, is a disease of the osseous tissue, consisting in a defi- ciency both of its earthy and organic elements, as is shown by the diminished quantity of phosphate and carbonate of Fig. 301. lime, and the absence of chondrin and gelatin, which form such important con- stituents of normal bone. The conse- quence is that the different classes of bone—the long, short, and flat—become so excessively softened as, in time, to yield under the slightest pressure, bend- ing and twisting in various directions, and thus occasioning serious and gene- rally irremediable deformity, as observed in the drawing, fig. 301, taken from a patient iu the Philadelphia Hospital. Rickets is emphatically a disease of early infancy, being most frequently wit- nessed from the eighteenth to the twen- tieth month, although many cases occur before the end of the first year. Now and then an instance is observed as late as the twelfth year; but this is extremely uncommon, and altogether contrary to the usual course of the affection. Occa- sionally rachitis shows itself as an intra- uterine malady. Both sexes are liable to it, and, apparently, nearly in an equal degree. Cases have occurred in which Rickets. it seemed to be hereditary, or in which it attacked several members of the same family. It would appear from the accurate and masterly account of this disease by Glisson, published upwards of two centuries ago, that it first took its rise in the western parts of England about the year 1620, from which it gradually spread over the rest of Europe; where, however, especially in Great Britain, it is now comparatively rare. In this country it has always been extremely uncommon, even among the lower classes, whose children are its most frequent subjects. Causes—Much labor has been spent by writers in endeavoring to ascertain the exciting causes of rickets, but really to so little purpose that our know- ledge regarding it can hardly be said, even at the present day, to be more accurate than it was in the time of Glisson and his immediate successors. From the circumstance of its appearing occasionally in several children of the same family, it has by many been considered as hereditary, nearly all the older, and not a few of the modern, authorities concurring in'this view of its origin. It has also been supposed, and apparently with as little reason, to have an intimate connection with a syphilitic, strumous, or scorbutic state of the constitution. Others, again, have referred its origin to the influence of a vitiated atmosphere, such as results from living in damp, crowded, and ill-ventilated under-ground apartments; but it does not appear, so far as I am able to ascertain, that the children of such residents either in this or other RACHITIS. 887 countries are particularly prone to the complaint; certainly not so much so as to render it a special object of observation. Finally, there are many practitioners who look upon it as being due to the use of unwholesome or imperfect alimentation, causing an impoverished state of the blood, with lesion of innervation and nutrition ; and this is, perhaps, as plausible a view as can at present be taken of the subject. With regard to its connection with scrofula, it may be observed that rickets rarely coexists with tubercle, and also that the former disease does not generally occur so early in life as the latter. If syphilis has any agency in the production of rachitis, it re- quires to be proved, which it has not yet been, that the offspring of persons laboring under that malady are more prone to its attacks than other children. Whatever the exciting cause may be, there is no question that the immediate one is a deficiency of phosphate and carbonate of lirne, upon which the solid- ity of the osseous tissue essentially depends. How far the want of chondrin aud gelatin, which are such important elements of healthy bone, may dis- qualify the osseous tissue in rachitis for the reception of earthy matter is a problem which has not been determined. Morbid Anatomy.—The alterations of the osseous tissue consequent upon this disease may be conveniently arranged under three heads, each possessing marked peculiarities. In the first, the bones seem to be saturated with a reddish, watery fluid; a considerable quantity of which is also interposed between their outer surface and the periosteum, on the one hand, and between the medullary merabrane and their internal walls, on the other. At a raore advanced period, this fluid is replaced by a sort of gelatiniform substance, which, being particularly conspicuous in the situations here specified, be- comes gradually organized and vascular, and ultimately adheres with great firmness to the parts with which it lies in contact. The periosteum is thick- ened and injected, the nutrient vessels are remarkably enlarged, and the medullary membrane is sensibly altered in its character; the changes which it has undergone being similar to those of the fibrous envelop just mentioned, though less in degree. The lamella? of the long bones, naturally so hard and compact, are a good deal softened, while the areolar structure is greatly rarefied, many of the cells being more than double the natural size. Similar alterations are observed in the short and flat bones. In the second stage, a peculiar spongoid substance is formed between the periosteum and the outer surface of the bones, varying from two to three lines, or upwards, in thickness ; and which, by the pressure it exerts upon the lamella? of the compact tissue, soraetimes forces them inwards upon the medullary canal, thus greatly reducing it in size, if not entirely obliterating it. Simultaneously with these changes the bones are rendered so soft that they raay easily be bent, cut, and even indented with the finger. In the third stage—that of resolution—the recently formed substance in the long bones, as well as in some of the flat and short, assumes a compact character, and becomes gradually identified with the pre-existing tissues, which at the same time regain their primitive solidity. Owing to the pre- sence of this new matter, the bones are much larger than in the natural state, and their firmness, especially in the adult, resembles that of ivory. Hence the term eburnation is sometiraes applied to this state of the skeleton. When rachitis proves fatal, the body is usually found in a state of excessive emaciation; the muscles are thin, pale, and flabby; the adipose matter is almost entirely consumed ; the cerebral substance is unnaturally soft; the liver and spleen are enlarged and flaccid ; the intestines are attenuated and distended with gas, and there is not unfrequently marked tumefaction of the muciparous glands ; the mesenteric ganglions are increased in volume and consistence; the heart is softened and smaller than comraon; the lungs, which are often congested, are more or less tuberculized in about one-sixth 888 DISEASES OF THE BONES AND TnEIR APPENDAGES. of the cases; and the bronchical ganglions are hypertrophied, loaded with serosity, and of a deep purplish hue. Occasionally there is partial ossification of the arteries, muscles, and other structures, as if they had become the reci- pients of the earthy matter which naturally appertains to the bones. Symptoms.—The symptoms of rickets possess nothing of a definite charac- ter in the earlier stages of the disease, the approaches of which are generally stealthy, and at times almost imperceptible. The child is observed gradually to lose its health and spirits, becoming dull and listless, and laboring under derangement of the digestive organs, especially flatulence and colicky pains. After a while, marked emaciation sets in ; the muscles are soft and flabby; the abdomen is tympanitic ; the skin is dry and sallow; the face looks pale and doughy; the urine is scanty, turbid, and lateritious; and the alvine evacuations are thin, watery, and fetid, there being nearly always consider- able diarrhoea. Dentition advances slowly, and the teeth, having a black, fuliginous aspect, often begin to decay almost as soon as they have pierced the gums. The fontanels and sutures are more open than in the natural state; and the whole process of ossification is peculiarly slow and imperfect, or, rather, it may be said to be almost stationary, if not actually retrogressive. As the disease advances, the bones grow more and more soft, and, being un- able to sustain the weight of the body or to resist the action of the muscles, are at length strangely and frightfully distorted. The head, although abnor- mally small, is disproportionately large to the size of the face, and is sunk down between the shoulders; the clavicles are bent and extremely salient; the spine is curved in various directions, especially laterally, and diminished in length; the pelvic bones are curved inwards, so as to lessen very materi- ally the corresponding cavity; the ribs are flattened, and the chest, in conse- quence, is sensibly increased in its antero-posterior diameter, giving it a narrow, pigeon-shaped appearance. The bones of the extremities are shortened, bent, and twisted upon their axes, while their articular ends, or epiphyses, are softened, rarefied, and greatly expanded, thus appearing much larger and more prominent than naturally. If the child has begun to walk, he becomes daily more feeble on his legs; he waddles, trips, falls, and soon returns to his nurse's arms. In rachitis, there is an actual arrest of development of the bones, and, although this want of growth pervades the entire skeleton, yet it is always most conspicuous in the lower extremities, the femur, tibia, and fibula being often fully one-third shorter than in the natural state, and also diminished in diameter, except at the epiphyses, which, as already seen, are always unusu- ally large and prominent, especially if the child has been a good deal on his feet. Under such circumstances, the head and neck of the femur are some- times forced by the weight of the body into a horizontal position below the level of the great trochanter; the individual is bow-legged, and the joints of the knee and ankle suffer great distortion from the weakened and relaxed condition of their ligaments. The flat bones, during the reparative process, become solidified and hypertrophied in their areolar texture, while the long ones are increased in thickness and strength along the concavity of their curvatures that they may be the better able to support the superincumbent pressure, and resist the effects of muscular action. Diagnosis.—The only disease of the bones with which rachitis is at all liable to be confounded is osteomalacia or softening. The signs of distinc- tion, however, are commonly very evident. In the first place, rachitis is an affection of infancy and early childhood, whereas mollescence never occurs until after middle age. Secondly, in rickets the softened and flexible state of the skeleton is only temporary; after a time, a process of repair is set up, and, gradually continuing, the affected tissues become at length more firm and compact than they are in the natural state; in osteomalacia, on the con- RACHITIS. 889 trary, the disease, once begun, generally progresses until the patient is worn out by his suffering, no attempt being usually made at restoration. Thirdly, in rachitis there is no material alteration in the urine, whereas in mollescence this fluid is always loaded with a large quantity of earthy salts, the kidneys taking on a vicarious action, and so carrying off the material destined for the supply of the bones. Lastly, in rickets there is an actual arrest of develop- ment, in consequence of which the bones remain disproportionately short, thin, and dwarfish; in softening, on the contrary, the affected pieces retain their normal shape, although they are so changed in their consistence that they may readily be cut and bent in almost any direction. Prognosis.—The prognosis of rachitis is generally unfavorable, for, although many patients escape with their lives, yet few recover without permanent deformity. In regard to the danger to life, it is commonly in proportion to the number of bones affected, the rapid progress of the com- plaint, and the age of the subject. Experience has determined that very young children are more liable to die of it than those who are more advanced in years, and those who are born of scrofulous parents than those who come into the world under more happy auspices. The duration of the disease is extremely variable ; being very tardy at one time, and very rapid at another. In general, even under the most favorable circumstances, several years elapse before complete recovery occurs. The progress of the cure is often fatally arrested by some intercurrent malady, as measles, scarlatina, smallpox, or cholera. The longer recovery is postponed, the greater will be the danger of serious deformity. The duration of life is not necessarily shortened in persons who get well of rickets, cases having occurred of their having attained the age of sixty, seventy, or even seventy-five. Treatment.—The treatment of rachitis is far from being satisfactory, or based upon sound philosophical principles. If, as has been asserted, every evil has its remedy, it is certain that human ingenuity has not yet succeeded in discovering any for this. The first point which it is of importance to in- culcate is that, in rachitis, active measures are out of the question, our chief reliance being upon a properly regulated regimen and the use of tonics, with a view to the invigoration of the general system, and an improved condition of the blood, which, although it has never been thoroughly investigated in this disease, is beyond doubt materially altered in some of its component elements. Whatever, therefore, has a tendency to strengthen the patient, and enrich the circulating mass, must prove indirectly beneficial in removing the disease, and should claim serious consideration in every case. The diet should be mild and nutritious, comprising an adequate amount of nourishment in the smallest possible space, so as not to oppress the stomach and create flatulence and acidity. The best article will, of course, be the mother's milk, or, when this is insufficient or unwholesome, fresh cow's milk, or, better still, the milk of the ass, which is now so much used in some of the larger cities of continental Europe, and which approaches nearer, in its com- position, to human milk than that of any other animal. If the teeth are properly developed, a small amount of animal food will be useful, especially fat bacon, well boiled, and not too salt, with good stale bread, and a little mashed potato. The body should be washed at least twice a day with salt water, followed by dry friction, or rubbed with a moderately stiff salt towel; and, if the system be not too much reduced, cool or cold bathing will be found highly invigorating. Frequent exposure of the little patient to the fresh air, and exercise suited to his age and strength, are to be rigorously enforced. The secretions are to be improved by alteratives, especially blue mass aud mercury with chalk, while the bowels must be kept soluble with rhubarb or oil, and acidity be allayed by the alkalies, especially lime water and bicarbonate of soda. 890 DISEASES OF THE BONES AND THEIR APPENDAGES. Tonic medicines, particularly quinine and iron, given in small doses, and long continued, with an occasional intermission for a few days, are always imperatively indicated, and there are few cases which are not promptly bene- fited by their exhibition, especially in the early stages of the disease, although they are nearly equally useful throughout its entire progress. The mineral acids, and the tincture of the chloride of iron, have long been favorite medi- cines, both with the empiric and the regular practitioner, and are particu- larly advisable when there is a coexistent scorbutic condition. Alterative doses of mercury occasionally exercise a salutary influence, especially when the patient labors under the strumous diathesis, the best form being the bichloride, in combination with a small quantity of iodide of potassium, dis- solved in water. The pain, which is often considerable, is controlled by opiates, either alone, or conjoined with diaphoretics. Lately, the phosphates, which were formerly so much employed in the treatraent of rachitis, on the ground that they would tend to supply the defi- ciency of earthy matter, have again come into vogue, but it remains to be seen whether they really possess any advantage over the more ordinary tonic remedies, already referred to, or whether they are not, indeed, inferior to them. Their best form of exhibition is the syrup. Doubtless, however, the best remedy of all in this complaint, so far as any individual article is concerned, is cod-liver oil, given several times a day, in doses suited to the age and other circumstances of the patient. Possessing highly nutritive and alterative properties, it is admirably adapted to support the system, to enrich the blood, and to improve the secernent powers, which are so much at fault in rachitis. It may be administered either alone or in union with some of the more important tonics above mentioned. Finally, the bed on which the rickety child sleeps should be perfectly smooth and somewhat elastic, so as not to permit the affected bones to sink down into any depressions or hollows, and so become bent and distorted. No pillow should be used, the head, body, and limbs all resting on the same plane. The clothes should be loose and light, but sufficiently warm to afford the requisite protection to the surface. In the earlier stages of the com- plaint, mechanical contrivances may not only be regarded as altogether inef- fectual, but as pernicious ; by and by, however, as the bones become softened, they should be supported with appropriate apparatus, to prevent deformity. Walking must, of course, be avoided as long as the extremities are unable to bear the weight of the body. SECT. IX.—FRAGILITY. Fragility of the osseous tissue is one of those affections which are to be regarded rather as an effect of disease than as a disease itself. It consists, as the name implies, in a peculiar brittleness of the bones, in which, especi- ally in its more advanced stages, their substance is so completely changed in its character as to give way under the most trivial circumstances. All the bones are liable to this morbid brittleness, and cases occur, although rarely, where it literally pervades the whole skeleton. In 1857, the body of a female, supposed to be upwards of seventy years old, was brought into the dissect- ing-rooms of the Jefferson Medical College, with upwards of eighty fractures, received a few days before in a fall from a third story window upon the pave- ment below. Nearly all the ribs, several of the vertebra?, and a number of the long bones were broken, and signs of former fractures existed in the humerus, thigh, scapula, and other pieces. Devergie examined the body of a woman who died under symptoms of fragility, in whose skeleton there were not less than eighty-three fractures. Dr. Gibson met with a young man, FRAGILITY. 891 whom I also saw many years ago, the bones of whose extremities were re- peatedly broken by the most trivial accidents. The clavicles had suffered still more frequently, having been fractured altogether eight times. This universal fragility of the osseous tissue occasionally occurs at a very early period; sometimes, indeed, even in the foetus in the womb. Chaussier met with a remarkable example of this kind, where the long bones had expe- rienced not less than one hundred and thirteen fractures, some being at the time perfectly consolidated, thus showing that they had taken place some time previously, while the rest were either recent or had partially united. The child survived its birth only twenty-four hours. General fragility, how- ever, is a comparatively rare affection; usually it is limited to particular bones, or, still more commonly, to particular portions of a bone; and those which are most prone to suffer are the head and neck of the femur, the ribs, sternum, radius, ulna, clavicle, and superior extremity of the humerus. When the affection exists in its highest state of development, the slightest accident is frequently sufficient to produce fracture, as a severe fit of cough- ing, kneeling upon a hard floor, or turning about in bed. Sometimes, in- deed, the fragility is so great that the individual cannot be touched rudely, without the occurrence of the injury. Of this description was the memora- ble case of the woman, whose history has been recorded by Saviard, who could not be moved about in bed without breaking some of her bones. After a confinement of six months she died, wheu it was found that she had had fractures in all the long bones of the extremities, as well as of the clavicles, ribs, vertebra?, and pelvis, many of the pieces being so brittle that they could not be handled without crumbling into fragments, similar to old, dry bark. Causes.—Fragility of the bones comraonly comes on without any assignable cause, and the general health not unfrequently continues good until a long time after it has made its appearance. In most cases, if not in all, it is merely symptomatic of some other disease, particularly of rheumatism, gout, syphilis, scrofula, and scurvy, attended with an altered and impoverished state of the blood, and impairment of the assimilative powers. The bones themselves are very much in the condition in which they are in osteomalacia, that is, their substance is more or less softened, in consequence of the removal of a large proportion of their phosphatic material, and they are often so completely saturated with fat as to render them unfit for preparations. On the other hand, however, they are sometimes remarkably dry and brittle. These facts would seem to show that their intimate structure undergoes some important anatomical change, the immediate result, it would appear, of inflammation, not of an active but tardy character. What tends to support this view of the nature of the affection is the circumstance that long before the bones manifest any disposition to break, the patient is harassed with severe pains, deep- seated, fixed, and referred to particular portions of the skeleton, and that, npon dissection, the diseased parts are generally found to be extremely vas- cular, their areolar structure being profoundly injected and infiltrated with bloody matter, apparently impoverished lymph, while the periosteum is very thick, spongy, and highly congested. Fragility of the bones is one of the usual attendants upon old age. As we advance in life, their vascularity sensibly diminishes, many of the vessels shrinking down, and becoming finally entirely obliterated. It is owing to this circumstance that old persons, especially females after the fifty-fifth and sixtieth years, are so much more liable to fracture than to dislocation, the part most prone to yield being the neck of the femur within the capsular ligament, whose areolar tissue is often astonishingly rarefied, while the com- pact is hardly as thick as ordinary letter paper. This affection is sometimes observed in several members of the same family. 892 DISEASES OF THE BONES AND THEIR APPENDAGES. Dr. Pauli, of Landau, has related an instance where it was distinctly trace- able through three generations on the father's side. All the grandchildren, five in number, had each had several fractures, one as many as five, in the bones of the extremities, and that mostly as the result of inconsiderable injury. They were all remarkably healthy, and there was no evidence in any of them of a scrofulous taint of the system. Symptoms.—There are, unfortunately, no reliable signs in this affection. Hence it is usually overlooked until it has reached its highest point of de- velopment, when it is always incurable. In general, the person is laboring under severe pain, which is usually regarded as of a gouty, rheumatic, or syphilitic character, and which is rarely, under any circumstances, referred to its proper source, until after the occurrence of curvature, or fracture, from causes so slight as to awaken, for the first time, a suspicion of the existence of disease of the osseous tissue. As the disorder progresses, the appetite and strength become impaired, the pains increase in violence, and the urine is surcharged with earthy constituents, especially phosphate and carbonate of lime. This alteration in the urine is observable at an early period, and, in general fragility, goes on gradually augmenting down to the time of death, which happens at from six to eighteen months, the patient meanwhile being perfectly bedridden. There are, then, only two circumstances which can be at all relied upon as diagnostic of this complaint; one is the severe and intractable character of the pain, deep-seated, and usually referred to the bones ; the other, the altered condition of the urine, as declared by the presence of an inordinate quantity of earthy matter, especially phosphatic. When these co-exist, the suspicion will be strong that there is serious lesion going on in the skeleton, and this suspicion will be converted into certainty when, superadded to them, there occurs, without any considerable external violence, curvature, fracture, or displacement of some of the bones. Fragility, like softening, may generally be looked upon as an incurable affection. The only exception, perhaps, to this rule is when it occurs as an effect of the syphilitic or rheumatic poison, and even then it seldom admits of complete relief unless it presents itself in a very circumscribed form. The fragility of old age is always incurable. Treatment.—No rational treatment has yet been laid down for this disease, nor will it be possible to do so until we shall have more enlightened views of its etiology, pathology and diagnosis. Until, therefore, we are placed in possession of substantial information upon these points, our treatment must necessarily be altogether empirical. In all cases, strict inquiry should be instituted into the origin of the disorder, when such remedies should be ad- ministered as the result may seem to indicate. As a general rule, it raay be stated that bleeding, except in very robust habits, is quite inadmissible, and even active purgation usually proves injurious. A touic and supporting course, cousisting of the different preparations of iron and quinine, and of the syrup of the phosphates, along with cod-liver oil, and vegetable acids, especially the citric, and a well-regulated, nutritious diet will afford the best chance of relief. Iodide of potassium and bichloride of mercury may be given in the syphilitic variety of the disorder; while in the gouty and rheu- matic forms, colchicum would probably prove beneficial. To relieve the ex- cessive pain which is so prominent a symptom in the latter stages of the affec- tion, especially when it involves a large portion of the skeleton, anodynes must be given in full doses once or twice in the twenty-four hours. Curvatures and fractures must be treated upon general principles. In most cases, the bones unite nearly as readily as under ordinary circumstances; sometimes, however, the process is very tedious, and at other times they refuse alto- gether to unite. ATROPHY. 893 SECT. X.—ATROPHY. 302. Atrophy of the osseous tissue is characterized by the partial absorption of its elementary constituents, as is evinced by its lightness and porosity. It may occur in any portion of the skeleton, but the long bones are oftener affected than the short or flat. Like hypertrophy, it may be partial or gene- ral ; that is, it may involve an entire piece, or be limited to a particular part of it. Atrophy, moreover, may be concentric or eccentric. In the former variety the bone is diminished in its diameter; in the latter it retains its original size, but is reduced in weight, and rarefied in its tissue. The causes under the influence of which it may take place are, protracted pressure, chronic inflammation, deficient nervous influence, and insufficient supply of arterial blood. a. The influence of pressure steadily exerted for a considerable length of time, in producing atrophy of the osseous tissue, is well exemplified in the cranial bones in tumors of the dura mater; in the sternum and dorsal ver- tebra? in aneurism of the aorta; and in the ribs in cancer of the mammary gland. In all these instances the compact substance is reduced to a thin, translucent plate, while the spongy texture is either wholly destroyed, or worn down to a few slender threads. The immediate cause of the wasting process here is absorption, acting simultaneously and equally upon the animal and earthy constituents. b. Atrophy from chronic inflammation is probably infrequent. One of the best specimens of it that I have ever seen occurred in a colored woman, who died of pulmonary phthisis at the age of forty. The body was much emaciated, and all the long bones were remark- ably reduced in weight, though they had experienced no change in their external configuration. The compact substance was wasted to a mere shell, scarcely thicker than common wrapping paper, while the cells of the spongy texture were increased many times beyond the natural size. The medullary canal was much enlarged, and filled with a greasy, reddish substance, not unlike fresh adipocire. These appearances are well shown in fig. 302, and afford a beautiful illustration of the eccen- tric form of atrophy. Atrophy is sometimes the result of local injury, as a blow, wound, or contusion. The wasting in this case raay be limited to the site of the original mischief, or it may extend to the entire bone, which, however, is rare. In what manner such an injury operates, whether through the agency of inflammatory irritation, or otherwise, in giving rise to atrophy, is unknown. c. Deficient nervous influence is a frequent cause of atrophy both of the osseous tissue and of the soft parts. In paralysis of the lower extremities, there is generally notable wasting, not only of the muscles, but also of the long bones, which are greatly reduced in weight, rarefied in their texture and diminished in size. d. The effect of a diminished supply of blood in inducing atrophy of bone is sometimes very conspicuous in old fractures. In such injuries there is often considerable wasting of the osseous tissue, in consequence merely of the obliteration of the nutrient artery by the pressure of the callus. The atrophy is always eccentric, and is usually limited to one-third, one-half, or two-thirds of the affected bone, according to the seat of the original injury, or, more Atrophy of bone. 894 DISEASES OF THE BONES AND THEIR APPENDAGES. properly speaking, the quantity of the new matter, and the extent of the vascular obliteration. e. Finally, there is what is termed senile atrophy. In old age, the bones are rendered light, porous, and brittle; the compact substance is reduced to a mere parchment-like shell, while the areolar texture is remarkably rarefied or expanded ; the muscular prominences are diminished in size ; the animal matter is partially absorbed; and many of the vessels are obliterated. These changes are nowhere more conspicuous than in the neck of the femur, which, in consequence, often breaks from the most trifling causes, and which, after this occurrence, is seldom, if ever, repaired by osseous matter. Fig. 303 is Fig. 303. Fig. 304. Atrophy of cellular structure of the Advanced stage of senile atrophy thigh-bone. of the thigh-bone. a section of a well-marked specimen of this kind ; the internal structure is very much rarefied; and the head of the bone, flattened and expanded, is approximated to the shaft, from the partial absorption of its neck. Fig. 304 exhibits the affection in a still more advanced stage. Atrophy of the osseous tissue does not admit of cure. All that the surgeon can do is to amend the general health, when that is at fault, and to remove any local causes of disease when they are found to exist. SECT. XL—HYPERTROPHY. Hypertrophy of the osseous tissue may be partial or general; that is, the abnormal growth may affect either a portion or the whole of a bone. The latter, however, is a very rare occurrence, though perhaps not so much so as has been imagined. Cases, indeed, not unfrequently occur in which the broad bones of the head present an extraordinary degree of development, being raore than an inch in thickness, and so hard that it is almost impossible to saw them. Under these circumstances, the two tables are extremely compact, the intermediate spongy structure being totally obliterated, or, rather, re- HYPERTROPHY. 895 placed by dense earthy matter. Similar appearances are sometimes witnessed in the cylindrical bones of the extremities. In an old femur in my private collection, the medullary canal is scarcely large enough to admit a common- sized quill; the whole shaft consists almost entirely of compact substance, in Fig. 305. General hypertrophy—internal structure. Fig. 306. General hypertrophy—external characters. many places more than six lines in thickness. The bones of the male are always larger and more distinctly developed than those of the female, and the bones of persons who take much ex- ercise than those who are indolent, or in- Fig. 307. active. By labor, their weight and dimen- sions increase; their spongy structure diminishes, whilst the compact becomes harder and more dense, and acquires an almost rock-like solidity; the muscular prominences are rendered more conspicu- ous ; in short, everything indicates that they are in a state of general hypertrophy. The osseous tissue usually contains a due proportion of animal matter, and hence it does not readily yield under external injury. The adjoining cuts are excellent repre- sentations of general hypertrophy of the femur of a man affected with tertiary syphi- lis. Fig. 305 is a section of the bone ex- hibiting its interior structure, which is very much condensed throughout, except at the superior extremity, where there are still some remains of the areolar tissue; the medullary canal is entirely obliterated, and the weight of the bone is nearly twice as great as in health. Fig. 306 shows the external appearance of the bone. The drawings are from a specimen in my cabinet. The adjoining sketch, fig. 307, is a speci- men of hypertrophy of the bones of the leg and foot, both in thickness and length. It Hypertrophy involving both the thickness and length of the bone. 896 DISEASES OF THE BONES AND THEIR APPENDAGES. is from a drawing of a preparation in the collection of Professor Buchanan, of Nashville. All the bones are much enlarged, increased in weight, and anchylosed, at the ankle, tarsal, and metatarsal joints. The interosseous ligament was completely ossified. The foot and leg had been the seat of ex- tensive ulceration, followed by exfoliation from the hypertrophied bones. General hypertrophy of the bones is usually incurable. It is only, or chiefly, when it depends upon a syphilitic taint of the system that it admits of relief; but as this subject has already been fully discussed elsewhere, it is not necessary to revert to it here. SECT. XII.—TUMORS. The bones, like the soft structures, are liable to two classes of tumors, the innocent and the malignant. The former includes exostosis, fibro-car- tilaginous growths, aneurism, hematoid formations, serous cysts, hydatids, and myeloid tumors; the latter, encephaloid, colloid, scirrhus, and melanosis. INNOCENT FORMATIONS. 1. EXOSTOSES OR BONY TUMORS. An exostosis, of which fig. 308 affords a good idea, is an osseous out- growth, the word, wdiich is a Greek compound, signifying a bone growing from a bone. It is in fact a local hypertrophy, a circumscribed tumor, pos- sessing essentially the same structure as the bone from which it springs, and with whose substance it is usually intimately identified. There is perhaps no term in surgical nomenclature which has been more abused than this, or which has been applied to so many different and almost diametrically opposite diseases. Among those who have especially contributed to bring about this confusion may be cited the name of Sir Astley Cooper, who, under the ap- pellation of exostosis, has described almost every variety of tumor, whether benign or malignant, whether fleshy, fibrous, cartilaginous, or osseous, con- nected with or growing from a bone. This classification, which was for a Fig. 308. Exostosis of the thigh-bone. long time blindly followed by most writers, has recently given way to a more correct appreciation of the subject, and I know no pathologist whose opinion is worth much who does not consider an exostosis as essentially a local hypertrophy, free from malignancy, formed in the same manner as the primi- tive osseous tissue, and composed essentially of the same anatomical elements; in short, as a bone growing from a bone, and not upon a bone. Exostosis is observed chiefly in young and middle-aged subjects, being very infrequent before puberty, and after the fiftieth year. It is more com- raon in males than in females, and is generally confined to particular bones, as those of the cranium and of the extremities, particularly the femur, and the phalanx of the great toe. The superior maxillary sinus is occasionally the seat of this disease. In a EXOSTOSES OR BONY TUMORS. 897 specimen in my Collection, the inner surface of the left antrum is literally studded with these growths, none of which exceed a small grain of wheat, which they also much resemble in shape. The tumor sometimes acquires an enormous bulk, and cases occur in which both cavities are affected simulta- neously, though not in the same degree. In the flat bones, as those of the head and pelvis, the outgrowth may occur upon either surface; in general, however, it evinces a preference for the external one, probably because it has a more perfect periosteura. When the tumor is attached to the inner surface, its tendency is to encroach raore or less seriously upon the contents of the cavity which the bone assists in form- ing. These internal exostoses, as they may be termed, are most common in the cranial bones of syphilitic subjects. A tendency to exostoses is sometimes observed in several members of the same family. A few years ago, I had a lady under my charge on account of a tumor of this kind on the shaft of the left radius, whose sister and brother had each a similar enlargement, the former on the occipital bone, and the latter on the clavicle. Boyer gives the particulars of a case where the disease was hereditary, the patient's father, brothers, sisters, nephews, and children, having all suffered in a similar manner. The number of these outgrowths varies from one to a considerable number. In general, they are solitary ; but cases occur where there are a great many, as if there existed a sort of exostosic diathesis, as in fact there does under such circumstances. In the Mutter collection is the skeleton of a female in which a large number of bones are thus affected. Exostoses sometiraes observe a symmetrical arrangement, tumors of the same size and shape occurring at the same points of the corresponding bones of the two sides. Such a disposition is occasionally witnessed on the frontal bone and lower jaw, but is most common on the humerus and femur, espe- cially the inferior extremities of these pieces. The volume of these growths is subject to no little diversity, some being very small, while others are extremely large, cases being occasionally noticed where they are of the size of an adult head. The most voluminous are usually found upon the bones of the extremities, particu- larly the lower part of the femur, though they are also sometimes seen upon the cranial, facial, and pelvic bones, where their presence is a source of the most hideous deformity. Their shape is also very variable ; some- times they have a distinct, well-defined outline, being of a globular, ovoidal, or hemispherical figure ; occasionally they jut out like long, slender spines or stalactites ; in another series of cases, they have a knobby, nodulated, tubercular, or mammil- lated appearance; and, lastly, instances occur, although they are rare, in which they present themselves in the form of plates or lamella?. These varieties of shape are doubtless entirely due to accidental circumstances; but they, nevertheless, de- serve attention, on account of their prac- tical relations. In regard to their surface, this may be either perfectly smooth, scabrous, or spiculated ; most generally the latter. The adjoining sketch, fig. 309, represents a remarkable form of exostosis, vol. I.—57 Exostosis of the femur. 898 DISEASES OF THE BONES AND THEIR APPENDAGES. from a drawing of a specimen kindly presented to me by Dr. Lewis, of Alexandria. It grew upon the right femur of a lady, fifty-one years old, having commenced when she was only nine years of age. The tumor, before removal, was about the volume of a cocoa-nut, oval, smooth, and very hard. The integuments over its summit had latterly become inflamed and ulcerated, followed by a discharge of sanious matter, and the protrusion of a portion of bone. The general health becoming somewhat impaired, amputation was performed at the lower third of the thigh, the woman making an excellent recovery. This case is additionally interesting frora the circumstance that several of the relatives of the patient had been affected with similar tumors. Causes.—The origin of exostoses is involved in doubt. There is no ques- tion that, in the great majority of instances, they arise without any assignable cause whatever. On the other hand, they can often be traced directly to the effects of external violence, such as a blow or kick. In the distal phalanx of the great toe, which is not an uncommon seat of the disease, it would seem probable that the pressure of a tight boot is able to produce it. Exos- tosis in the stump after amputation of the thigh and leg is probably caused by the jarring which the femur and tibia experience during the operation of sawing, aided, perhaps, by a partial laceration of the periosteum. A syphi- litic taint of the system has generally been considered as an excitant of the complaint, and that it is capable of exerting such an influence hardly admits of doubt. Nevertheless, it is extremely probable that its agency has been greatly overrated; for I can recall but few cases that have come under my observation where it was possible to trace the relationship in a satisfactory manner. Rheumatism and gout are also often accused of causing exostosis, and although it is impossible, in the existing state of the science, to deter- mine the character and degree of their agency in this respect, yet sufficient is known to justify the belief that it is very considerable. However this may be, it is extremely probable that these diseases play a most important part in the production of general exostoses, the history of most of the cases of the kind clearly proving such a connection. Whatever may be the exciting cause of exostosis, there can be no doubt that the immediate cause is inflammation leading to a deposit, in the first instance, of plastic matter, and afterwards, of osseous, the process of develop- ment being precisely similar to that which presides over the formation of the original bone. The concomitant inflammation is not always seated exclu- sively in the bone, but partly in the bone and Fig. 310. partly in the periosteum ; and cases occur where there is reason to believe that the latter is mainly involved in the production of the turaor. Structure.—In regard to its structure, an ex- ostosis differs in no wise frora healthy bone. It is essentially composed of two parts, a compact and an areolar, the former inclosing the latter like a dense, firm layer, varying in thickness frora the sixth of a line to a quarter of an inch, according to the volume of the turaor. The compact substance sometimes constitutes the greaterbulk of the morbid mass, and there are cases, especially when it in- volves the cranium, where it is of the consistence of ivory, being so close and hard as to render it extremely difficult to saw it. Such a structure is represented in fig. 310, from a specimen in my collection. The areolar texture is sometimes di- An ivory-iike exostosis, showing rectly continuous with that of the bone from which its internal structure. the exostosis grows ; at other times, however, it EXOSTOSES OR BONY TUMORS. 899 is independent of it, being either in immediate contact with the compact structure, or separated from it by a stratum of fibro-cartilage, cartilage, or fibrous tissue. Its cells are of variable size and form, and are generally loaded with fatty matter, just as in a short bone of the skeleton, or in the articular extremity of the long. The identity of the structure of exostosis with that of natural bone is proved, moreover, by chemical analysis. Even when the new substance is of unusual firmness, as in the eburnized variety of exostosis, the difference is much less than might, at first sight, be imagined. The following comparative analyses of healthy bone and of an ivory exostosis, by Berzelius, places the subject iu a strong light. The principal difference, it will be observed, consists in the presence, in the latter, of an unusual quantity of phosphate of lime, and in a marked diminution of carbonate of lime and salts. Healthy Bone. Eburnized Exostosis. Animal matter .....33.30 28.57 Phosphate of lime and magnesia . . 54.20 68.88 Carbonate of lime and salts . . . 12.50 2.00 Loss ......00.00 00.55 100.00 100.00 When an exostosis is seated in a part of the body which is habitually the subject of considerable motion, as, for example, the inferior portion of the femur, it is usually surrounded by a distinct capsule, a sort of synovial burse, the object of which evidently is to ward off friction and facilitate gliding. The inner surface of the capsule, which is of a fibro-cellular nature, and of variable thickness, is perfectly smooth, unadherent, and lubricated by a sero- oleaginous fluid, so as to qualify it the better for the performance of its func- tions. Where no motion is required, the growth lies in immediate contact with the natural structures, the union between them being commonly so inti- mate as to demand a careful use of the knife to effect their separation. Oc- casionally, indeed, the soft parts are partially imprisoned in the osseous tumor, thereby rendering the dissection peculiarly tedious and difficult. Progress.—The progress of this disease is generally tardy; it is only now and then that a case occurs which pursues a different course, or where the symp- toms partake of an acute character. A syphilitic exostosis occasionally attains a considerable bulk in a short time, and the same thing has been observed, though less frequently, in the rheumatic form of the complaint. Under such circumstances, the formation of the tumor is generally attended with severe pain, liable to nocturnal exacerbations, tenderness and swelling of the part, and more or less constitutional disturbance. Ordinarily, however, there is nothing of the kind; the disease comes on slowly and almost imperceptibly, the first thing that arrests attention being a small tumor, which is altogether insensible, and exceedingly tardy in its progress, years elapsing before it acquires the size, perhaps, of a pullet's egg. If it be superficial, so as to admit of examination, it will be found to be hard and immovable from the first, and so it generally continues ever afterwards, whatever may be its bulk. Mean- while, although it may itself be entirely indolent, yet it may be productive of pain in the surrounding structures, by the compression which it exerts upon the nerves, and in this way the suffering is sometimes rendered exceedingly severe, being often of a neuralgic character, darting about in different direc- tions, and extending far beyond the seat of the bony growth. When the tumor is situated in parts which are much exposed to motion, these parts are liable to become inflamed and tender, thus greatly aggravating the local dis- tress. As the raorbid mass enlarges it must necessarily act obstructingly, interfering with the functions of the affected structures, and ultimately, per- haps, entirely abolishing them. Thus an exostosis of the orbit may continue to increase until it pushes the eye completely out of its socket, not only filling 900 DISEASES OF THE BONES AND THEIR APPENDAGES. the whole cavity, but encroaching more or less extensively upon the cheek and cranium. In a similar manner a bony tumor may project into the pelvis, and materially impede the delivery of the child. An exostosis of a rib may compress the lungs; of a vertebra, the spinal cord; of the cranium, the brain. Another effect which such a tumor produces is to stretch, flatten, and displace the muscles, tendons, nerves, and vessels, thereby partially disquali- fying them for the exercise of their functions. Sometimes the coverings of the tumor are invaded by ulceration and even gangrene, thereby more or less freely exposing its surface, which occasionally, in its turn, takes on the same kind of action. At other times the morbid mass perishes, apparently from the want of nourishment, and is detached very much in the same manner as a slough of the soft parts. Exostoses of im- mense volume occasionally experience such a fate. The occurrence will be most likely to happen when the tumor has a narrow, cartilaginous base. Diagnosis.—The diagnosis of exostosis cannot always be easily determined unless the tumor is situated superficially, when its great firmness and immo- bility will generally serve to point out its true character without any difficulty. When the tumor occupies some internal cavity, its nature may be suspected, but no surgeon, however skilled in the art of discrimination, can positively say to what class of growths it really belongs. Besides, an exostosis may sometimes seriously interfere with the diagnosis of other affections. Thus, a tumor of this kind, occupying the pelvic cavity, may impinge against the bladder, or even project into it, in such a manner as that the sound, coming in contact with its surface, shall impart a noise and sensation similar to those communicated by the presence of a calculus. Prognosis.—The prognosis of this complaint varies. So long as the tumor remains small and indolent, it may commonly be considered as of little conse- quence ; but when it increases rapidly, or is so situated as to interfere with the functions of a joint, or to encroach upon an important organ, it becomes a matter of serious import; the more so, because it is then not always pos- sible to get rid of it by an operation, and there is generally nothing else that can reach it. When an exostosis projects into a joint, an operation becomes a hazardous undertaking, liable to be followed by the worst results; and when it occupies an internal cavity it is generally utterly inaccessible. An exostosis of the inner surface of the cranium usually proves dangerous by determining epilepsy, paralysis, and other bad symptoms; in the pelvis it may, as already stated, interfere with parturition, and in alraost any part of the body it may induce neuralgia. Treatment.—The treatment of exostosis must be guided, in great degree, at least in the earlier stages of the disease, before the tumor has acquired any considerable bulk, by the nature of the exciting cause, and hence special inquiry should always be made with reference to this particular point. When there is reason to believe that the affection has been occasioned by a deranged state of the system, or induced by the action of the rheumatic, gouty, or syphi- litic poison, colchicum, aconite, and iodide of potassium, either alone, or in conjunction with bichloride of mercury, will be indicated, and can hardly fail, if judiciously administered, to prove highly beneficial. Under the influence of these remedies the growth of the tumor is often promptly arrested, and ultimately even entirely dispersed. The use of mercury is particularly ser- viceable in these cases, but to produce its full effects it is generally necessary to carry it to the extent of gentle ptyalism, maintained for sorae time, espe- cially in obstinate cases. When the complaint gives rise to much pain, opium, conjoined with diaphoretics, will be required. Topical applications are particularly useful when the tumor is of rapid growth, exquisitely sensitive, and the result of external injury, or of a syphi- litic taint of the system. In the earlier stages of the disease, the remedies FIBRO-CARTILAGINOUS TUMORS. 901 most to be relied upon are leeches, blisters, saturnine lotions, and the tinc- ture of iodine, employed in the ordinary way. If blisters be used, and my experience is that they are generally the most valuable of all topical means, the skin over the tumor should be raised very thoroughly, and a free discharge should afterwards be maintained by some stimulating unguent, the object being to excite a permanent pyogenic effect. In the syphilitic form of exos- tosis, mercurial fumigation sometimes answers a good purpose, succeeding when all other remedies fail. When the tumor has attained considerable bulk, and, above all, when it is of long standing, and of great firmness, or productive of excessive suffering, the only chance of relief is ablation, or, if this be impracticable on account of the nature and extent of the exostosis, amputation of the affected limb. The incisions through the integuments are made as in cases of ordinary growths, the most eligible shape being the crucial, elliptical, or T-like. Free exposure is effected, and in doing this care is taken not to interfere with any important structures, the division of which might afterwards impair the use- fulness of the parts. If the skin is diseased, or much attenuated, the affected portion is, of course, removed. The exostosis is then attacked with the knife and a common metacarpal saw, the former alone, if stout, being commonly sufficient to effect ablation when the tumor has a cartilaginous base, or an unusually soft structure. -In general, however, the saw will be necessary, and there are many cases where the gouge, chisel, aud trephine may advantage- ously be employed. If the tumor has a very large base, and is insensibly confounded with the substance of the bone from which it grows, it should be divided into several sections, by perforating it at different points, and then detaching them separately, or piecemeal. Yarious kinds of saws have been invented for removing exostoses, but they are all raore or less complicated and unwieldy, and may well be replaced by the more simple instruments in common use. In whatever manner the ablation be effected, there is one cir- cumstance which should claim special attention, and that is to make the bony wound as smooth as possible by means of the raspatory, otherwise the rough surface will serve as a serious obstacle to cicatrization. As it is, there will, in any event, be more or less suppuration,, retarding the progress of the case, and the patient may congratulate himself if he escape erysipelas and other serious consequences. The hemorrhage attending the operation is usually very slight. The edges of the wound should be lightly approximated, and the parts kept constantly wet with water-dressing, either cold, cool, or tepid, according to the exigencies of each particular case. 2. FIBRO-CARTILAGINOUS TUMORS. The fibro-cartilaginous tumor, the enchondroma of recent writers, depicted in fig. 311, may be deve- loped in the cancellated structure, or upon the outer surface of the bones, beneath the periosteum. Its figure is globular; its surface rough, or nodulated; its consistence firm, dense, and elastic ; its color white, or grayish. When boiled, it yields a peculiar form of gelatin, termed chondrin. The tumor is essentially composed of a fibrous and of a cartilaginous substance. The former constitutes the nidus in which the latter is deposited, and consists of a vast number of oblong or rounded cells, from the size of a clover-seed to that of a pea. These cavities cannot generally be distin- guished until the cartilaginous element has been scraped away, or removed by maceration. The morbid mass is strikingly conglomerate, and often attains a large Fig. 311. Fibro-cartilaginous tumors of the hand. 902 DISEASES OF THE BONES AND THEIR APPENDAGES. bulk. When it originates, as it commonly does, in the central part of the bone, it gradually encroaches upon the compact tissue, which it expands into a thin, porous shell, either entirely osseous, or partly osseous and partly cartilaginous. Finally, the attenuated lamella gives way at one or more points, and thus allows the raorbid growth to protrude beneath the peri- osteum, which is itself often very much altered in its character. This tumor ordinarily affects only one bone, is not malignant, and is pro- ductive of little inconvenience, except from its size. It is peculiar to early life, is often directly chargeable to external violence, manifests no tendency to degeneration, not even when of long standing, is generally slow in its pro- gress, and occasionally appears simultaneously in several parts of the skeleton. Every portion of the osseous system is liable to it; but the pieces most fre- quently affected are the metacarpal bones, the phalanges of the fingers, the humerus, and the lower jaw. To the turaor now described, especially when it is hard, fibrous, and interspersed with the debris of osseous matter, or red and dense, like half-boiled beef, or fresh pork, the unmeaning title of osteo- sarcoma is usually applied by surgical writers. When the disease is of long standing, the growth sometiraes undergoes partial ossification, as in the speci- men represented in fig. 312. Fig. 313 exhibits a fibro-cartilaginous tumor of the ribs, from a drawing of a preparation in my collection. Fig. 312. Fig. 313. Enchondromatous tumor undergoing ossiflca- Enchondromatous tumor of the ribs. a. External tion. appearance, b. Internal structure. The only remedy for this affection is free excision. All local and general means, even in its earlier stages, are unavailing. 3. ANEURISMAL TUMORS. Aneurism of the osseous tissue consists in an extraordinary development of the minute vessels, and presents precisely the same anatomical features as aneurism by anastomosis of the soft parts. Confined usually to one bone, it may occur in several, or even in a considerable number. In one case it was discovered in the cranium, sternum, ribs, vertebra?, and innominate bone of the same subject. Its favorite seat is the upper extremity of the tibia, ANEURISMAL TUMORS. 903 just below the knee. It raay arise at various periods of life, but is most common in young adults. The tumor varies in volume from a pullet's egg to a cocoa-nut. The disease always begins in the cancellated structure, which is converted into chambers of various sizes, filled with coagulated blood, disposed in con- centric layers, as in old aneurismal tumors. Some of the cells occasionally contain fluid blood, or blood partly fluid and partly clotted; but this is rare. The outer table of the bone is expanded, attenuated, and perforated, or so soft, flexible, and elastic that it may be bent like cartilage. In some instances, on the other hand, it is remarkably brittle, and may be crushed like the shell of an egg. The periosteum is thickened and indurated; but the joints in the immediate vicinity of the disease are commonly healthy, even when they are separated from it merely by a thin layer of cartilage. The vessels which ramify through the substance of the bone are tortuous, brittle, increased in size, and open by numerous little orifices into the aneurismal sac at various points of its extent. There is a form of this affection in which the vessels, as was first clearly shown by Mr. Stanley, consist principally of enlarged capillaries, exhibiting the same general characters as an anastomotic aneurism or an erectile tumor Fig. 314. Anastomotic aneurism of bone. of the soft parts. The disease, represented in fig. 314, has hitherto been chiefly noticed in the broad bones, especially those of the cranium, of young children. The causes of this lesion are involved in obscurity. In some instances it has been traced to the effects of a blow; in others, to a fall, or jump from a considerable height. Either of these occurrences, by disturbing the vascular action of the bone, might produce the disease. The enlargement, even in its early stage, is tense and painful; being attended with distension of the superficial veins, swelling of the surrounding structures, and slight discoloration of the skin. In a short time a deep- seated pulsation, or throbbing, synchronous with that of the left ventricle, and similar to what is witnessed in some erectile tumors, raay be perceived in the affected part. In the advanced stage of the malady the beating is accompanied by a sort of undulating movement, and is easily interrupted by compressing the main artery of the limb between the turaor and the heart. The enlargement varies in size. In a case mentioned by Mr. Bell, it was more than nineteen inches in circumference, by upwards of six in length. In some instances, pressure applied to the tumor with the finger imparts a 904 DISEASES OF THE BONES AND THEIR APPENDAGES. peculiar crackling sensation, not unlike that of dry parchment or an egg-shell. The soft parts around the disease are generally cedematous, the whole limb is apt to be swollen, and the motion of the contiguous joints is constrained and painful. Towards the last the general health always seriously suffers. The only effectual remedy for this disease, provided its location be favora- ble, is amputation. In the early stage relief may possibly be afforded by securing the main artery of the limb. Lallemand relates a case in which ligature of the femoral artery completely arrested an aneurismal affection of the head of the tibia; but this must be regarded as an exception to the general rule. The anastomotic form of this disease admits of removal only when it is of limited extent. When it is situated in the cranial bones, it gradually destroys the osseous tissue, and ultimately involves the brain and its envelops, render- ing interference out of the question. Several cases have been reported in wdiich the carotid arteries were tied for this disease, but in none with any permanent benefit. 4. HEMATOID TUMORS. There is a variety of tumors, closely allied to that just described, which, for the sake of uniformity in medical nomenclature, I shall term hematoid. It is produced by a deposition of blood in the cancellated structure, forming a firm, oval, and elastic tumor, filled with dark, solid coagula. The best specimen of this disease that I have met with, occurred to me, about ten years ago, in a man aged thirty-five, a portion of whose lower jaw I ampu- tated, on account of what was supposed to be a bony tumor. The growth, which was about the size of a common orange, extended from the canine tooth on the right side to the middle grinder of the left, and consisted of a mere osseous shell, without any vestige of the cancellated structure; it was occupied by three red, solid coagula, the largest of which did not exceed the volume of a pigeon's egg. The cavity was only partially filled by the clotted blood, which adhered to the inner surface of the bony wall, and was evidently organized. The tumor had appeared three years before without any assign- able cause. Whence was this blood derived ? Did it proceed from a rup- ture of some of the vessels of the bone ? If so, the fact could not be ascer- tained by the most careful examination. 5. SERO-CYSTIC TUMORS. Serous cysts, similar to those which occur in the soft parts, especially the ovary, kidney, and liver, are occasionally met with in various pieces of the skeleton, particularly in the lower jaw, the tibia, and femur. They are always developed in the areolar tissue, and show themselves in two distinct forms, the unilocular and multilocular, of which the first is by far the more frequent, the other being, in fact, extremely uncommon. Pathologists failed, until recently, to seize the distinctive features of this disease, and to assign to it a proper place in their nosological tables. Mention, it is true, was made of it by some of the authors of the last century, especially by Bordenave, but it was only in an incidental manner, and it remained for Dupuytren to furnish the first clear account of it. It is more than probable that what the older surgeons were in the habit of calling osteosarcoma and spina ventosa were frequently, if not generally, growths of this description, with cavities filled with liquid or solid matter. I have certainly commonly found them so, and it may, therefore, be concluded, that the same thing has happened to others. Morbid Anatomy.—The unilocular cyst varies in size from that of a hemp- seed to that of a pullet's egg, its shape being generally irregularly rounded, SERO-CYSTIC TUMORS. * 905 or somewhat globular. It consists essentially of a thin, delicate, polished membrane, having, apparently, all the characteristics of the serous tissue. This membrane is closely adherent to the bony wall of the cyst, and under- goes important changes in consequence of age, and repeated attacks of in- flammation, becoming dense, thick, opaque, and tough. The contents of the cyst are variable: sometimes clear and limpid, like well water; sometimes cloudy, ropy, or glutinous; sometimes sero-purulent; and finally, again, though this is uncommon, thin and discolored, from the admixture of hematin. Some of the older cavities occasionally contain solid matter, of an albumin- ous, curdy, or fibrous nature ; and I have seen specimens in which they were occupied by a peculiar, micaceous-looking substance, not unlike cholesterine. The multilocular cyst, represented in fig. 315, is less frequent than the unilocular. As the name imports, it is composed of a greater or less number of cells, divided by Fig. 315. bony septa, and lined by a serous membrane, simi- lar to that in the unilocular cyst, of which the multilocular appears to be merely an exaggerated variety. Its contents are generally of a sero- sanguinolent character, although sometimes they are clear and purely serous, like those of hydro- cele. In one case, I found it thick and red, like the dregs of claret wine. In a group of multilocu- lar cysts, a few will occasionally be seen to be filled with solid matter, or matter partly solid and partly fluid. When this is the case, it may generally be assumed that the cysts are old, and that their ves- sels have undergone important changes in their secretory action, in consequence of which they pour out concrete instead of liquid substance. I have witnessed instances, however, in which the material was of such a nature as to induce the belief that it was originally deposited in a solid form. How- ever this may be, the substance is generally of a fibrous or fibro-cartilaginous character, and so firmly adherent to the walls of the cysts which contain it as to be with difficulty enucleated. Interspersed cystic disease of the femur. through this substance are occasionally little no- dules, fragments or spicules of bone, and earthy concretions, or a combination of calcareous with osseous matter. Age and Sex.—Serous cysts of the bones are most comraon in young adults and middle-aged subjects; being seldom met with before puberty, or after fifty. Both sexes are liable to them, but in what proportion, has not been determined. Their causes are involved in obscurity. In general the disease arises spontaneously. In the lower jaw, which, as has already been stated, is its most frequent seat, its origin is often ascribed to the irritation of a decayed fang, or to violence done in the extraction of a tooth; but before we can admit the influence of either as a cause of serous cysts, it must be remembered that thousands of persons constantly suffer in this way, without any such occurrence, and hence the development of these bodies may, after all, under such circumstances, be a mere coincidence. So, also, with respect to blows, fractures, contusions, and other mechanical injury, so often invoked as sources of this and other organic maladies of the bones. If they are really capable of producing such an effect in one case, why should they not in another? We must, therefore, look beyond these causes, and conclude that some other agent is concerned in their origin, although of the nature of that agent we are entirely ignorant. 906 DISEASES OF THE BONES AND THEIR APPENDAGES. Progress.—The progress of this disease is always slow. In the jaw we often meet with cases of serous cysts of six, twelve, and even fifteen years' standing, without any serious disturbance of the general health, or any par- ticular local disorder, save wdiat results from the pressure of the tumor upon the surrounding structures. Neither the cysts, their fibrous contents, nor the parts adjacent manifest any tendency to malignancy, and I am inclined to believe that whenever such an occurrence is observed it is to be received as a strong evidence that the growth was originally of a bad character, and not that it became so in consequence of any new epigenesis. When the tumor is large, whether it be multilocular or not, fluid or solid, it generally exhibits a marked tendency to destroy the bone in which it is located, pressing aside the compact lamella, and gradually involving its entire circumference. In the lower jaw the parts most commonly affected are the body and ramus, extending often beyond the middle line in front, and backwards as far as the condyloid process. Symptoms.—The symptoms of cystic disease of the osseous tissue are ob- scure. The first thing that usually attracts attention is a dull aching pain, in sorae particular bone, as, for example, the jaw, which is often mistaken for toothache, or rheumatism ; this gradually increases in severity and frequency, and is at length found to be dependent upon the presence of a hard tumor, or the expansion of a portion of the bone, more or less tender on pressure and motion, but unattended by any discoloration or intumescence of the over- lying textures. The progress of the disease is always tardy, and it often happens that, after having attained considerable development, it remains, to all outward appearance, for some time perfectly stationary. Then, taking a new start, it again increases, and thus it continues, now advancing and now halting, until it has perhaps acquired the volume of a large orange, or even of a fist. Still, the general health continues good, there is no emaciation, and the countenance is perfectly free from that distressed, anxious, and sallow state which characterizes it in malignant disease. Even the pain is generally comparatively trivial, and if it were not for the mechanical obstruction occa- sioned by the encroachment of the tumor upon the adjacent parts, the patient would hardly be conscious of being unwell. If the parts be now carefully examined, they will be found to be of unequal consistence, the firmer parts being incompressible, while the softer ones readily yield under the finger, emitting a peculiar crackling noise not unlike that of dry parchment. In the absence of signs of malignancy, pulsation, lividity, and varicose enlargement of the overlying vessels, these circumstances afford the best evidence of the true nature of the disease, but if there be any doubt respecting it, this may generally be promptly dispelled by a resort to the exploring needle, the escape of serous, or sero-sanguinolent fluid determining the diagnosis. The tardy growth of the tumor and the absence of constitutional disorder are, indeed, commonly of themselves sufficient to mark the character of the ma- lady. Between cystic and hydatic diseases of the bones no signs of dis- tinction exist, nor is this a matter of importance, as the treatment is essentially similar. Treatment.—The only available treatment in cystic disease is removal of the morbid mass, and sorae of the most brilliant exploits in modern surgery have been performed upon tumors of this kind. When it involves the jaw, the greater portion of that bone sometimes requires excision, the affected part being cut away along with a portion of the sound tissue, the same prin- ciple guiding the surgeon as in the extirpation of morbid growths of the soft structures. When the cysts are small and not numerous, they may sometimes be effectually scooped out, the cavity being afterwards stuffed with lint, and made to heal by the granulating process. On the other hand, cases occur, as when the disease involves the entire circumference of one of the bones of HYDATIC TUMORS. 907 the extremities, where, neither of these procedures being available, nothing short of amputation will answer. I am aware that various plans of treatment have been suggested for arrest- ing this disease in its earlier stages, or curing it without the knife when it has attained a considerable magnitude. So far, however, as I am informed, there are none which are entitled to any confidence. The most plausible of these are iodine injections and the introduction of the seton; the former of which experience has proved to be ineffectual, while the latter is so un- scientific as not to be thought of, much less practised, in any case. 6. HYDATIC TUMORS. One of the most remarkable diseases of the bones is the development of hydatids in their spongy structure, an occurrence which, although uncommon, has now been so repeatedly observed as to entitle it to distinct notice in a systematic treatise on surgery. The first account of these bodies was given by two Dutch pathologists, Van Vy and Vander Haar. Since then atten- tion has been directed to them by other observers, who, minutely detailing the facts which have come under their notice, have thus laid the foundation of our knowledge of this interesting subject. Although it is extremely probable that all the different classes of bones are liable to these formations, yet they have hitherto been observed almost exclusively in the long and flat bones, particularly in the tibia, for which, judging from the frequency of their occurrence here, they appear to have a sort of preference. They have been found three times in the frontal bone, twice in the iliac bone, twice in the humerus, once in the femur, and once in a vertebra. What was formerly known under the vague name of spina ventosa was an osseous tumor which probably occasionally contained bodies of this kind. Situation.—Hydatids of the bones are always developed in the spongy texture of the skeleton, as this alone affords them an opportunity of growing and expanding, the compact tissue being too dense and firm to admit of their increase. The only exception to this occurs when they form in the frontal sinus, but even here there is, it will be observed, no new law in operation, since the cavity in question is, in fact, only a large cell, exceedingly well adapted as a residence for such creatures. In the tibia, the disease is always situated in the spongy structure which exists in such abundance in the head of this bone, just below the knee. How these bodies are developed is still a mystery. That the germs are conveyed to the spongy tissue of the bones in the blood which is sent to them for their nutrition and growth is evident enough, but why they should be deposited here in preference to other parts of the body is a question which the most refined pathology is unable to answer. Nor is anything certainly known in regard to the nature of the exciting causes of these bodies; for if, as has occasionally happened, they have shown themselves in a particular portion of the skeleton after the occurrence of a blow, contusion, or other injury, it does not prove that their development was the consequence of such injury. Sex does not appear to exercise any particular influence upon the develop- ment of hydatids of the bones, as they have been observed with nearly equal frequency in men and women. Most of the patients in which they have hitherto been found were adults, but in one instance they occurred in a child three years of age. Borchard has narrated a case where they existed in several situations in the same individual. Morbid Anatomy.— Exaraination has proved that these bodies are really acephalocysts, similar to those which are occasionally met with in the liver, ovaries lungs and other internal viscera. Of a spherical or rounded shape, 908 DISEASES OF THE BONES AND THEIR APPENDAGES. they are sometimes irregularly flattened, or compressed, and vary in size from that of a pea to that of a marble, their dimensions being evidently influenced by their age, and the extent of the cavity in which they are developed. Their number, which is seldom large, is usually in an inverse ratio to their volume. They are inclosed in a sort of parent-cyst, soft in structure, thin, and of a whitish appearance, and they float about in the midst of a serous fluid, of a saline taste, and partially coagulable by heat, alcohol, and acids, circumstances clearly betraying its albuminous character. The cavity in which these bodies are situated is deserving of special atten- tion. It is evidently, in the first instance, simply one of the cells of the areolar tissue, in which the germ of the animal is deposited, and where it is destined afterwards to attain its full development. As its growth proceeds, it presses upon the osseous matter, pushing its fibres farther and farther apart, at the same time causing a partial removal of it by the action of the absorbents, until what remains is at length converted into a mere bony sheet, hardly as thick as a piece of parchment, elastic, and crackling under the finger. The shell is lined, as already stated, by a thin, closely adherent membrane, which evidently plays an important part in the development and protection of the new being. Cases occur in which it consists of several compartments, cells, or lodges, although in general it is unilocular. The bone immediately adjacent to the disease is usually thickened and roughened by irregular deposits. Symptoms.—The symptoms attending the formation of these bodies are extremely obscure, and cannot, for a long time, be separated from those which accompany other diseases in and about the skeleton. Their growth is always very tardy, and a long time elapses before there is any pain and discoloration of the integuments. The patient is merely aware that there is some tumor, gradually augmenting in bulk, and slowly encroaching upon the surrounding parts; hard and firm at first, afterwards more soft, and ultimately becoming quite elastic, and emitting a peculiar crackling sound on pressure very similar to that of dry parchment. If it be deep-seated, it will cause a gradual wast- ing of the superimposed tissues, the muscles and tendons being spread out like thin ribbons, while portions of the fibrous membranes are actually ab- sorbed. Meanwhile, the tumor mechanically impedes the functions of the surrounding parts, pain and tenderness set in, and the integuments show signs of irritation and discomfort. At this stage of the complaint the affected bone sometimes gives way under the most trivial accident, refusing after- wards to unite, or undergoing consolidation only after a long while and after much trouble. Occasionally, the most prominent portion of the tumor ulce- rates, and discharges a part of its contents ; such an event, however, is ex- tremely rare. The general health remains good for years, but in the end it is always much impaired in consequence of the local distress. Diagnosis.—The most important diagnostic signs are, the tardy progress of the tumor, the want of pain and swelling, the change from a hard, incom- pressible substance to one of comparative softness and even elasticity, and the complete absence of all appearance, both local and constitutional, of malignancy. After all, however, these symptoms are merely of a negative character; for at last the only reliable source of information is the explor- ing needle, though this also, unfortunately, is not available until the morbid growth has acquired a great bulk, and is almost on the verge of bursting. Even the elastic feel and crackling noise which, in the latter stages of the complaint, form such prominent features, are of no diagnostic avail, as they are common to several other varieties of bony tumors. Prognosis.—Hydatic disease of the osseous tissue is always a grave oc- currence, not so much on account of the damage it does to the general health as on account of the injury it inflicts upon the affected bone, weakening its MYELOID TUMORS. 909 structure, and thus impairing its usefulness, generally to an irremediable ex- tent. In several of the recorded cases the acephalocysts burst into the knee-joint, causing violent suppuration, and destruction of the functions of the articulation. In a few others, the animals perished, and shrunk up into dirty, reddish-looking masses, which afterwards became a source of irritation, followed by high constitutional disturbance, excessive pain, and hectic fever. Treatment.—The only remedy that can at all reach this disease is extirpa- tion, and the earlier this is performed the better, for then there is no serious structural lesion of the bone, involving the necessity of resection or amputa- tion. As soon, therefore, as the diagnosis is fully established, the tumor should be freely exposed by an incision, either crucial or elliptical, and at- tacked with the saw, pliers, trephine, or chisel and mallet, as may seem advisa- ble. Its contents being turned out, the lining membrane of the osseous shell is carefully peeled off, or, when this is impracticable, painted with a strong solution of iodine, to destroy its secreting surface, lest there should be a speedy reproduction, if not of hydatids, at all events of serous fluid. The cavity is then filled with lint, smeared with cerate, and the flaps being approximated are lightly held in place with a few strips of adhesive plaster. The cavity will gradually shrink, and a cure be effected by the granulating process. When the case is one of an aggravated nature, involving the entire cir- cumference of the affected bone, or when the hydatids open into a joint, the only question will be whether the treatment shall be by resection or amputa- tion. The former procedure can only be suitable when the disease is of limited extent; and in that event, it raay probably always be replaced by ex- cision, so that, in reality, it would be difficult to imagine how or when it could be of service. Amputation will be necessary when the case is despe- rate, as when the bone is irremediably destroyed, or broken and unwilling to unite, or when the tumor has discharged its contents into a neighboring ar- ticulation, and has induced so much disturbance, local and constitutional, as to threaten life. 7. MYELOID TUMORS. The osseous tissue is more liable to the myeloid tumor than any other class of textures, and it is here that the new structure generally acquires its most perfect development. Doubtless it may occur in all, or nearly all, the pieces of the skeleton, but its favorite sites would seem to be the tibia, femur, and inferior maxilla, especially the latter. Commencing generally, if not always, in the cancellated structure, its point of departure is probably the endosteum, extending from thence to the compact layers, which it gradually disparts, and converts into thin, cartilaginous plates, bending and crackling under the finger like dry parchment. Continuing its growth, it may, in time, attain the size of a fist, or even of a foetal head, encroaching seriously upon the surrounding parts, and interfering, more or less, with the exercise of their functions. The arteries leading to it are generally somewhat enlarged, and the turaor itself is commonly quite vascular. A section of it exhibits a smooth, compact appearance, of a reddish, pink, or lilac tint, inlaid, as it were, with soft bony fibres, and pervaded by little cysts, either simple or compound, and occupied by different kinds of fluids, as serum, sanguinolent matter, or altered blood, or all these substances commingled. There are no signs by which this growth can be distinguished from other tumors of the bones; its rapid development, its elastic feel, and its lobulated form assimilate it very much, in its external characters, to encephaloid, and the resemblance is still further shown by the fact that the disease is liable to recur after extirpation, and also that, in its advanced stages, the patient presents all the evidences of the cancerous cachexia. The only remedy is 910 DISEASES OF THE BONES AND THEIR APPENDAGES. excision or amputation ; excision, when the tumor involves the jaws, amputa- tion, when it is seated in the bones of the extremities. MALIGNANT FORMATIONS. The various malignant affections of the bones raay, as far as practical pur- poses are concerned, be all conveniently grouped under one head. Of these affections, encephaloid is much the most common ; next in point of frequency is colloid, then comes scirrhus, and fiually, as the most rare of all, melanosis. The origin, progress, and termination of these formations are the same here as in other organs and tissues. 1. Encephaloid, hematoid fungus, cerebriform cancer, or osteocephalonia, generally, if not invariably, originates in the spongy structure of the bones, from which it gradually extends to the compact lamella, and finally to the periosteum. It most commonly attacks the upper and lower jaw, and the long bones of the extremities, particularly the femur, humerus, and digital phalanges. No portion of the skeleton, however, is exempt from it. The most terrific feature of the encephaloid is its tendency to recur in some other part of the body, after it has been dislodged frora its original situation. It may show itself at any period of life, but young persons are most prone to it. Although encephaloid may occur as an infiltration, it most comraonly pre- sents itself in the form of a tumor, arranged in rounded, lobulated masses, of the color and consistence of the medullary structure of the brain. Not un- frequently it contains small cavities, filled with clotted blood, dirty looking serum, or soft, gelatinous, oily, sebaceous, or melliceroid matter. Occasion- ally one part of the tumor exhibits the brain-like character, while another is strictly hematoid, or composed of a mixture of blood and encephaloid. In the great majority of cases, however, the two substances are pretty intimately blended together. Vessels, sometimes of considerable volume, may be seen ramifying over the surface of the morbid growth, and dipping into its interior. The outer table of the bone is transformed into a thin, parchment-like lamella, perforated in various places, or entirely destroyed by absorption. A section of the turaor usually exhibits, in addition to the appearance just described, osseous fragments, or pieces of fibro-cartilage. The superincumbent integu- ments, traversed by large bluish veins, are at first soft and glossy; but at length, frora the constant and increasing pressure exerted upon them, they ulcerate, and allow the fungous mass to protrude. Fig. 316. Encephaloid disease of the tibia. Some of the more extraordinary alterations which the osseous structure is capable of undergoing in this disease are well seen in fig. 316, from a speci- MALIGNANT FORMATIONS. 911 men in the cabinet of Professor Buchanan. The patient was a mulatto girl, about twelve years of age, who had labored for some time under a large, lobulated tumor, partly elastic and partly inelastic, situated in the lower part of the leg, and attended with great dilatation and distension of the subcuta- neous veins. Amputation being performed, the stump healed kindly, and for several weeks the girl did well: but in a few months she began to complain of pain in her hip and side, and she died in less than a year, apparently from internal malignant disease. A section of the tumor displayed an immense number of osseous spicules, of extraordinary length and delicacy, whose in- tervals were occupied partly by cartilagi- nous and partly by gelatinous substance, with here and there a cyst containing bloody-looking matter. The external cha- racters of encephaloid are well displayed in the adjoining cut, fig. 317, from a speci- men in my collectiou. 2. Of colloid of the osseous tissue very little is known. It is most frequently met with in the diseased conditions of the bones denominated osteosarcoma and spina ventosa, which are often almost Fig. 318. Colloid tumor. wholly composed of cells and cavities, filled with jelly-like matter. The ques- tion, however, respecting the identity of these affections can be determined only by future observation. A case in which a colloid tumor grew from the body of the sphenoid bone, outside the dura mater, came under my notice in 1844, in the medical ward at the Louisville Hospital. The patient died at the age of thirty-nine years from epilepsy, produced by a fall twelve months previously. On examination, Dr. Colescott and myself found, in the situa- tion referred to, a lobulated tumor, of irregular form, and about the size of a pullet's egg, which had flattened the Varolian bridge, and evidently induced the disease in question. A section of the morbid mass, fig. 318, showed that it was composed of several compartments communicating with each other, and occupied by a white, semi-concrete substance, in all respects simi- lar to that of colloid. 3. Scirrhus of the osseous tissue is extremely uncommon. It occurs ex- clusively in old subjects, and is usually concomitant of the same disease in the breast or sorae other organ. Generally limited to a single bone, it may affect several pieces simultaneously, and always begins in the cancellated structure. Its favorite seat is the femur, but it may appear in any part of the skeleton, in the short and flat bones, as well as in the long. Fig. 317. Encephaloid disease of the thigh-bone. 912 DISEASES OF THE BONES AND THEIR APPENDAGES. The heteroclite matter is deposited under two varieties of form, the infil- trated, and the tuberoid. In the former it is diffused through the areolar tissue, and exhibits the color and consistence of fibro-cartilage, or the rind of fresh pork. In the tuberoid variety the morbid mass is either solitary, or it consists of several agglomerated nodules, from the volume of a hazel-nut to that of an almond. Occasionally three or four distinct tumors are deve- loped simultaneously in the same bone. They are of an irregularly rounded or oval shape, dense and firm in their consistence, and of a greenish, whitish, or yellowish color. The bone is seldom much altered in its size or external configuration, but is liable to be absorbed, and fractured at the seat of the disease. 4. The occurrence of melanosis in bone is very infrequent. It may ap- pear in sraall, disseminated masses, nodules, or clusters, or in the form of an infiltration. It has been observed in various parts of the skeleton, but is most comraon in the pieces of the extremities, particularly the femur and tibia. Co-existing generally with melanosis in other organs, it is situated either upon the surface of the bone, beneath the periosteum, in the medul- lary canal, or in the spongy structure, the latter of which it sometimes dyes of a deep black color. In its progress and mode of termination it closely resembles medullary sarcoma. General Diagnosis, Prognosis, and Treatment.—Much has been said, espe- cially of late years, respecting the diagnosis of cancerous diseases of the osseous tissue, and from reading the accounts of these formations in the books one would suppose that their recognition was a matter of the greatest facility. Nothing, however, is more untrue. With the exception of ence- phaloid, it is extremely difficult to detect the real nature of any of them dur- ing any portion of their progress, and even encephaloid cannot always be satisfactorily discriminated until it has acquired an unusual bulk. In the latter case, the most reliable guides are, the early period of life at which the tumor shows itself, the rapidity of its growth, the great bulk it attains, the depth of its situation at the commenceraent of its development, the lobulated condition of its surface, and the extraordinary enlargement of the subcuta- neous veins. In general, too, it will be found that the disease is developed in one of the long bones, as the humerus, femur, or tibia, and in preference, as it were, in their articular extremities. The moment ulceration occurs the case speaks for itself, the diagnosis being no longer equivocal. The progress of encephaloid is generally very rapid, especially when it occurs upon the periphery of the bones, a few months usually sufficing for the formation of an immense tumor, and the complete destruction of the osseous tissue, or its conversion into a soft, sarcomatous, or fibro-cartilagi- nous mass, with hardly any trace of the primitive structure. The growth is commonly of a lobulated character, and of varying degrees of consistence, being soft at one part, tolerably firm at another, and perhaps almost bony at a third, according to the nature of the portion examined. As it increases in size, it displaces the surrounding textures, flattening the muscles and nerves, and thus impairing their functions; the integuments are stretched, and, in places, attenuated; and the subcutaneous veins are enlarged, varicose, and of a bluish color. The colloid tumor is also capable of attaining a great bulk, but its progress is usually much more tardy than that of encephaloid, and there is seldom any considerable augmentation of the subcutaneous veins. Scirrhus of bone usually co-exists with scirrhus of the mammary gland, uterus, or liver, and the only symptom leading even to a suspicion of its existence is the peculiarity of the attendant pain, which is usually either sharp and lancinating, or else dull, heavy, or aching, and fixed in its posi- tion, the affected part being, at the same time, exquisitely tender on pressure and motion. The patient often becomes bedridden during the progress of TUBERCULAR DISEASE. 913 the case, and the diseased bone not unfrequently gives way under the most trivial accident, as a mere twist of the limb in stepping out of the bed upon the floor. Melanosis of the osseous tissue is seldom discovered during life, unless it happen to be seated in a superficial bone, as the sternum, or one of the ribs; in nearly every instance that has yet been observed, it was present at the same time in other parts of the body. Cancer of bone follows the same course as cancer of the soft parts. If left to itself, the malady inevitably proves fatal, and hardly any one makes a permanent recovery after an operation, however early and thoroughly ex- ecuted. In all the cases of encephaloid of the extremities that I have either operated upon myself, or seen operated upon by others, there has been a speedy recurrence of disease, often indeed in less than three months, either at the cicatrice, the neighboring lymphatic ganglions, or in some internal organ, carrying off the patient a short time afterwards. I am aware that exceptional cases are sometimes reported, but they are only exceptional, and nothing more, to say nothing of the fact that there may occasionally be in these cases an error in the diagnosis, the tumor, although possessing some of the outward properties of osteocephalonia, being in fact merely a benign one, appertaining to the osteosarcomatous class of the older writers. Judg- ing from personal observation, I am. inclined to believe that malignant growths of the maxillary bones are less liable to relapse after operation than those of any of the other pieces of the skeleton, and in this view of the sub- ject, if I mistake not, the opinion of practitioners generally coincides. Nevertheless, even here the ultimate issue of the case is nearly always unfa- vorable. The circumstances justifying interference in this class of maladies, have already been so fully pointed out in the chapter on carcinomatous dis- eases generally, as to render any further discussion of them unnecessary in this place. In regard to the choice of the operation, as to whether this should be amputation or excision, the decision must always be given in favor of the former whenever the raorbid growth occupies an extremity, the removal being effected as high up, or as near to the trunk, as possible, as conferring greater safety. Thus, when the hand is involved, the forearm should be cut off near the elbow, and in encephaloma of the radius and ulna, the limb should be amputated pretty close to the shoulder. If the tumor be seated in the upper jaw, the whole of that bone should be excised, together, perhaps, with por- tions of the palate, spongy, and malar bones. Thorough work must be made, or interference will be productive of infinite harm. After recovery from the operation, the patient must be put upon a properly regulated diet, with an alterative and tonic course of treatment, and exercise in the open air. SECT. XIII.—TUBERCULAR DISEASE. Tubercles of the bones are much more common than is generally imagined. The bones usually affected are the vertebrae, the short bones of the hand and foot, and the articulating extremities of the long bones. The particular seat of tubercles is the spongy texture, though occasionally they are formed upon the outer surface of the bones, between it and the periosteum. _ There are two varieties of form in which this matter is deposited. In one, perhaps the more common, the tubercles are encysted, the inclosing membrane, which varies in thickness from the fifth of a line to half aline, being composed of coagulating lymph, very soft at first, but gradually becoming harder and harder, until finally, in some cases, it acquires the character of fibro-cartilage. It is of a dull gravish color, is made up of delicate, inelastic fibres crossing each other in every conceivable direction, and is frequently furnished with small vessels, passing into it from the surrounding structures. The number vol. 1.—58 914 DISEASES OF THE BONES AND THEIR APPENDAGES. of tubercles is seldom very great; their size ranges from that of a pea to that of a nutmeg; and in most cases they present a yellowish, opaque appearance. When these bodies become softened, the matter will either work its way out, or pass, by a sort of fistulous route, into a neighboring joint, establishing thereby an analogy with pulmonary tubercles opening into the bronchial tubes. Sometiraes a spontaneous cure takes place, the heterologous substance being absorbed, and the cyst contracting so as to obliterate its cavity. In the second variety, the tubercular matter is deposited directly into the cells of the osseous tissue, forming grayish, semi-transparent, opaline patches, from the one-sixth of an inch to an inch in diameter. This infiltration, exhibited in fig. 319, is noticed chiefly in the bodies of the vertebra? and in the bones of the tarsus, where it is frequently pervaded by numerous vessels, too delicate to be discerned with the naked eye. The bony tissue immediately around is sometimes deeply injected, but seldom otherwise diseased. In this, as in the preceding variety, the tubercular deposit, after hav- ing existed for some time, gradually softens, its vascularity disappears, and the cells in which it was contained are filled with earthy matter. This, however, is not always the case; for now and then the ulcerative process continues until the bone is totally destroyed. The progress of tubercular disease of the bones is always chronic, though not equally so in both forms, the infiltrated proceeding more tardily than the en- cysted, and causing generally also a greater amount of havoc in the osseous tissue. No definite information, however, can be furnished in regard either to the commenceraent of the softening process, or to the ultimate elimination of the matter produced by that action, from the affected structures. Much will doubtless depend, in every case, upon the condition of the system, the age of the patient, and the presence or absence of local complications. As a general rule, from six to twelve months will elapse from the moment of the deposition of the tubercular substance to the completion of the softening pro- cess. The matter resulting from the disintegration of the heteromorphous deposit is similar to that which occurs in the lungs in the advanced stage of phthisis, being of a pale yellowish color, bordering slightly upon greenish, and of a thin fluid consistence, with small whitish flakes not unlike soft-boiled grains of rice. After an opening has been effected into the abscess, the dis- charge generally becomes very watery and bloody, as well as irritating, and comes away in large quantities, a number of sinuses often existing in the dis- eased parts, as if they were necessary to carry off the superabundant secre- tions. In many cases, broken-down osseous tissue is intermingled with the pus, passing off either as little granules or as minute fragments, which not unfrequently choke up the abnormal track, and thus excite new irritation. The adjoining cut, fig. 320, from a specimen in my cabinet, exhibits the effects which a tubercular abscess may exert upon the osseous tissue, in caus- ing a well-marked excavation, similar to what we see in the lungs. The abscess that arises from the disintegration of the tubercular matter is the form which is usually met with in bone, the phlegmonous, as stated else- Section of bone infiltrated with tubercular matter, NEURALGIA. 915 where, being of extremely rare occurrence. The symptoms attending it are generally obscure, but its existence may be suspected when, along with the ordinary signs of osteitis, the affected part is the seat of circumscribed, deep- Fig. 320. Tubercular excavation of the cuneiform bone. seated, gnawing pain, with excessive tenderness at one particular spot, and a glossy, shining, cedematous condition of the integuments. The breaking of the abscess is always preceded by considerable swelling of the soft structures, and by more or less disturbance of the system, the constitution frequently sympathizing severely with the local trouble. In addition to these circum- stances, the history of the case, as the age of the patient, the site of the morbid action, and the absence or co-existence of strumous disease in other struc- tures, will generally furnish useful light, and thus materially aid in the estab- lishment of a correct diagnosis. The treatment of tuberculosis of bone differs in no material respect from that of tuberculosis in the other organs and tissues. Bearing in mind the fact that the local deposit is, in general, merely a reflection of the state of the system, the judicious practitioner will not neglect the employment of such remedies as are necessary to modify this condition of the constitution and to provide for the supply of a better and richer blood. The principal means included under this head are, a well-regulated and adequately nutritious diet, cod-liver oil, and the various chalybeate preparations, either alone, or in union with quinine, mild purgatives, and gentle exercise in the open air, especially if the seat of the disease do not act interferingly. The local remedies are, of course, of the ordinary antiphlogistic character, consisting of leeches, blisters, and the dilute tincture of iodine, with early and free incisions of the soft structures to relieve pain and tension. If the existence of an abscess is suspected, prompt recourse is had to the trephine, the operation and after-treatment being conducted upon the same principles as in acute or phlegmonous abscess of bone, already described. SECT. XIV.—NEURALGIA. Neuralgia of the osseous tissue is infrequent. I have seen a large number —perhaps it would be more correct to say an immense number—of cases of neuralgia of the soft structure in almost every part of the body, but only a few of neuralgia of the bones. In nearly every instance that has fallen under my observation the disease was associated with some organic lesion of the affected texture, such as abscess, caries, exostosis, or interstitial deposits into the Haversian canals and cancellated tissue, thereby compressing the vessels and the nerves distributed through their tunics. A lady, aged fifty, a personal friend of mine, had long been afflicted with neuralgia of the cranium, caused by the falling of a window-sash upon the upper and posterior angle of the left parietal bone. The pain, without observing any regularity in its accession, 916 DISEASES OF THE BONES AND THEIR APPENDAGES. gradually increased in severity, and became at length so intense as to require from one to two drachms of morphia a week, besides enormous quantities of sulphuric ether, for even its temporary subjugation. The seat of pain was a small spot, not larger than the end of the finger, and exquisitely tender to the touch. A disk of bone, embracing the affected portion, being removed with the trephine, an exostosis, not more than the eighth of an inch in thick- ness, was discovered upon its inner surface, which thus at once explained the nature of the case, complete recovery following the operation. A married woman, aged twenty-eight, had suffered, at times, most acute and distressing pain from a small bony tumor at the anterior and outer part of the lower extremity of the left radius. The tumor had come on about twdve years previously, and had all along been exquisitely sensitive on pres- sure and even on the slightest touch. It projected but little beyond the na- tural level, and was unaccompanied by any visible change in the soft parts. The pain bad been liable to periodical exacerbations, and was often so severe as to deprive the woman of appetite and sleep. The general health was always good, the complexion denoting rather a robust state of the system, and the menstrual function being performed with great regularity. Upon removing the turaor, I found that its substance was almost of the consistence of ivory, offering great resistance to the instruments. The pain at once dis- appeared, and has never returned. I have met with a number of cases similar to the last, which raay be re- garded as, in some degree, typical of this affection as it usually appears in the skeleton. Most of them occurred in young females, between the ages of twenty and thirty, without, seemingly, any direct connection with the cata- raenial function, which was usually well executed, and without any marked hysterical predisposition. In all the cases that I have met with, the pain was liable to periodical exacerbations, not, however, by any means always coin- cident with menstruation, and the parts were exquisitely sensitive under mo- tion and pressure. The pieces which I have found most frequently affected were the radius, ulna, tibia, fibula, clavicle, and cranial bones, especially the frontal and occipital. In several instances I have known the coccyx to be the seat of neuralgia, the pain being so severe as to cause the greatest possi- ble suffering. So far as my observation goes, the disease never attacks this bone except in married women who have borne children, and I presume that it depends here, as elsewhere, upon the presence of interstitial deposits, either as a simple hypertrophy, or a ^mall exostosis, compressing the vessels and nerves of the osseous tissue. Neuralgia of bone generally results from direct injury, as a blow, wound, or contusion, causing inflammation in the affected part, followed by a deposit of new osseous substance. It may also be produced by a syphilitic taint of the system, as we see in the tertiary form of this disease, in which the pains are not unfrequently of a darting, shooting, lancinating nature, or else dull, heavy, and aching, as in neuralgia of the soft structures. In abscess of bone the suffering is frequently of the same character, and hence the difficulty which the practitioner so often experiences in discriminating between the two affections. The disease is frequently associated with neuralgia in other parts of the body. The treatment of neuralgia of bone is too often conducted upon empirical principles; a circumstance which is doubtless due to the fact that it is gene- rally difficult, if not impossible, to ascertain the true nature of the disease. In recent cases, especially in such as are directly chargeable to the effects of external injury, a free incision down to the seat of the disease, dividing the periosteum and even the superficial layer of the bones, will occasionally effect a prompt cure, especially if the wound be kept open for some time with stimulating dressings to promote discharge. Now and then a sraall issue, GENERAL CONSIDERATIONS. 917 made with the actual cautery, will answer an excellent purpose. When the cause is of a syphilitic nature, iodide of potassium and mercury afford the best means of relief. Quinine, arsenic, and strychnine are indicated when the disease is of miasmatic origin. In obstinate cases, the only reliable plan is removal of the affected bone with the trephine or other suitable instruments ; the object being to get rid of the compressing agent, whether this be merely simple hypertrophy of the part or an exostosis, properly so-termed. Dr. Nott, of Mobile, has on two occasions excised the greater portion of the coc- cyx for the cure of this disease, but the results have not, I believe, been as satisfactory as had been anticipated. SECT. XV.—FRACTURES. 1. GENERAL CONSIDERATIONS. There is no class of injuries which a practitioner approaches with more doubt and misgiving than fractures, or one which demands a greater amount of ready knowledge, self-reliance, and consummate skill. Constant in their occurrence, and often extremely difficult of diagnosis and management, they frequently involve consequences hardly less serious and disastrous to the sur- geon than to the patient himself. If I were called upon to testify under oath what branch of surgery I regarded as the most trying and difficult to practise successfully and creditably, I should unhesitatingly assert that it was that which relates to the present subject, and I am quite sure that every enlight- ened practitioner would concur with me in the justice of this opinion. I certainly know none which requires a more thorough knowledge of topogra- phical anatomy, a nicer sense of discrimination, a calmer judgment, a more enlarged experience, or a greater share of vigilance and attention; in a word, none which requires a higher combination of surgical tact and power. As for myself, I never treat a case of fracture, however simple, without a feeling of the deepest anxiety in regard to its ultimate issue; I cannot retire at night or rise in the morning without a sense of discomfort, so long as I am con- scious that, despite my most assiduous attention and my best directed efforts, my patient is likely to become deformed and lame for life. If this feeling were more general, it is easy to perceive that there would be comparatively few cripples from this cause, and comparatively few suits for malpractice, unfortunately so common, of late years, in this country, and so disreputable to the profession. A crooked limb, rendered so by injudicious treatment, is an unpleasant sight to a sensitive surgeon, reminding him constantly of his bad luck, his want of skill, or his inattention; not unfrequently it is a stand- ing, living, speaking monument of his disgrace, planned by his own mind, and erected by his own hands. I would certainly not wish it to be under- stood by these remarks that it is always in the power of the surgeon to cure these accidents without deformity or impairment of function. To utter such a sentiment would be contrary to all experience and common sense. There are cases, and, indeed, they are not infrequent, where it is impossible to avoid such occurrences; cases where injury to bone, joint, and soft parts is so severe and complicated as to render any other result totally impracticable, however attentively and scientifically they may be treated. The physician cannot cure all diseases; such is their character that many must, of necessity, prove fatal, and of such as do not terminate in this manner, there are many which, notwithstanding the most skilful management, sadly cripple the patient for life. The only difference between the surgeon and the physician, under such circumstances, is that the former is often blamed, if not severely censured, for the result of his treatment, perhaps long, arduously, and anxiously 918 DISEASES OF THE BONES AND THEIR APPENDAGES. continued, while the latter often receives nothing but commendation and praise, when he may be no more entitled to it than the other. Every one thinks he can judge correctly of a surgeon's skill, but very few persons attempt to fathom that of a medical practitioner. A fracture may be defined to be a solution of continuity of the osseous tissue, or, in other words, a yielding aud separation of the bony fibres, occa- sioned either by external violence or muscular contraction. The lesion pre- sents itself in various forms, of which the principal are the simple compound, comminuted, impacted, and complicated. To these may be added the incom- plete fracture, in which a bone, instead of being entirely broken across, is divided only in a portion of its diameter. A fracture is said to be simple when it is unaccompanied by any wound of the soft parts directly over the end of its fragments, thus exposing them to view, or, at all events, permitting them to be felt. The case is a simple one, as far as the bone is concerned, even if there be a wound in the immediate vicinity of the fracture, provided it has no direct communication with it. A compound fracture is one where the opening in the skin and muscles extends down to the bone, the ends of which often protrude through the wound, girted, perhaps, by its edges. When a bone is broken into a number of pieces, the term comminuted is applied to it. The word impacted is era- ployed to signify that the extremity of one fragment is forced into that of the other. Finally, a fracture is complicated when it is associated with dis- location, wound, hemorrhage, laceration, or other mischief. It will greatly facilitate the discussion of the subject if we discard all these terms, with the exception of the first and last. Hence, after some general observations, we shall treat first of simple fractures, and afterwards of fractures complicated with other lesions. All the bones of the body are liable to be broken, though not by any means with equal frequency. Those wdiich are most prone to suffer in this manner are the long bones of the extremities, particularly those of the leg and fore- arm. The clavicle is also frequently fractured. The scapula, the two jaw- bones, the sternum, ribs, innominatum, vertebra?, sacrum, and coccyx, to- gether with the bones of the hand and foot, are rarely broken, owing either to their protected situation, to their mobility, or to the manner in which they are united to each other and to the surrounding parts. It may be stated also, as a general law, that the long bones are raore liable to give way at or near their middle than at their extremities; a circumstance of some importance in a diagnostic and practical point of view. The relative frequency of fractures of the bones of the superior and infe- rior extremities has not been satisfactorily determined. It doubtless varies in different institutions and in different localities, according to the nature of the occupations of those who are the subjects of them. The following tables, composed of the statistics of different hospitals, shows the preponderance to be very slightly in favor of the lower limbs :— No. of cases. Upper Lower extremity. extremity. . 1473 572 901 . 1856 850 1006 . 1280 7U4 516 . 1346 665 (J8l 5955 2851 3104 Respecting their direction, fractures may be oblique, transverse, or longi- tudinal. Of these varieties, the first is by far the most common, though it is impossible, frora the want of statistics, to estimate its relative frequency. My experience teaches me that transverse fractures are extremely rare. In Pennsylvania Hospital . Hotel Dieu, Paris Middlesex Hospital, London Native Hospital, Calcutta GENERAL CONSIDERATIONS. 919 the extensive osseous collection of Dr. Mutter, there is not a solitary speci- men of the kind; and my own is equally barren. I am speaking now, of course, onlyof fractures of the long bones, and especially of fractures of their shafts; for in the short and flat bones such an occurrence is not without a certain degree of frequency. There is reason to believe that many of the so- called cases of transverse fractures of the shafts of the long bones are in reality oblique fractures, approaching raore or less closely to°the horizontal line, yet not strictly falling within it. There are few practitioners, I imagine, who will not coincide with me in this view, and who, like myself, have° not had frequent occasion, upon further and raore thorough exploration, to cor- rect their diagnosis in cases of this description. If the question were one solely of a speculative nature, it would be of little consequence; but when we consider its practical bearing, it is impossible to lay too much stress upon it. As it will, however, be again adverted to when we come to speak of the treatment of fractures, nothing further need be said respecting it here. The annexed cut, fig. 321, conveys a good idea of an oblique fracture. Fig. 321. Oblique fracture of the bones of the forearm. Longitudinal fractures are extremely rare, so much so, indeed, that great doubt was at one time entertained respecting the possibility of their occur- rence. That they do, however, occasionally take place, is sufficiently established by the cases that have been published from time to time in our'medical journals, and by the speci- mens that are to be seen in different museums and private collections. They are nearly always produced by gunshot violence, and have hitherto been met with chiefly in the hu- merus, femur, and tibia. In a very few cases the fracture has passed nearly through the entire shaft of a bone; but, in general, it is not more than a few inches in extent. Occa- sionally a fissure of this kind, after having passed a certain distance, runs off in an angular direction towards the surface of the bone, where it terminates, as in fig. 322. A longitu- dinal fracture is sometimes seen at the inferior extremity of the humerus, and also, but more rarely, at the lower end of the femur, separating one of the condyles of these bones, or even both of these protuberances, as happens when there is at the same time a horizontal or oblique fracture a short distance above the corresponding joint. A longitudinal fracture is occasionally met with in the patella. The extremities of the fragments of a broken bone exhibit much diversity in regard to their form and size; in general, one is much larger than the other, as well as more sharp, rough, and irregular, as in fig. 323. In the majority of cases, they have a ragged, serrated, or denticulated appearance, the projecting pieces of one end corresponding with the depressions in that of the other. This arrangement, which is produced by the irregular division of the osseous fibres, bears no little analogy to that which occurs in the edges of a lacerated wound. The truth is, to carry out the analogy still further, an oblique fracture is nothing Longitudinal and oblique fracture. 920 DISEASES OF THE BONES AND THEIR APPENDAGES. but a lacerated wound of the osseous tissue, which presents the same difficulty in regard to its perfect coaptation and speedy reunion as a similar lesion in the skin and muscles. The irregularities upon the extremities of the frag- Fig. 323. Appearances of the ends of the fragments. ments are often sadly in our way, offering a great obstacle to the successful reduction and subsequent maintenance of the parts. Sometimes, indeed, the projecting pieces are so long and sharp as to pierce the integuments, or to require to be sawed off before the bone can be properly set. Such an occur- rence is not uncommon in fractures of the tibia, and it is also witnessed, though less frequently, in the femur, the radius, and clavicle. Sometimes the fracture is impacted, that is, the end of one fragment is forcibly driven into the other, so as to be, as it were, interlocked. Such an occurrence, of which fig. 324 affords an excellent Fig. 324. illustration, can only arise, as a general rule, in those bones which contain an extraordinary amount of areolar substance. As a bone may give way at any part of its extent, at its middle, or at either end, it follows that the two fragments are rarely of the same length; instead of this, there is often a most marked disparity, as is exemplified in fractures of the extremities of the long bones, as the femur, in which, especially in fractures of its neck within the capsular ligament, the superior fragment is sometimes hardly an inch and a half in length, while the other is perhaps up- wards of a foot and a quarter. Fracture of the impacted fracture of the neck olecranon affords a similar illustration. Such an of femur. occurrence is not without its influence in regard to the treatment and final issue of the lesion; for the nearer, as a general rule, the length of the fragments corresponds, the easier, all other things being equal, will it be to maintain their apposition, and secure prompt and perfect union. A fracture raay be single or multiple; that is, a bone may break at one or raore places, sometimes as many as three, four, or even five; in other words, it may be literally crushed and comminuted. Such lesions are generally the result of inordinate violence, and are always liable to be followed by serious consequences; often, indeed, by loss of limb and life. In fractures of the leg and forearm, affecting both bones, it is extremely rare to find the injury situated on the same level; on the contrary, there is generally a considerable distance between the two fractures, amounting, ac- cording to my observation of numerous cases, ordinarily to from one to two, three, and even four inches. The interval is usually considerably greater in the leg than in the forearm, probably because of the greater inequality in the size of its two bones. What the cause of this occurrence is it is not easy to determine; but it may be supposed that it is due mainly, if not entirely, to the manner in which these pieces are respectively articulated to the wrist and ankle-joints, in consequence of which the violence occasioning the lesion is GENERAL CONSIDERATIONS. 921 transmitted raore forcibly along one bone than along the other, thereby com- pelling the former to yield before the latter. Thus, as the tibia is more intimately connected with the foot than the fibula, it follows, if this explana- tion be correct, that it ought to break lower down than the fibula, and this, I believe, is what usually happens, although there are many exceptions. Fractures occur at all periods of life. During delivery, the bones of the arm and leg are occasionally broken in rude attempts at extraction. In 1856, an infant, four weeks old, was brought to me on account of a fracture of the shaft of the right femur, caused two days previously by a child rolling over it in bed. The thigh was much swollen, and at least an inch and a half shorter than the sound one; all the extension and counter-extension that I could make with my hands failed to restore it to its normal length. Frac- tures occasionally occur in the foetus in the womb. Chaussier met with a remarkable example of this description, in which each of the long bones had suffered more or less from these lesions, some of which were recent, others beginning to unite, while others were consolidated. The child survived its birth only twenty-four hours. Cases of a somewhat similar character have been reported by other observers. In childhood, the bones being remarkably flexible, on account of the large amount of animal substance which they con- tain, are particularly prone to give way at their epiphyses ; in old age, on the contrary, they are very dense and brittle, from the presence of an inordi- nate quantity of earthy matter, and are therefore extremely liable to break from the slightest causes. Thus, a fracture of the neck of the femur within the capsular ligament is often produced by a mere twist of the thigh in bed, by catching the big toe in a fold of the carpet, or by stepping off the curb- stone. Causes.—The causes of fractures are generally divided into predisposing and exciting; the first having reference to the part and system, or to local and constitutional circumstances, the second to external violence and muscu- lar action. The conformation, situation, and office of certain bones are so many pre- disposing causes of fracture. Thus, as was before stated, the long bones, which are the great levers of locomotion, and which, in consequence, are constantly under the influence of large and numerous muscles, are much more subject to this accident than the short or flat bones, which are more passive in their character, as well as more closely articulated together, so that any force that may be communicated to them is more easily broken. The body of the scapula is seldom broken, because it is not only thickly covered by muscles, but, having no fixed point below, it is incapable of being injured by any shock transmitted by the hand, elbow, or shoulder. The acromion process, however, owing to its exposed situation, is not unfrequently frac- tured; while the coracoid process, protected by the deltoid, clavicle, and head of the humerus, rarely suffers from this cause. The radius, being arti- culated with the hand, is more liable to break than the ulna; the fibula, owing to its slender form and brittle texture, is oftener broken than the thick and heavy tibia; and every surgeon knows how very prone the collar-bone is to fracture, its exposed situation, the peculiarity of its conformation, and its connection with the sternum and scapula rendering it particularly obnox- ious to this occurrence. Of the influence of age, in promoting the occurrence of fracture, mention was made in a previous paragraph, and it need not, therefore, detain us here. It may be stated, however, that, as we advance in life, there is superadded to the preternatural brittleness of the osseous tissue, another cause of fracture, namely, abnormal rigidity of the muscles, thus rendering us more liable to falls, and, consequently, more prone to the accident in question. Various diseases or states of the general system have usually been regarded 922 DISEASES OF THE BONES AND THEIR APPENDAGES. as predisposing causes of fracture. Of these, the most common are syphilis, cancer, scurvy, and rickets. That a syphilitic state of the system, involving the skeleton, may so affect sorae of the bones as to render them abnormally fragile is sufficiently estab- lished by modern observation. In 1847, I attended a man, aged thirty-one years, for a fracture of the body of the right humerus, caused, a short time previously, by throwing a sraall chip at a person. He was perfectly well at the time, with the exception of some nocturnal pain in the arm and forearm. He had had primary syphilis seven years previously, and had been treated with mercury. The bone united in five weeks. It is well known that cancer may so alter the osseous tissue, fig. 325, as to render it preternaturally brittle, and thus predispose it to fracture. Such an occurrence, indeed, is probably not so uncommon as is generally supposed. I have myself, however, seen only one instance of it. The patient was a female, seventy-three years old, from whom I had removed, with the assistance of my former col- league, Professor Miller, nine months previously, the left mammary gland, on account of scirrhus, under which she had labored for nearly three years. The wound healed kindly, but, some time after, the disease reappeared at the cicatrice, and gradu- ally carried her off, not, however, before she had become extremely emaciated and bedridden. Du- ring the last month of her life, she complained of alraost constant pain in the right thigh, deep- seated, and particularly severe at night; and three days before she expired, in an attempt to turn in bed, the femur broke just above its middle. The limb was free from swelling and discoloration. No cancerous matter could be detected in the af- fected bone, which was quite soft, humid, and brittle, for some distance above and below the seat of fracture. Of the influence which scurvy exerts upon the osseous tissue, in predisposing it to fracture, the modern practitioner has little opportunity of judg- ing, as the disease at the present day seldom ap- pears in that violent form which characterized it in former times. As described by the older writers, it was often attended wdth the most horrible ravages, in which the skeleton not unfrequently participated, the synovial membranes, cartilages, and ligaments being ulcer- ated, and the epiphyses separated from the bones. In 1855-6, the scurvy prevailed extensively in certain regions of the United States, especially in the Southwest, but I am not aware that it predisposed any of its subjects to the occurrence of fracture, or that it retarded the process of reunion in those who suffered from it at the time. There are certain states of the skeleton, including rickets, in which the bones become so remarkably brittle as to break under the most trivial injury. Cases are recorded where, from these and other causes, nearly every one of the long bones was broken not only once, but a number of times. What is remarkable in these cases is that they usually recover quite as soon as ordi- nary fractures. I have in my collection a part of the skeleton of an old woman, who, in falling from a second-story window down upon the pavement Fig. 325. Encephaloid of the thigh, fol- lowed by fracture. GENERAL CONSIDERATIONS. 923 below, received not less than fifty-three fractures, involving the vertebrae, the scapula, the bones of the pelvis, and most of the bones of the extremities. Gout and rheumatism are sometimes enumerated as predisposing causes of fracture. The following case, which I saw with Dr. Metcalf, would seem to countenance the possibility of such an occurrence. Henry Welker, a common laborer, aged thirty-two, had always enjoyed good health until two years and a half ago, when he was attacked with articular rheumatism, affecting the principal joints, first of the superior, and then of the inferior extremities, where it had continued for the last twelve months. The only cause which he could assign for his suffering was expo- sure to cold and fatigue in a pork-house, where he had worked for fourteen successive winters. In December, 1855, he broke his thigh-bone, at the junction of the lower with the middle third, while pulling o(f his boot with his hands, the foot being at the time bent at a right angle with the leg. No pain or swelling followed the accident. The most remarkable feature in the case, when Dr. Metcalf first saw it, was the imperfect aeration of the blood, as indicated by the livid state of the face; the bowels were torpid, the tongue was coated, and there was considerable emaciation, but no disease of the heart and lungs. No chalky deposit existed in the joints. At the end of a month and a half, the parts being united, the dressings were removed, and the man was permitted to walk about on crutches. A week after this, he struck the affected thigh slightly against the rail of the bed, fracturing the bone at its upper third. Union took place in about the same time as before, the quantity of callus in each case being uncommonly large. The exciting causes of fracture are two, external violence and muscular contraction. The former, whieh is by far the more common, may act upon a bone either directly, or indirectly through some other bone. In the first case, the force is applied to the bone itself, as in fracture of the jaw from the kick of a horse, or in fracture of the leg from the passage of the wheel of a carnage. Most fractures are of this description, and hence they are gene- rally complicated with more or less injury of the soft structures. In the other case, the force, instead of being applied immediately to the bone, is trans- mitted to it through another bone, or perhaps a chain of bones. It is in this way that the radius is so frequently broken just above the wrist by falls upon the hand, the force being concentrated upon its inferior extremity, in conse- quence of the manner in which it is articulated with the carpus, while the ulna, which is but slightly connected with it, generally escapes. Fracture of the clavicle affords an instance of a bone being broken by indirect mechanical violence operating at two opposite points. Thus, in falls upon the shoulder, the sternal end being impelled by the weight of the body, and the acromial end by the object which it strikes against, the bone, acted upon by the two forces, gives way at its weakest part, which is usually about its middle. When a bone is very brittle, the slightest external violence may be sufficient to break it. In old people the neck of the femur is frequently fractured by the merest twist of the lirab in bed, or by stepping carelessly out of the bed upon the floor. It is not often that a bone is broken by muscular action, and yet such an accident is not, perhaps, as uncomraon as is generally imagined. I have myself met with several instances of it. In three, the subjects were remark- able for their health and muscular developments, and the fracture in each was produced while they were engaged in feats of strength, in which the elbows were planted firmly upon a counter, and the hands interlocked with each other. While the muscles of the arm and forearm were in a state of the utmost tension, the humerus snapped off suddenly, with a loud noise; in two cases at its middle, and in the other at its inferior extremity. In another case, the fracture, also seated in the humerus, was caused by throwing a 924 DISEASES OF THE BONES AND THEIR APPENDAGES. small chip. In this instance, alluded to in a previous paragraph, the bone had suffered for a considerable time under nocturnal pains, and had evidently been rendered brittle by the effects of the syphilitic virus. The patient, aged thirty-one, was otherwise in good health, but the muscles of his arm were rather soft and flabby. The patella and olecranon are frequently fractured by the action of the extensor muscles of the thigh and arm. From the above cases, it is evident that a diseased state of the bone is not at all necessary to the production of this accident by muscular contraction, although such a change is perhaps generally present at the time of the fracture, and therefore deserves to be considered as a predisposing cause of it. When the osseous tissue is preternaturally brittle, mere muscular spasm is capable of producing fracture, as in the interesting case related by Dr. Lente of a boy, twelve years of age, who broke both his thigh-bones during a severe epileptic convulsion. 2. SIMPLE FRACTURES. The symptoms of fracture may be considered, first, in relation to the broken bone itself; secondly, in relation to the soft parts; and thirdly, in relation to the constitution. So far as the affected bone is concerned, there are only three symptoms which are at all reliable as evidences of the existence of fracture. These are crepitation, deformity, and preternatural mobility. Crepitation is the peculiar noise which is produced by rubbing the two ends of the broken bone against each other, and is always, when well marked, characteristic of the nature of the injury. In general, it can be both heard and felt. In order to produce it, it is necessary that the ends of the frag- ments should be at least partially in contact, and hence, to effect this object, the surgeon is often obliged, as a preliminary step, to extend and counter- extend the affected limb. For this reason it is always absent in impacted fractures, while in fractures of the leg and forearm, involving only one of the bones, it is usually very faint and indistinct from the difficulty of moving the broken pieces upon each other. Much swelling or great depth of muscle will also obscure the crepitation. Deformity, although not invariably present, is, in general, one of the raost prominent symptoms of fracture. It exhibits itself in different forms, as in shortening, or in angular displacement, and usually occurs at the time of the accident, the cause which produces the fracture being itself the cause of the distortion. Occasionally, however, it does not come on until several hours, or perhaps even days after; as, for example, in a partially impacted fracture of the neck of the thigh-bone, in which the patient may be able to walk some distance, and yet the limb retain its normal shape. The degree and character of the deformity are greatly influenced by the nature and situation of the fracture. Thus, the more oblique a fracture is, the greater, as a general rule, will be the displacement of the ends of the fragments, and, consequently, also, the distortion of the limb. Soraetimes, as in fracture of the patella, the ole- cranon and calcaneum, the deformity manifests itself by a vacuity or hollow at the natural situation of the bone, and by an unusual protuberance upon the lower part of the thigh, arm, and leg, caused by the separation of the upper fragment by the action of the extensor muscles." Finally, the deformity may be much increased by the extravasation of blood consequent upon the injury, or by the effusion of serum and lymph consequent upon the resulting inflammation. Preternatural mobility is, next to crepitation, the most important and reliable symptom of fracture. There are few instances in which it is wholly absent, while in the great majority it exists iu a well-marked, if not in a high, SIMPLE FRACTURES. 925 degree. It usually appears immediately after the occurrence of the accident, and continues to a greater or less extent until the completion of the consoli- dation of the fracture. In the impacted fracture it may be entirely wanting, or remain absent until the ends of the fragments are unlocked. In fracture of the leg and forearm, involving only one bone, the degree of mobility is sometimes very slight, the sound bone impeding or altogether preventing the motion of the affected one. In every fracture produced by external violence, whether applied directly or indirectly to the part, there must, of necessity, be a certain degree of con- tusion of the soft structures at the seat of the injury. It may be limited to the skin and subjacent cellular tissue, or it may extend deeper, and involve the muscles, aponeuroses, vessels, nerves, periosteum, and even the bone itself. In consequence of this occurrence, there is not unfrequently a con- siderable effusion of blood beneath the skin, and in the connective tissue of the muscles, causing distension and sometimes discoloration. For the same reason, there is generally a good deal of pain, often of a sharp, spasmodic character, which is aggravated by the slightest motion of the parts, and by every attempt at exploration. It has its seat rather in the soft structures than in the affected bone, although the latter generally participates in it, and by the sharpness of its extremities frequently increases its severity. A short time after the accident, swelling usually sets in, and often proceeds to a con- siderable height, its degree being greatly influenced by the amount of injury sustained by the soft parts, by the motion to which the fractured bone is subjected, and by the state of the system at the time of the accident. As a general rule, it may be affirmed that the pain and swelling are less in fractures produced by muscular contraction than in such as are caused by mechanical violence, whether directly or indirectly applied. Inability of motion in the affected bone, and in the portion of the limb articulated with it, is generally a prominent symptom. Cases, however, occur in which it is either very slight or where it is entirely absent. In an impacted fracture of the thigh, for instance, a patient has sometimes been known to be able to walk for a considerable distance without the slightest assistance even from a cane, and in fracture of the clavicle, I have repeatedly seen him carry his hand to his head, and even circumduct the arm. Another symptom, consequent upon fracture, is spasm of the muscles at the seat of the injury; it is most common in nervous, irritable persons, and generally comes on within a short time after the accident. When severe, as it frequently is, it constitutes a source of real suffering. It is aggravated by motion and inflammation, and may continue, with more or less interruption, from several hours to several days. Finally, the patient often experiences a sense of numbness in the affected part, reaching frequently to the distal extremity of the limb. This may be caused either by the injury sustained by a nervous trunk at the time of the accident, or by the compression of the soft parts by extravasated blood, or the ends of the broken bone. Sometimes it does not arise until inflammation has supervened, and then it is generally owing to the presence of an unusual quantity of serum and lymph. The amount of constitutional disturbance in fracture varies, in different cases, frora the slightest exaltation of the normal action to the most intense excitement, depending mainly upon the nature of the fracture, the degree of violence sustained by the soft parts, and the state of the system at the time of the accident. In very many cases, there is an entire absence of traumatic fever, while in others it is present in a very high degree, the pulse being strono" and frequent, the countenance flushed, the skin hot and dry, the thirst intense, and the appetite and sleep much impaired, if not totally suspended. In the more severe forms of fracture, the patient often experiences a severe 926 DISEASES OF THE BONES AND THEIR APPENDAGES. shock, from which he may not fully recover for many days, or which may even terminate in death. Whenever there is much constitutional disturbance, the affected limb will be apt to be in a high state of inflammation, the parts being hot, swollen, and painful, and, at times, even covered with small vesicles, such as a heedless observer might easily mistake for the phlyctenula? which so often announce the occurrence of gangrene. Displacement of the Ends of the Fragments.—The displacement of the frag- ments shows itself, as already stated, in two principal directions, the longi- tudinal and horizontal. Of these, the former is by far the more common, as it is present, to a greater or less extent, in nearly all cases of oblique fracture, in whatever portion of a bone occurring. It is produced by the overlapping of the extremities of the broken bone, the lower being drawn above the upper, or the one riding over the other, as it is sometimes expressed. The extent of this form of displacement varies from the slightest possible change in the length of the affected bone to two, three, and even four inches, which raay be regarded as its maximum. It is generally most conspicuous in fracture of the femur and humerus, while in fracture of the forearm and leg, affecting only one bone, it is either very slight or totally wanting. Finally, the dis- placement may be lateral, anterior, or posterior, according to the nature of the exciting cause. In the horizontal displacement, the lower fragment may form an angle, more or less acute, with the superior, thereby giving the bone an arched appearance; or, the two pieces remaining in contact with each other, the inferior one may perform a rotatory movement, while the other continues perfectly stationary. In some cases, as in fracture of the lower end of the radius, there is often considerable lateral displacement, and similar pheno- mena are apt to occur in fracture of the tibia and fibula at or near the ankle-joint. The causes of displacement are, muscular action, mechanical violence, and the weight of the limb connected with the broken bone. Of these the first is the most common, and it need hardly be added that a knowledge of the fact is of the greatest practical importance in regard to the proper manage- ment of the injury. In some instances the displacement is entirely produced by the vulnerating body. Thus in fracture of the nose, the blow which in- flicts the injury also displaces the fragments. The wheel of a carriage passing over the leg may not only break its two bones, but likewise cause great deformity by forcing asunder their extremities. Finally, the displace- raent may be occasioned by the weight of the limb connected with the injured bone, as in fracture of the clavicle, in which the outer fragment is drawn downwards and inwards by the weight of the shoulder and arm. Diagnosis.—The most valuable symptoms of fracture, diagnostically con- sidered, are, crepitation, deformity, and preternatural mobility. The co- existence of these symptoms is unmistakably denotive of the nature of the accident, but. unfortunately, they are not always associated; one or even two may be absent, and hence a case that ought to be treated in the most prompt and decisive manner, may, for the want of a correct appreciation of its character, be either entirely neglected, or, at all events, grossly misman- aged. Besides, the symptoms here enumerated may be simulated by other accideuts, especially dislocation, and certain affections of the joints. The crepitation of fracture is sometiraes imitated by the grating produced by an effusion of plastic matter into a joint, the sheath of a tendon, or a synovial burse; aud the difficulty may be still further increased, if, under such circumstances, the suspected" fracture is situated near a large articula- tion. In general, however, it will be sufficiently easy to distinguish between them by a consideration of their respective characters. In fracture, the cre- pitation can be both felt and heard; it is dry, coarse, or rough, resembling SIMPLE FRACTURES. 927 the sensation and noise produced by rubbing two unequal surfaces against each other. The crepitation from plastic matter, on the contrary, is of a finer quality, or more faintly marked, and may be likened to the feel and noise caused by gently rubbing over each other two pieces of sole leather; in a word, it lacks the roughness and distinctness of the other. Moreover, it must be remembered that it is never present until after the occurrence of inflammation, whereas the other alwTays exists from the very beginning of the accident. Crepitation, it is true, might be produced in consequence of pre- vious disease, and the possibility of such an occurrence should not be lost sight of in our examinations. Finally, when the case is obscure, the crepi- tation may sometiraes be detected by the aid of the stethoscope, especially when the bone is thickly covered by muscles, as in fracture of the neck of the femur within the capsular ligament, or in fracture of the ribs in corpulent subjects. This mode of examination was originally suggested by Lisfranc, but, as the expectations held out by him have not been realized, few practi- tioners of the present day resort to it. The deformity in fracture manifests itself either in shortening, in lateral displacement, or, as not unfrequently happens, in the two united. Elonga- tion is never present, in which respect fracture differs from certain forms of dislocation, in which lengthening is a prominent symptom. The degree of shortening varies from a few lines to several inches, and is, therefore, an oc- currence of much value in a diagnostic point of view. It may exist from the commencement of the accident, or it may not show itself until some time after its occurrence, being materially influenced by the action of the muscles, and the nature of the treatment. Whatever the degree of the deformity may be from these causes, it may always be effectually removed by extension and counter-extension, either alone or aided by pressure; but as soon as these forces cease to operate, it is usually immediately reproduced, wdiich is not the case in dislocation. Here, the reduction having been effected, the parts generally retain their relations until some new cause produces a new dis- placement. Too much stress cannot be placed upon preternatural mobility as a sign of fracture. Next to crepitation, it is unquestionably the most important diag- nostic symptora. There may be unnatural latitude of motion in a disloca- tion, but this can happen only wdien the accident is attended with extensive laceration of the ligaments of the joint; in ordinary cases there is either an absence of motion, the displaced bone being firmly fixed in its new position, or the motion is so slight as to bear only a faint resemblance to that observ- able in fracture. The general expression of the affected parts, fig. 326, often affords valua- ble diagnostic signs. The de- formity, for example, of the hand and wrist, in fracture of the lower extremity of the ra- dius; the eversion of the toes in intra-capsular fracture of the femur, and the shortened and retracted appearance of the arm in fracture of the humerus, are generally unmistakable evi- dences of the nature of the accident. The manner in which the patient inclines his head and supports the elbow and forearm in fracture of the clavicle, is too significant to be overlooked by any one that has ever witnessed it. The peculiar aspect and attitude of a broken thigh, Fig. 326. Fracture of the lower end of the radius. 928 DISEASES OF THE BONES AND THEIR APPENDAGES. conjoined with the utter helplessness of its muscles, or the absence of all voluntary power, are signs which seldom admit of misinterpretation. The pain, swelling, and loss of function, present in suspected fracture, are of no practical value, as similar phenomena are produced by other injuries, as contusions, wounds, sprains, and dislocations. Their occurrence being wholly accidental, must, therefore, not influence the surgeon in his attempt to form a correct estimate of the real nature of the case, or the relative value of the symptoms of this and other analogous affections. Mode and Time of Examination.—Although the symptoms which have now been described will generally be sufficient, along with a careful consideration of the history of the case, to enable the surgeon to determine the diagnosis of this lesion, especially if he will take the trouble of comparing them with the symptoms of other accidents, it will, nevertheless, be proper, in conclud- ing this branch of the subject, to say a few words respecting the manner of conducting the examination of the affected parts, as the ultimate issue of the case will greatly hinge upon this circumstance. My experience satisfies me that few practitioners know how to examine a broken lirab. They take hold of it as if they were afraid of giving pain, or causing suffering, and the consequence is that the result is often most dis- astrous. I am far frora wishing to be understood as being an advocate of rough surgery; on the contrary, no one abhors it more than I do, yet there are times and circumstances when the best interests of the patient demand that he should be raost thoroughly examined, no matter what amount of pain he raay be compelled to undergo. But there is no need any longer of such infliction now that we can prevent suffering by anaesthesia. The patient being rendered insensible, perquisition is performed at the surgeon's leisure, slowly and deliberately, and with an eye to the ultimate result, not forgetting self. The sooner such manipulation is instituted the better, for there will be less likely to be inflammatory swelling and other obstacles calculated to embar- rass our progress and obscure the diagnosis. Fractures of the shafts of the bones will rarely afford any difficulty, inasmuch as their symptoms are gene- rally so well marked that the most casual inspection will be sufficient for their detection. But it is different when the lesion involves their extremities. Here the most laborious and pains-taking examination sometimes hardly enables the practitioner to form an accurate judgment respecting the real nature of the injury. Under such .circumstances, therefore, he must not con- tent himself with one or two trifling explorations, but he must handle the parts again and again, until he has thoroughly established the diagnosis. If, after repeated trials, he is still in doubt, it is his duty to state this doubt to his patient, and to seek the advice of a professional brother in order to aid him in solving the question. By adopting this course, he will be raore likely to do justice to his patient, and at the same time escape personal blame. For the reason already assigned, the parts should always be examined as early as possible after the infliction of the injury, but I would make no ex- ception where some time has elapsed, and a good deal of swelling has super- vened; for it is impossible that a broken bone, or the parts by which it is covered, should do well as long as its extremities are displaced, and thus permitted to fret, irritate, and perhaps prick the muscles and other structures in contact with it. Hence, the sooner the fracture is adjusted or the parts are placed in their natural relations, the more likely will they be to do well, and escape the ill effects of inflammation. There are instances, however, where, as may be supposed, immediate interference might prove highly pre- judicial, using the term immediate here with reference to the surgeon's first visit. The patient may have been neglected, or his attendant may have mis- taken the nature of the case, and in this manner several days may have passed SIMPLE FRACTURES. 929 uselessly away. The limb is now found in a very swollen and painful condi- tion, intolerant of the slightest manipulation, nay, perhaps in an erysipelatous condition. To make an elaborate examination under such circumstances would be highly improper; for it could not fail to aggravate the raorbid action, and perhaps urge it on to gangrene. The hand is withheld ; the lirab is placed in an easy position, and antiphlogistics, both local and constitutional, are freely plied ; when action has sufficiently abated, but not until then, the proper examination is effected, and the diagnosis, if possible, established. The mode of conducting the examination varies. In the upper extremity the surgeon will usually be able to get on without any assistance, but in frac- ture of the thigh and leg it will often be necessary to make extension and counter-extension while the parts are subjected to methodical manipulation. When there is marked displacement, the merest touch of the hand will gene- rally suffice to detect the nature of the lesion ; but, under opposite circum- stances, the nicest digital exploration may be required before a satisfactory result can be obtained. In general, it will be necessary to make pressure and counter-pressure at the seat of the injury, and to rotate the portion of the limb below the fracture upon its axis. In this manner, especially if pro- per extension have been made, the ends of the fragments being brought in contact may be made to yield the friction-sound, previously described, and at the same time display the full extent of their mobility. Another procedure is to grasp the two extremities of the suspected bone, and then, while the superior one is firmly held with the thumb and fingers, to roll the inferior upon its axis. If, while this is being done, both parts move together, the probability is that there is no fracture, but if the lower should move, aud the upper remain stationary, there can be no doubt of the fact. Mode of Repair.—The mode of repair in fracture is precisely similar to that of the soft parts, the only difference being the superaddition of the car- bonate and phosphate of lime, or the earthy constituents of bone. In order, however, to be thoroughly understood, it is necessary to study it with refer- ence to the situation and disposition of the ends of the fragments of the broken bone, as the rapidity and perfection of the cure are greatly influenced by the manner in which they are arranged and held together during the treat- ment. The more perfect this is, the more complete, generally, all other things being equal, will be the reunion. For practical purposes, the whole subject of repair may be considered as consisting of four stages. The first stage, which, on an average, extends from the first to the eighth day, is one altogether of preparation, in which nature clears away the rub- bish, and places the ends of the fragments in a suitable condition for the process of repair, properly so called. The blood which was extravasated at the moment of the accident, at and around the seat of the fracture, is in great degree, if not entirely, absorbed ; the inflammatory products, especially the intermuscular, are also disposed of; the swelling subsides, the pain disap- pears, and there is no longer any tendency to spasmodic action, the muscles having become calm and quiet under their new relations. Any traumatic fever that raay have been present will also be found to have vanished. Thus the part and system have happily passed through the preliminary stage of the reparative process. If the parts be examined at the commenceraent of the second stage, it will be seen that the ends of the broken bone, as well as the periosteum, and the other soft parts in their immediate vicinity, are abnormally red and injected, and covered by plastic matter, resembling very much in its color and consist- ence pale currant jelly, or a thick solution of isinglass. It is usually raost abundant upon the surface of the bone, and is often sufficient to lift up the periosteum ; a considerable quantity is also generally seen between the peri- VOL. i.—59 930 DISEASES OF THE BONES AND THEIR APPENDAGES. osteum and the muscles, and even among the muscles themselves, all these structures being more or less actively engaged in the process of repair. A similar substance, but usually less abundant, is poured out within the medul- lary canal, the lining membrane of which is also in a state of inflammation, as is evinced by its discolored and injected condition. In the latter part of this stage, which lasts from the eighth to the twentieth day, the newly-effused matter, which differs in none of its properties from that which serves to unite a recent wound, becomes gradually more and more solid, until at length it assumes the consistence of a concrete substance. The third stage is characterized by still further changes in the consistence of the effused matter, and by its gradual conversion, first into fibro-cartilage, then into cartilage, and finally into bone ; or, more correctly speaking, cells are developed in the new substance, into which the osseous granules are de- posited, the whole process bearing the closest possible resemblance to that which takes place in the formation of the original bone. The period at which the bony matter begins to be developed in the adult varies frora the eighteenth to the twenty-fifth day, its appearance and progress being in- fluenced by numerous local and constitutional causes, to be described under another head. The ossific process proceeding in the way now described, two layers of bony matter are formed, one lying upon the outer surface of the fragments, the other within the medullary canal, each extending some distance beyond the seat of fracture, as is seen in fig. 327. To these two strata is confided Fig. 327. Fractured tibia, bisected, to show the formation of new bone beneath the periosteum, and within the medullary canal. the office of temporarily supporting the fragments, or of holding them together until their ends are permanently united by osseous substance; a circumstance which does not take place, as a general rule, until several months later. To this new matter the older pathologists applied the term callus, in considera- tion of its hardness, which, when the process of repair is completed, is fully equal to that of the original bone, which it also closely resembles in its struc- ture. From its office, the outer and inner callus, or that which invests the broken bone and lies in its medullary canal, is now universally known as the temporary or provisional callus, while that which is placed between the two ends of the bone, and thus serves to cement them together, is designated as the definitive or permanent callus. The temporary callus is, figuratively speaking, nature's splint, or the means which she employs to support the fractured bone until the continuity of the fragments is re-established by the deposit and organization of osseous matter between their extremities. As the first stage in the reparative process is one of preparation, so the last is one of completion ; reunion having been effected, nature now busies herself in removing whatever is redundant or superfluous, thereby fitting both bone and muscle for the resumption of their respective functions. The pro- visional callus, having ceased to perform its office as a splint, is gradually brought under the influence of the absorbents, its more superficial portions being taken away first, and afterwards the more deep, until the broken bone regains not only its original form and volume but also its pristine smooth- ness, all evidence of fracture disappearing, excepting, perhaps, a little seam or ridge corresponding with the line of junction of the two fragments. While SIMPLE FRACTURES. 931 these changes are going forward upon the exterior of the bone, nature is busy at work in its interior, disposing of the provisional callus in that situation, and thus restoring the medullary cavity to its normal condition. This can occur, however, only when there has been perfect apposition of the ends of the fragments; for when the reverse is the case, the new bone remains per- manently in the canal, as is shown in fig. 328, from a specimen in my collec- tion. Fig. 328. United fracture, showing the condition of the medullary canal. Any cartilaginous or osseous matter that may have been formed between the periosteum and muscles, or among the muscles themselves, is likewise removed as a substance foreign to the part, and therefore useless, if not positively prejudicial. It will thus be seen that the fate of the provisional callus is precisely similar to that of the plasma which is effused between the edges of a wound, both gradually disappearing as soon as their service can be dispensed with, or as soon as the parts have acquired sufficient firmness to enable them to maintain their connection. The period required for effecting these changes in a broken bone varies frora a few weeks to several months, according to the circum- stances of the case. Such is a brief but accurate account of the several changes which attend the repair of bone in the more simple forms of fracture, when the ends of the fragments are thoroughly maintained in their natural relations. Under such circumstances there is but little need of provisional callus; the ends of the fragments soon inflame, and unite almost by the first intention. But it is seldom that a patient is so fortunate; on the contrary, the fracture being generally oblique, is subject to more or less displacement, thus compelling nature to provide a temporary splint by the formation of provisional callus. I do not believe, however, as has recently been so much insisted upon, that there ever is an entire absence of this kind of callus, however intimately the ends of the bones may be in apposition with each other. To prove the truth of this remark, it is only necessary to examine the numerous specimens of fracture of the skull and other portions of the skeleton in our museums; they will conclusively demonstrate that even the most simple fracture, unaccom- panied by the slightest displacement, is never repaired without the develop- ment of a certain quantity of osseous matter upon its surface. At the same time it must be admitted that the provisional callus, in such cases, is very small, and that it bears no proportion to the enormous amount of substance that is so often formed when the ends of the bone are separated from each other. Under the latter circumstances, nature labors under great disadvantage, and is, therefore, obliged to make extraordinary efforts to effect reunion, which she can do only by the development of a large provisional callus. From these facts, then, we may deduce the general law that the quantity of new bone is always, other things being equal, in proportion to the contact of the ends of the fragments, being small when this is very accurate, and more or less large when it is imperfect. When the ends of the bone are not accurately approximated, the first thing that nature does is to round off their edges, and to close the medullary cavity by a shell of new bone, as in fig. 329; the next, is the formation of a large 932 DISEASES OF THE BONES AND THEIR APPENDAOES. provisional callus for the more secure consolidation of the fracture. The whole process is one of time and labor, not of speed and ease, as in the Fist. 329. Fig. 330. Fracture of the arm-bone of a chicken. From a spe- cimen in the author's col- lection. Appearances of the ends of the fragments in old, ununited fracture. former case. When the ends are completely separated but opposite, or nearly opposite to each other, they are generally united by a bridge of new bone, extending from one to the other, as in fig. 330, and ultimately affording sufficient strength for the support of the weight of the body upon the affected limb. Or, instead of this, especially in elderly subjects, the junction is effected by fibrous, fibro-ligamentous, or cartilaginous matter. Finally, osseous union is not impossible when the extremities of the fragments overlap each other to an extent even of several inches, provided they are in contact; for in this case inflammation is established in the contiguous surfaces, followed, after a long time, by a large permanent callus. We see many curious speci- mens illustrative of this fact, though, in general, the union is ligamentous. There are certain pieces of the skeleton in which in fracture no provisional callus ever forms. Such are the olecranon, acromion, patella, and neck of the femur. Instead of uniting by osseous matter, as the other bones do, the cure is generally effected through the medium of fibrous, ligamentous, or cartilaginous substance, and the conse- quence is that the part commonly remains weak ever afterwards. Various causes conspire to produce this result, as the difficulty of maintaining the contact of the broken surfaces, and the inordinate secretion of synovial fluid, which, mingling with the effused plasma, thus impairs its vitality, and renders it unfit to become the nidus of bony deposit; but the most efficient one of all is the want of nourishment of the smaller fragment produced Ify the lacera- tion of the nutrient vessels. Thus, in fracture of the neck of the femur within the capsular ligament, the upper piece, consisting of the head of the bone and of a portion of its neck, the only connection between it and the rest of the body, is by the round ligament, the arteries of which are altogether unequal to its proper support. Treatment.—The leading indications in the treatment of fracture are to procure reunion and to prevent deformity. Before we proceed to speak of the manner of fulfilling these indications, it is proper that we should lay down certain rules for the transportation of the patient and the manner of preparing his bed. Fractures are often received by persons at a considerable distance from their homes, either on the road, in the field, or at some secluded building. This renders it necessary to carry them to their own houses or to some hos- pital, in order to undergo the proper treatment. In fractures of the superior extremity, clavicle, scapula, or ribs, the requisite dressings may be applied at once; or, if this be not convenient, the patient may either walk or ride, the SIMPLE FRACTURES. 933 suffering lirab being supported in a sling, or, as in the case of a broken rib, the body may be swathed with a long napkin. It is only, as a general rule, in fractures of the inferior extremity, spine, or pelvis, that the patient will re- quire to be carried, and the best way of effecting this, if the distance be not too great, is to place him upon a narrow door, a long shutter, or two pieces of board, supported by two cross-pieces, the ends of which are intrusted to four assistants, a pillow and comfort having been previously put under the patient's head and body. Or, instead of this, the transportation may be conducted by means of an easy furniture-car, provided with a good mattress, and drawn slowly along in order to avoid jolting. Whatever mode be adopted, the limb should be temporarily splinted, and placed in as comfort- able a position as possible, an intelligent person sitting by his side, and rendering such aid as may be required on the way. In carrying him to his chamber, four assistants will generally be necessary, two to support the body, which they do by crossing their arms behind the trunk, and interlock- ing their hands, and two for the lower extremities, the surgeon himself taking charge of the broken one. A comfortable bed is to a man with a broken thigh or leg an indispensable article, and the practitioner who fails to give the proper instructions respect- ing it, is guilty of a gross dereliction of duty. Indeed, for his own sake hardly less than for that of his patient, he should give prompt attention to this subject, inasmuch as it is impossible to effect a good cure without it. When we reflect upon the fact that in fractures of the lower limbs, the patient is often compelled to remain in the recumbent posture for weeks together, and how difficult it is, in most cases, to maintain the requisite extension and counter-extension, the force of this injunction cannot fail to be perceived in its true light. The essentials of a good fracture-bed are, first, firm and stout slats, instead of a cord or sacking bottom; secondly, a well constructed mat- tress of hair, moss, or cotton ; and thirdly, a hole in the mattress, opposite the buttock, for the evacuation of the bowels, the opening being closed by a door of similar manufacture, and furnished with hinges and other appliances. If long confinement be necessary in one posture, or if the patient have been worn out by previous disease, an air-mattress may be required, in order to prevent bed-sores. If a sheet be used, its edges should be carefully secured to the sides of the mattress, otherwise it will soon become rumpled, and thus act as a source of annoyance. It has been a question which has been much mooted in modern times, whether a fracture should, as a general principle, be set as soon as possible after its occurrence, or whether time should be allowed for the subsidence of the resulting inflammation. It appears singular that upon a subject so clear as this there should be any difference of opinion. It certainly requires no great knowledge of the nature of accidents to discover why such cases should receive the earliest possible attention ; as long as the ends of the fragments are permitted to remain apart, their tendency inevitably must be to excite spasm and inflamraation, thereby increasing the suffering of the patient and retarding his cure. Of this fact there can be no doubt, and hence my plan has always been to treat every case of the kind that has come under my ob- servation as early as possible with the bandage and splint; applied, of course, not firmly, but gently and cautiously, simply with a view of giving support to the parts, and thus preventing further mischief from the sharp and pro- jecting ends of the broken bone. I can hardly imagine an instance to which such treatment would not be adapted. I certainly have never seen one. We might as well expect that a man's limb would do well if it had a thorn im- bedded in its muscles, as that it would be comfortable with two pieces of bone sticking in them. It is an absurdity to think it could be otherwise. Apparatus.__Before an attempt be made to set the fracture, it is necessary 934 DISEASES OF THE BONES AND THEIR APPENDAGES. to provide the requisite apparatus for effecting its maintenance. The means which are employed for this purpose are splints, cushions, bandages, and adhesive strips. Splints are made of various materials, as wood, trunk-board, leather, felt, gutta percha, tin, and iron, according to the nature of the fracture or the fancy, whim, or caprice of the practitioner. In fracture of the thigh and leg, especially in that form which requires permanent extension and counter-ex- tension, the best article is wood, adapted to the size and shape of the limb, at the same time that it combines lightness with strength. In fracture of the superior extremity, particularly of the humerus and of both bones of the fore- arm, splints made of trunk-board generally answer best, as by a little mani- pulation, after immersion in hot water, they may easily be moulded to the form of the limb. A piece of pasteboard affords a capital support to a broken jaw or finger. Unoiled leather and felt, the latter being rendered stiff by gum shellac, make excellent splints, which I have often used with much satis- faction in fractures both of the upper and lower extremities. Previously to applying them, they must be softened in hot water, the sharp angles and edges having been pared off with a knife. The tin case I have employed a great deal, especially in fracture of the humerus at the elbow, and of the tibia at the ankle, ever since I entered the profession. Iron splints, in the form of the double inclined plane, are much in vogue in England; but in this country, little use is made of them. Many years ago, I was induced to make trial in a few cases of fracture of the condyles of the humerus and of both bones of the forearm, of a splint composed of light wire, adapted to the size and shape of the limb; but not answering my expectations, on account of its not being as manageable as I had been induced to expect, I soon abandoned it. For fracture of the bones of the hand and fingers, carved splints are sometimes employed. During the last twenty-five years an immense number of patented apparatus have been presented to the notice of the profession; but I am not aware that any of them have come into general use, or that they possess any particular advantage over the more comraon contrivances. Splints made of gutta percha have recently come into vogue, not, perhaps, without reason on account of their neatness and easy adaptation. Cut into a proper shape and size, they may, after having been dipped in hot water, be readily moulded to the form of the part, which, upon cooling, they always retain. Previously to applying them, they are lined with wadding, or old linen, to prevent irritation of the skin, which this substance might otherwise induce. Mons. Maisonneuve employs splints made by saturating a piece of cloth, linen, or muslin, with a thick solution of plaster of Paris in water, and then doubling the cloth upon itself as many times as may be requisite to obtain the proper strength, when it is immediately secured to the limb with a roller. The advantages of this apparatus are that it dries in a few minutes, and that it thus forms almost instantaneously a firm, stiff shell for the broken lirab, perfectly adapted to its inequalities, exceedingly light, indisposed to absorb discharges, and admitting of easy application and removal. Fracture-cushions are generally made in the form of small bags, stuffed with bran, fine chaff, cotton, wool, hair, moss, or any other soft material. They are designed to fill up the inequalities between the splints and the lirab, and must necessarily vary in shape, length, breadth, and thickness, according to the exigencies of each particular case. Instead of cushions, simple pads or compresses are often used, especially iu fractures of the superior extremi- ties. For enveloping short splints, calico or muslin is employed ; or, what I always prefer, sheet wadding. The same article answers admirably for filling up the inequalities between the short splints and the affected limb. Bags filled with sand are sometimes very convenient and useful, especially in frac- SIMPLE FRACTURES. 935 tures of the leg. Stretched along each side of the limb, they keep up steady, equable pressure, well calculated to prevent displacement of the fragments. The fracture bandage should consist of coarse linen, calico, or muslin, and should possess sufficient strength to answer the purpose for which it is in- tended. Nothing is worse, or more likely to cause annoyance, than a thin, flimsy bandage. If the material is new it should be washed before it is used, to rid it of its starch, and the selvage should be torn off to prevent it from exciting irritation, or producing welts in the skin. The bandage most com- monly used is the ordinary single-headed roller, of a length and breadth suit- able to the affected limb or part of the body to which it is to be applied. In fractures of the leg and thigh, especially such as are of a complicated charac- ter, the bandage of Scultetus raay often be advantageously employed, as it can be easily undone and reapplied without the slightest disturbance of the limb. It consists of numerous strips of the ordinary roller, of equal or un- equal length, according to the size and shape of the part which they are in- tended to surround. In applying them, they are arranged in such a manner that one overlaps another nearly one-half. The practitioner cannot observe too much caution in the use of the ban- dage in the treatment of fractures. It is an agent for good or for evil; for good, if applied properly; for evil, if applied improperly. Its object is twofold: first, to afford uniform compression of the limb, thereby preventing swelling and spasm ; and secondly, to retain the necessary apparatus. Its application is governed by the general principles laid down in a former part of the work, the rule being always to begin at the remote part of the lirab, and to proceed thence upwards some distance beyond the seat of the frac- ture, care being taken to put it on with sufficient tightness to fulfil the object for which it is designed, without incurring the risk of interrupting the circu- lation, or of doing other mischief. If it be too slack to support the parts in a proper and uniform manner, it will be useless; if, on the other hand, it be too tense, it will give rise to severe inflammation, swelling, and even gan- grene. For the want of this precaution, many limbs have been lost, and a still greater number rendered permanently useless. American surgeons are now much in the habit of employing adhesive strips in the treatment of fractures, either as retentive means, or for the purpose of effecting and maintaining extension and counter-extension. In their latter capacity, I was the first, I believe, to call attention to the subject, in my Treatise on the Diseases of the Bones and Joints, published in 1830. I had witnessed their excellent effect in the practice of my former preceptor, Dr. Joseph K. Swift, of Easton, in a case of oblique complicated fracture of the leg, attended with so much iujury of the soft parts as to interfere effectually with the employment of the gaiter and other counter-extending bands. The man had suffered a great deal of pain, until his patience was almost ex- hausted, when trial was made with adhesive strips, carried along the sides of the limb towards the knee, their free extremities being tied below the foot, to the transverse block connecting the two splints. Great comfort was the con- sequence, and the case progressed favorably frora that time forward. Soon after I had occasion to use adhesive strips in a case of my own, with results equally gratifying. Since then I have employed this substance with great advantage in the treatment of fracture of the clavicle, olecranon, and patella, as well as in the treatment of fracture of the thigh and leg. Valuable papers have been published on this mode of management, within the last few years, by Dr. E. Wallace, Dr. Gilbert, and Dr. Neill, of this city, and Dr. Crosby, of New Hampshire. In a short article in the Philadelphia Medical Ex- aminer for 1852, I also called attention to the subject, giving very briefly the results of my experience up to that period. Dr. John Swinburne, in a paper recently published on fractures of the long bones, states that he has 936 DISEASES OF THE BONES AND THEIR APPENDAGES. been in the habit, for several years past, of treating these injuries almost ex- clusively with the aid of adhesive plaster, generally dispensing with the roller and often even with splints. The importance of this agent, for the purposes referred to, will be fully pointed out under the head of special fractures. Coaptation and Dressing.—Everything having thus been provided, and the requisite number of assistants obtained, the surgeon proceeds to restore the broken pieces to their original situation, or, to use a common expression, to set the fracture. This may be done either by simple manipulation, or pressure and counter-pressure, or by this means aided by extension and counter-extension. The former will usually suffice in fracture of the upper extremity, the jaw, and nose, while the latter will generally be required in fracture of the thigh and leg; in either case, the affected limb should be held as quietly as possible, not only during the adjustment of the fragments, but also during the application of the dressings. It need hardly be observed that these manipulations should be conducted in the raost gentle manner, with an eye both to present comfort and future consequences. There is no de- partment of surgery, where the humane practitioner may exhibit his skill and sympathy to greater advantage than in this, or where his conduct will be more closely watched and commented upon, than on such an occasion. Extension and counter-extension are always necessary in oblique fractures of the thigh and leg, attended with displacement. By the term extension is understood the force which is required to draw the upper end of the lower fragment to a level with the lower end of the upper fragment, in order to place them in their natural relations ; by counter-extension, on the contrary, is implied the resistance which is employed to prevent the limb, or even the body, from being dragged along by the extending power. The extension is generally made upon that part of the limb which is articulated with the lower piece, and the counter-extension upon that which is articulated with the upper. Thus, for example, in fracture of the shafts of the bones of the forearm, the extending power acts upon the hand, and the counter-extending power upon the arm, while in fracture of the body of the humerus the two forces are respectively exerted upon the forearm and the chest; and so in regard to fracture of the inferior extremity. When but little muscular re- sistance is anticipated, as in a child or feeble person, the extension and counter-extension may be applied directly to the two fragments, but at as great a distance from the seat of the injury as practicable. On the whole, however, I give the former method a decided preference, as it is much less likely to irritate and worry the muscles. In reducing a fracture, the injured parts should be put in the most favor- able position for relaxing the muscles, and the extending forces should be applied in as slow and gradual a manner as possible. If the limb be sud- denly pulled, or stretched by fits and starts, the muscles which are concerned in effecting and maintaining the displacement will inevitably be thrown into violent spasmodic contraction, thus not only causing pain but, perhaps, se- vere injury to the soft structures, if not actually frustrating our intention. The degree of force which should be used in making extension must vary accord- ing to the amount and character of the displacement, and the number and power of the muscles concerned in producing it; in all cases it should be sufficient to remove the shortening of the limb, or, what is the same thing, to restore it to its normal length, and to surmount every obstacle that op- poses the reduction. The extension is always begun in the direction of the lower fragment, and is afterwards continued in that of the injured bone, until the object of its application has been attained. The ends of the frag- ments being now pressed into their natural situation, the fractured part of the limb is enveloped in a suitable bandage, and immovably fixed by splints, every hollow between them and the skin being filled with cotton, to ward off SIMPLE FRACTURES. 937 pressure. A sling, to suspend the hand and forearm, completes the dressing, if the fracture occupy the superior extremity. In fracture of the thigh and leg, the patient lies in bed until the ends of the broken pieces have become completely consolidated, or, at all events, until he has made such progress towards recovery as to admit of the use of the starch bandage, and of exercise in the open air upon crutches. During bis confinement, the limb is placed in the most favorable manner for relaxing and resting the muscles which pass over the fracture ; for this purpose it should be put in the extended position, and be well secured with apparatus designed to maintain permanent extension and counter-extension. In some cases the limb is placed in the semi-flexed position, over a double inclined plane, but such a course will seldom be necessary or proper, except, perhaps, in fracture of the upper part of the body of the thigh-bone, attended with great and obstinate displacement of the superior fragment, in consequence of the joint action of the psoas and iliac muscles. In transverse fracture of the patella, the thigh and leg are sometimes placed over a single inclined plane, the foot being considerably elevated above the level of the trunk. After-treatment.—The fracture having been reduced and dressed, the patient is carefully watched, in order that he may be safely conducted through his long and arduous confinement. His diet, for the first few days should be light and cooling, and the bowels should be opened, if necessary, by some mild aperient, as a dose of castor oil, Epsom salts, or citrate of magnesia. If fever supervene, the antimonial and saline mixture is freely used, aided, if the symptoms are urgent, and the patient is plethoric, by venesection, although such a procedure will rarely be called for. Action having subsided, the pa- tient gradually resumes his accustomed diet, being still careful, however, to err rather upon the side of abstinence than on that of excess. Pain is relieved by anodynes ; the bladder, if necessary, by the catheter. During all this time the fractured limb is carefully watched, the patient being visited for a while at least once a day, or, if the case be at all trouble- some, even twice a day, until all danger of mischief is over. If there be con- siderable pain and swelling, it will be well to remove the dressings at the expiration of the first twenty-four hours, otherwise they may be retained for some time longer. While I am an advocate for the careful watching of the dressings, I am opposed to frequent change, as calculated to produce injurious disturbance in the ends of the broken bone, and impediment in the process of repair. If the first dressings have been applied lightly, as they always should be, and the parts be well seen to afterwards, it is hardly possible for the patient to do badly. The great danger, in nearly all cases, as far as the safety of the limb is concerned, is during the first week; that passed, there is seldom any risk. In nearly all fractures of the long bones there is apt to be more or less spasm, jerking or twitching of the lirab, coming on within the first ten or twelve hours after the accident, much to the discomfort both of the part and system. This is owing partly to the pressure and irritation produced by the ends of the fragments, and partly to the inflammation of the muscles, and is in general easily remedied by the rectification of the displacement, aided by warm applications and a full anodyne, either alone or in union with camphor and tartar emetic. The worst forms of this complaint are met with in nervous, irritable persons, in Fig. 331. whom it occasionally persists with great obsti- nacy, despite our remedies, for a number of days, much to the annoyance of all concerned. In fractures of the thigh and leg, especially the latter, the limb must be carefully protected from the pressure of the bedclothes, by means of a con- trivance SUCh as that exhibited in fig. 331. It Wire rack for fracture of leg 938 DISEASES OF THE BONES AND THEIR APPENDAGES. consists of two pieces of wood connected by several serai-circles of hoop, or wire, attached by a longitudinal piece. In fracture of the superior extremity, the patient is often able to walk about immediately after the accident, taking out-door exercise, and, perhaps, even attending to business. But it is very different when he has a broken leg or thigh. Here, as a general rule, he is obliged to keep recumbent, often for a most unreasonable time, until, it may be, he is bedridden, and worn out with suffering. This is wrong. Such a case demands an immediate change of treatment. The starched bandage is substituted for the previous dress- ings, and the patient is sent out into the open air upon crutches. Prompt amendment follows; the general health rapidly improves, and the process of repair, having received a new impulse, steadily advances to completion. As fractures are constantly liable to be followed by weakness and stiffness of the limb, the rule is to move the joint nearest the injury as soon as the union is sufficiently advanced to preclude the possibility of displacing the fragments or interrupting the consolidating process. This constitutes what is called passive motion, a most important element in the management of this class of lesions. It should not be commenced, as a general rule, before the end of the second week, and should be repeated once a day, or every other day, according to circumstances; it should be very gentle at first, and be gradually increased until the limb has completely regained its normal func- tions. During its performance the parts are properly supported by assist- ants, and the dressings are reapplied the moment it is over. The restoration of lost function will be greatly promoted by frequent washing with warm water and soap, followed by frictions with some sorbefacient lotion as spirits of camphor, soap liniment, or weak solutions of iodine. As soon as the callus has acquired sufficient firmness to sustain the ends of the broken bone, the splints and bandages are either discontinued, or applied more loosely, the object now being merely to keep the parts at rest until the union is perfectly consolidated. In fractures of the inferior extremity, some days should usually elapse before the patient is allowed to rise, or bear any weight upon the affected limb; the new bone is still weak, no definitive callus has yet formed, and the patient, awkward from long disuse of his joints, is liable to fall from the slightest accident. These precautions are extremely important, and should, therefore, always receive the most scrupulous atten- tion. Immovable Apparatus.—The treatment of fractures of the extremities may often be advantageously conducted with the immovable apparatus, concern- ing which so much has been said and written of late years as a comfortable and time-saving expedient. When this method of treatment was first an- nounced, in 1834, by Dr. Seutin, of Brussels, it was almost universally re- garded with suspicion, and even now, after the numerous trials that have been made with it in different parts of the world, it is questionable whether it is receiving the attention it merits. In this country it has been but little em- ployed at any time, either in private or hospital practice. It is difficult to determine to what this neglect is attributable, whether to fear, to indolence, or to apathy. Many practitioners are afraid that the apparatus will do mis- chief; others feel themselves incompetent to apply it properly; while a third, and perhaps the most numerous class of all, reject it on account of the sup- posed trouble attending its use. Such objections are altogether frivolous. The accumulated experience of the profession during the last twenty years is sufficient to convince any one, even the most sceptical, of the safety and utility of this mode of dressing fractured limbs. It is not, of course, appli- cable to all cases; but if proper judgment be exercised in their selection there are few in which, in some stage or other of their progress, it will not be beneficial. I am myself averse to the early use of the immovable appa- SIMPLE FRACTURES. 939 ratus, convinced that the safest plan is always to wait until there is complete subsidence of the resulting inflammation and swelling. From ten days to a fortnight is a good average period for the commencement of its application ; employed earlier, it may induce undue compression, and thus compel removal. I would, then, have an eye to time and circumstances; avoiding premature interference, on the one hand, aud too long delay on the other. The immovable apparatus may be prepared with various substances, all of them possessing more or less, though not equal, merit. Cowper, an English surgeon, employed compresses and bandages, saturated with a mixture of the albuminous part of eggs and wheat flour, which was replaced by Lawrence by powdered chalk. Seutin was the first to recommend starch ; Velpeau uses dextrine; Sraee prefers gum Arabic and whiting. Gum shellac and glue have also been highly lauded, and of late much has been said in com- mendation of the plaster of Paris bandage. Of these various articles the starch is perhaps the best; it certainly possesses the advantage of cheapness, and of being easily prepared, applied, and removed, as well as being always easily procurable. The apparatus of Smee, called the moulding tablet, is also an excellent contrivance, nowise inferior to the starch, and but little raore expensive. It consists of two layers of coarse, old sheeting, cemented together by means of a thick paste made by rubbing very finely powdered whiting with mucilage of gum Arabic. The sheeting soon dries, without shrinking, into a hard, firm substance, which, with the aid of a sponge and hot water, may afterwards be accurately moulded to the fractured limb, and worn with great comfort and efficiency. Dextrine is a yellowish white, pulverulent substance, obtained from amy- laceous vegetables and plants; it exists in union with fecnla, amidine, dias- tase, and gum, and possesses remarkably glutinous and adhesive properties, well adapted to the object for which it is employed. Besides, it is very cheap, and generally dries in one-sixth of the time that starch does. The only ob- jection to it is the greater difficulty of removing it. It is converted into a paste of the consistence of thin molasses, with equal parts of water and cam- phorated spirits, the latter being allowed to soak in well before adding the former. Plaster of Paris, originally employed by the Moors of Spain, was first tried in Europe, as a scientific dressing in the treatment of fractures, by Pro- fessor Kluge, of Berlin, in 1829. The bandage is prepared by rubbing the dry plaster thoroughly into the meshes of a thick muslin roller, the ends of which are freely sprinkled with water previously to the application made with as few reverses as possible. The great advantages of this dressing are the rapidity with which it dries and adapts itself to the parts, and the fact that it forms an unusually firm, hard casing, which permits the limb to be handled and moved with great ease during any transportation that may be necessary to place the patient in more comfortable quarters. The chalk and gum bandage forms an excellent substitute for the plaster and starch bandage. It is prepared in the same manner as the latter, over which it possesses the advantage of more rapid desiccation and of greater strength, so as to render a resort to strips of pasteboard rarely necessary. The adhesive mixture consists of equal parts of precipitated chalk and gum Arabic, made into a suitable consistence with boiling water. The starch bandage which I prefer, on account of its simplicity and the facility of procuring it, is thus applied :—Supposing the leg to be the part injured, the first thing to be done is to procure a pint of starch, without any lumps, a bundle of wadding, several long rollers, two light binder's board splints, and an apparatus for maintaining extension and counter-extension until the dressing is perfectly dry. The fragments being accurately adjusted, 940 DISEASES OF THE BONES AND THEIR APTENDAGES. the limb is surrounded, in its entire length, from the toes to within an inch and a half of the knee, with two layers of wadding, in order to protect its bony prominences frora the pressure of the bandage. Special pains, more- over, are taken to fill up the hollows on each side between the ankle and the tendo Achillis. A wet roller is now applied from below up in the usual manner, care being taken not to make the reverses over the edge of the tibia, lest they should occasion unpleasant, if not injurious, compression. A layer of starch is next put on, either with the bare hands or with a paint brush, the substance being well rubbed into the meshes of the cloth. Resuming the roller, it is now carried down the limb as far as its extremity, when the starch is again applied, and so on until three layers have been formed. Two splints, made of binder's board, not too thick or heavy, and accurately shaped to the foot and leg, are steeped in hot water, and, being carefully moulded to the parts, are secured with another roller, also thoroughly saturated and covered with starch. Finally, the dressing is completed by the application of a dry bandage. If the fracture is a very simple one, unattended with any disposi- tion to displaceraent, as often happens when the tibia alone is broken, the limb is simply placed in an easy position upon a pillow arranged in the form of an inclined plane, or in an ordinary fracture-box; otherwise it will be neces- sary to use the apparatus of Desault, as modified by Physick, or some similar contrivance, in order to keep up extension and counter-extension until the bandage is completely dried; an event which seldom happens before the ex- piration of thirty, thirty-six, or forty hours, even in very hot weather, as the evaporation always proceeds with difficulty. The desiccation, however, may often be materially expedited by artificial means, especially by warm sand- bags stretched along the sides of the limb. When the apparatus is perfectly dry it forms an immovable case for the limb, making equable and uniform pressure throughout, and maintaining the fragments of the broken bone accurately in apposition with each other. If the parts feel entirely comfortable, the patient may now sit up in bed or on a chair, or he may even walk about on crutches, the leg being properly sup- ported in a sling. Generally, however, it will be found that there is for a day or two a sense of soreness, with, perhaps, some degree of throbbing, inviting recumbency rather than the erect posture. If the apparatus causes marked discomfort, by bearing unequally upon any portion of the limb, or if throbbing and swelling arise, immediate measures must be adopted for its removal. For this purpose it should be slit up along the outer side of the limb, about an inch or an inch and a half external to the crest of the tibia, by means of Seutin's scissors, FiS- 332- represented in fig. 332, one of the blades of which is probe-pointed, and therefore well adapted to the object. The lirab being properly sup- ported by an assistant, the hardened shell is gently peel- seutin's scissors. ed off from its surface, which is next carefully sponged with alcohol and laudanum, or spirits of camphor, wdien the apparatus is imme- diately reapplied with the aid of a roller. Thus, by simply removing the bandage from time to time, an opportunity is afforded of inspecting the limb, and ascertaining its precise condition, not only at the seat of fracture, but everywhere else. When the patient is able to move about on crutches, the limb should be carefully supported in a sling, arranged in the manner represented in fig. 333. SIMPLE FRACTURES. 941 If the fracture be seated high up in the leg, the apparatus should extend a short distance above the knee, as it then becomes a matter of great moment to keep the joint in as passive a condition as possible. In compound frac- ture, attended with discharge, a hole should be cut in the apparatus opposite the wound, so as to admit of the necessary drainage, as represented in fig. 334. Fig. 333. Fig. 334. Fracture of the thigh, done up in starch bandage. Dressing in compound fracture of the leg. Great care should be taken that the edges of the splints do not produce any injurious compression ; to obviate this, it is usually recommended that they should be torn instead of being cut, it being alleged that, when treated in this manner, thev will be much less likely to create mischief. My own experience, however, is that this is not the fact, and I, therefore, invariably bevel the inner edges with a stout knife, thus effectually preventing all risk of this sort. It is not possible, also, to bestow too much attention upon the bandage ; the care or negligence with which this is applied will make all the difference in the result, both as it respects the patient's comfort and the character of the cure. The plaster of Paris bandage, prepared in the manner already mentioned, is applied in the same way as the starch, the limb having been previously enveloped in cotton wadding and a dry bandage. Great care is taken with the reverses and the various depressions of the limb. The bandage, more- over must not be drawn with quite the ordinary firmness, allowance being made for shrinkage. Splints may usually be entirely dispensed with, espe- cially if folded cloths, saturated with plaster, be applied whenever more than usual support is required, but extension must be kept up by assistants until the bandage is perfectly dry, as it always will be in a few minutes. 942 DISEASES OF THE BONES AND THEIR APPENDAGES. 3. COMPLICATED FRACTURES. The only class of fractures, besides the simple, which deserves to be con- sidered under a distinct head is the complicated, as it is easy to comprise under this denomination every form of accideut that can possibly arise either at the moment of the injury, or during the progress of the treatment. The propriety of this arrangement will become more obvious as we proceed with the discussion of the subject. In adopting this plan, I shall treat successively, and as concisely as possible, of fractures complicated with wounds, hemor- rhage, dislocation, comminution of the bone, excessive laceration of the soft parts, erysipelas, pyemia, and, lastly, tetanus. Complicated fractures may be oblique, transverse, or longitudinal, the frequency of their occurrence being in the order here enumerated. They are always caused by mechanical violence, as gunshot, falls from a great height, severe blows, or the passage of the wheel of a carriage, wagon, or railroad car. Complicated fractures frora the latter cause have, of late, be- come very common, and are a frequent source of loss of limb and life. The symptoms of this variety of fracture are, like those of simple fracture, soraetimes extremely obscure, requiring great care and skill on the part of the surgeon to determine their character. In general, however, they are sufficiently well marked to enable him to distinguish them from such as attend other eccidents, especially if an opportunity be afforded him of exa- mining the parts before the supervention of much swelling. There is usually greater pain and shock than in an ordinary fracture, the resulting inflamma- tion is more severe, and there is greater risk of violent secondary effects, as erysipelas, gangrene, copious suppuration, necrosis, caries, prostration, hectic irritation, and tetanus. In fact, complicated fractures are among the most serious occurrences that are met with in practice, being alike perplexing to the surgeon and dangerous to the patient; demanding the nicest judgment and skill for. their successful management, and entailing, not unfrequently, the greatest possible suffering, horrible deformity, and loss of limb, if not also loss of life. It may be stated, as a general rule, that complicated frac- tures of the lower extremity are more dangerous and difficult of management than those of the superior, as well as more apt to be followed by distortion and permanent lameness. The process of repair in complicated fracture proceeds on the same prin- ciple as in the simple form of the lesion, only that it is usually more tedious, and that it is attended with a larger quantity of callus. When there is a wound in the soft parts, the union is generally effected through the medium of granulations, which, arising from the ends of the fragments, ultimately assume the ossific disposition, and thus form the connecting link between them. The treatment of this form of fracture varies according to the circumstances of the case, or the nature and severity of the complication ; a fact which imposes the necessity of considering the subject somewhat in detail. When the case is complicated with a wound in the soft parts, constituting what is usually called a compound fracture, fig. 335, and the limb is deemed capable of preservation, the first and raost important consideration is the reduction of the fracture. This may generally be done by putting the limb in the most favorable position for relaxing its muscles, and by well-directed and gentle efforts at extension and counter-extension, along with proper manipulation, especially if the fracture be transverse, and the opening large; but if it be oblique, and there is a projection of one or both ends of the frag- ments, they occasionally fail, and compel us to resort to other measures. Under such circumstances, the soft parts which seem to gird or bind the COMPLICATED FRACTURES. 943 bone, and prevent it frora yielding, should be carefully divided, when a renewed attempt at reduction will probably be successful. Should every reasonable effort of the kind, however, prove fruitless, then, instead of leaving Fig. 335. Fracture of the leg, complicated with wound and comminution of the bone. the bone in its exposed situation, where it would be sure to die, the proper plan will be to cut away a portion of it, especially if it terminate in a very long and narrow poiut. Whatever may be the character of the wound, its edges should be carefully approximated by suture and plaster, aided by collodion to exclude the air; or, instead of this, the wound may be covered with a light compress wet with blood, and supported by a bandage. In this way, a compound fracture may occasionally be speedily converted into a simple one, union sometimes occur- ring in a few days. The hemorrhage in complicated fracture may be open or concealed, accord- ing as there is a wound or no wound ; arterial or venous; insignificant or copious. In the first case, the bleeding will manifest itself in the usual man- ner, and is to be arrested by ligature or compression ; in the second, it will be indicated, if it be at all considerable, by unusual swelling, attended with a sense of fluctuation or unusual softness, and by more or less discoloration of the integuments. If the principal artery of a lirab has been severed, there will be an absence of pulsation in the parts below, with coldness of the sur- face. When no doubt remains concerning the diagnosis in such a case, the main trunk of the vessel is exposed some distance above the seat of fracture, and ligated; or, if this be deemed improper, an incision is made through the bloody tumor, and, its contents being turned out, the divided artery is sought and secured above and below the seat of injury. This, in fact, is usually the preferable procedure, especially as there must frequently be considerable un- certainty whether the effusion is arterial or venous; a circumstance which, perhaps, thus leads to the performance of a most serious operation in a case where one of a most simple character might suffice. When the fracture is attended with a dislocation, the case necessarily assumes a very serious character, as it may give rise, especially if the joint involved be a large one, or the bone greatly shattered, to the question of primary amputation. In such an event the most experienced surgeon will often find it difficult to come to a prompt and correct decision. The prin- cipal circumstances which should induce him to make an attempt to save the limb are the integrity of the patient's health at the time of the injury, toge- ther with a knowledge of his previous habits, and the simplicity of the dislo- cation or the almost total absence of complication, as it respects the affected j0int ' if on the other hand, the dislocation is compound, and the bone is badly broken at the same time perhaps that it protrudes at the articulation ; 944 DISEASES OF THE BONES AND THEIR APPENDAGES. if all these injuries exist, or if, along with them, serious mischief has been inflicted upon the soft parts, as a violent contusion of the skin and muscles, or the laceration of important vessels or nerves, no doubt can be entertained respecting the propriety of the operation, and the sooner it is performed after the occurrence of reaction, the better it will be for all parties concerned. I believe that a compound fracture, extending into a large joint, as the knee or ankle, and attended with extensive rupture of the ligaments, muscles, and other structures, should always, as a general rule, be treated in this way. It is true a case apparently of the most desperate character occasionally re- covers, but such a consideration should not have too much weight, or induce us to neglect a measure which is sanctioned not less by reason than by expe- rience. When the case is not such as to demand amputation, the dislocation should always be reduced before an attempt be made to adjust the fracture. Great difficulty will sometimes attend such an operation, but this may usually be overcome by patience and perseverance, aided by the means furnished by modern improvement. It is sheer folly to postpone the reduction of the dis- location until the bone has become sufficiently consolidated to enable it to bear the requisite manipulation ; one of two things would be almost sure to happen in such a case, either a reproduction of the fracture, or an utter failure to replace the luxated bone. The most common causes of comminuted fracture are, gunshot violence, railroad accidents, falls from a great height, and the passage of the wheel of a carriage. If the bone be broken into several pieces, and any of them are completely detached, or so loose as to render their reunion improbable, all such pieces ought to be carefully removed; after which the edges of the wound should be gently approximated, and kept in position by sutures and adhesive strips, covered with collodion. The limb being surrounded by the bandage of Scultetus, and supported by appropriate apparatus, is placed in an easy position, care being taken to moderate inflammation by the usual antiphlo- gistic means. If the wound suppurates, it must be covered with an emollient poultice or the warm water-dressing, with as little disturbance as possible to the broken bone. When the fracture is complicated with violent contusion of the soft struc- tures, the retentive apparatus should be applied rather slackly, and the parts be kept constantly wet with cold water, or, what is better, a strong solution of acetate of lead and opium. If the inflammation run high, recourse may be had to bleeding, purgatives, and antimonials. The limb is carefully watched, in order that prompt advantage may be taken of any change as soon as it arises. In consequence of injury sustained by the skin, either at the time of the accident, or from the pressure of the bandage, the cuticle is sometimes raised into little vesicles, filled with a thin, limpid, reddish, or yellowish fluid. Such an occurrence always awakens anxiety both in the patient and practitioner, especially if he be young and inexperienced, as it is apt to be associated with the idea of gangrene. From this, however, it may always be easily distin- guished by the absence of lividity, severe pain, and other symptoms of ex- cessive action. The proper treatment consists in puncturing the vesicles with a fine needle, and using the warm or cold water-dressing. If the principal artery, vein, or nerve of a limb has been destroyed, at the same time that there is extensive laceration of the soft parts around, the case will probably require amputation, especially if there has been severe shock or extensive hemorrhage, with previous derangement of the general health. Such a case is, at all events, a bad one, liable to be followed by loss of limb, if not also of life. If, on the other hand, the principal artery retains its in- tegrity in the midst of the torn and broken structures, and the patient is COMPLICATED FRACTURES. 945 young and vigorous, although he may have bled severely, we should by all means make an attempt to save the limb,-having previously explained to the patient and his friends the risk which such an undertaking* involves. Some of the most gratifying results that reward the care and skill of the practitioner are cases of fracture complicated with extensive laceration of the soft struc- tures and comminution of the bone. I have several times succeeded in effect* ing excellent cures when, the main artery being intact, the limb hung merely by a comparatively sraall quantity of skin and -muscle, and when I was com- pelled to remove a number of pieces of bone, or even saw off the ends of the fragments. Accidents after Complicated Fractures.—The raost common and important accidents after complicated fractures are erysipelas, oedema, abscess, gangrene, spasm, tetanus, pyemia, delirium, and congestion of the brain and lungs. Erysipelas usually comes on within the first forty-eight hours after the occurrence of the injury. The disease is raost apt to appear in persons of intemperate habits, and in such as are dyspeptic, or enfeebled by previous suffering, and generally adds very much to the danger of the case, perhaps already great before. Its extent and continuance will depend upon various circumstances, which will readily suggest themselves to the mind of the reader. The treatment is conducted upon general principles, our main reliance being upon the correction of the secretions, and the support of the system, by quinine, iron, milk-punch, nutritious food, and anodynes, with the topical application of tincture of iodine diluted with equal parts of alcohol. The occurrence of oedema is sufficiently common in .complicated fractures of old, dilapidated subjects, and is best remedied by the bandage, aided by spirituous lotions, tonics, and a nutritious diet. Punctures will seldom be necessary, and should always be used with the greatest caution. Abscesses, diffuse, painful, and troublesome, may form either at the seat of the fracture, or in its immediate vicinity. In either case, the matter should be speedily evacuated; otherwise it may not only cause extensive havoc among the soft parts, but caries and necrosis of the ends of the broken bone, with risk of pyemia and phlebitis. Gangrene may be produced by injudicious bandaging obstructing the cir- culation, excessive inflammation, or injury of the main artery, vein, or nerve of the affected limb. The occurrence is most liable to happen in unhealthy subjects, and in young persons "after railroad and other severe accidents, and often makes fatal progress before its presence is suspected by the patient or his attendant. Great pain in the part of a smarting, pungent, or burning character, accompanied with discoloration aud tumefaction in the distal por-' tion of the limb, should always excite alarm and lead to a thorough examina- tion. Tight bandaging in particular should be avoided in complicated frac- tures, especially in the early stages of the treatment. Severe spasm frequently attends this class of injuries, but as this subject has already been discussed in connection with simple fractures, nothing fur- ther need be said respecting it here. Pyemia, as an effect of complicated fracture, is uncommon, at least in private practice, except when the accident has been caused by railway injury, the bursting of a gun, the passage of the wdieel of *a wagon, or some similar violence. It is distinguished by its usual insidious character, and generally sets in from.the fifth to the tenth day, its approach being announced by vio- lent rigors, alternating with flushes of heat, great depression of the system, delirium, and excessive restlessness. The structures which are most apt to suffer are the lungs, liver, spleen, joints, and connective tissues. The treat- ment is supportant and alterant; by quinine, brandy, and nourishing broths, for the former ; by mercury, in moderately large and properly sustained doses, vol. i.—60 946 DISEASES OF THE BONES AND THEIR. APPENDAGES. for the latter. In general, such cases fare badly, death occurring within a week from the commencement of the attack, despite our best directed efforts. Tetanus in complicated fractures, is most liable to supervene in nervous, irritable subjects, during hot weather, although it raay take place a't any sea- son of the year, as well as in every description of individuals. It is an ex- tremely formidable symptora, whjch should be promptly met by the removal of the affected parts, and by large quantities of anodyne and antispasmodic remedies. If occasionally a case is cured without amputation, it forms the exception, not the rule. In such an event, there is no time for delay ; what- ever is done must be done quickly and effectively, at the very inception of the disease, before there is any decided evidence of stiffness in the muscles of the jaw. Traumatic delirium is sufficiently frequent after these accidents, especially in old intemperate persons, and should be treated upon the principles laid down in a previous chapter. Congestion of the lungs and other internal organs, as a consequence of these injuries, is most liable to occur in elderly persons, as a result of a determina- tion of blood either from actual irritatiou or a sluggish condition of the ves- sels from protracted confinement. As such attacks are very apt to prove disastrous, everything should be done to prevent them, by getting the patient as speedily as possible out upon crutches in the open air. Amputation.—Allusion has already been incidentally made to the circum- stances which are likely to call for priniary amputation, and it may now be added that it should always be resorted to, as a general rule, whenever, along with a shattered or comminuted condition "of the fractured bone, there is ex- tensive laceration of the soft parts, with almost total disorganization of their substance. It is true, as was before intimated, that apparently desperate cases are sometimes cured, and that limbs, so mashed and wounded as. to render amputation the only probable chance of success, are now and then saved. But it is equally true that such instances are extremely rare, and if we take into account the protracted sufferings of the patient, and the likeli- hood of his ultimately falling a victim to his ailments, the reasons for per- forming immediate amputation are, to use the language 'of Mr. Percivall Pott, "vindicable upon every principle of humanity or chirurgic knowledge." It is not uncommon for cases to occur in which the fracture is multiple, or in which the bone is broken at several points, but where the upper fracture is perfectly simple, and perhaps situated in a portion of the limb which it is desirable to preserve. Hence it becomes an important question how the surgeon is to act in such an event. To my mind, the subject is a very plain one. If it be really important to save the broken bone beyond the part that must necessarily come off, in order to make a longer ^nd a better stump, there can certainly be no objection to such a course, provided, however, that the proximal fracture be perfectly simple in itself, aud that there is no serious lesion of the soft structures, endangering limb and life by gangrene or other bad consequences. I have more than once adopted this plan, and have not, so far as I recollect, had any cause to regret it. Xo sensible surgeon would, of course, allow a bone to remain, under such circumstances, if it were com- minuted, or if, the fractnre being simple, there were serious injury of the muscles, integuments, or other important textures; to do so would only be to trifle with the safety of the case. Secondary amputation will be necessary wdien, after an attempt to save a limb, and the employment of suitable antiphlogistic remedies,'the parts be- come gangrenous; or when the consolidation of the fracture is prevented by profuse suppuration, and the patient is gradually wearing out by diarrhoea and colliquative sweats. In the first case, the operation is performed as soon as the mortification is arrested, and there is a distinct line of demarcation INCOMPLETE FRACTURES, OR BENDING OF THE BONES. 94T between the dead and living parts; in the second, as soon as it is perceived that the suppuration cannot be arrested, and that the patient has still suffi- cient strength to bear the pain and shock which must necessarily attend its performance. •. Statistics of Compound Fractures—We have no very copious statistics of compound fractures of different parts of the body. The following account, for which I am indebted to Dr. Frederic D. Lente, relates to cases of com- pound fractures of the lower extremities, treated in the New York Hospital from January, 1848, to July, 1857, the whole number being 392, fractures of the tarsus and metatarsus not being included. Of these, 68 occurred in . the thigh, and 324 in the leg. Of the former, 3 involved both thighs, and of the latter, 16 both legs. Of the entire number, 190 were cured, 182 died, and 20 were relieved. In 39, or 20.5 per cent., amputation was performed. Of the 68 fractures of the thigh, 18, or 26.5 per cent., were cured, and 2 relieved; amputation having been performed in 7. Of the 324 fractures of the leg, 175, or 54.0 per cent., were cured, and 14 relieved. In 35, or 20.0 per cent, of these, the limb was removed. Of the whole number pf cases of fracture, amputation was employed in 91, or 23.3 per cent., and of these 49, or 53.8 per cent., died. '■ Of 301 cases treated without amputation, 140, or 46.5 per cent., died, 3- having refused to submit to amputation. Of the whole number of fatal cases, in which amputation was not per- formed, 74, or more than one-half, died within the firsl week; in many of these there was no reaction, and death ensued in from twenty-four to forty- eight hours. Of 45 fractures of the thigh which occurred at or below the middle, 14 recovered, or 31.1 per cent.; while of eleven that occurred further down, 4, of 36.3 per cent., recovered. Of 227 fractures of the leg, occurring at or below the middle, 130, or 58.1 per cent., recovered; of 30 above the middle, 17, or over one-half, got well.' Of 334 compound fractures of the.thigh and leg, 164 occurred on the right 'side, and 170 on the left. 4. INCOMPLETE FRACTURES, OR BENDING OF THE BONES. The bones are liable not only to break, but also to bend, as seen in figs. 336 and 337. Such an accident can only happen in young subjects, princi- pally in infants and children, in whom the osseous tissue, Flg- 336- containing apreponderance of animal matter, is compa- ratively soft, flexible, and elastic. Bending of the bones of the skull, espe- cially the frontal and parie- tal, is occasionally witnessed at an early age, as an effect of external violence, as that, for instance, produced when a child falls, head foremost, down a flight of .stairs, or out of a second story win- dow upon the pavement be- low.' Under such circum- stances the cranial bones, at the part struck, are depressed beyond their natural'level, and yet there is-cot, so far as can be ascertained, any fracture, Fig. 337. Incomplete fracture of the bones of the forearm. 948 DISEASES OF THE BONES AND THEIR APPENDAGES. • strictly so called ; they are merely bent or indented, and if no untoward occurrence take place, they will, generally in the course of a few days, resume their proper position by their own resiliency, aided, doubtless, by the loco- motive action of the brain, propelling them outwards away from its surface. In an adult, an accident, capable of producing such a -result, would almost certainly lead to fracture of the skull, and that probably of a very grave cha- racter; for the reason that the cranial bones, after a certain time, are always loaded with a large quantity of earthy matter, in the form of carbonate and phosphate of lime, the presence of which renders thera raore or less brittle, and thus predisposes them to fractures. This tendency to fracture increases in proportion as we advance in years, and is, consequently, most distinctly marked in old age and decrepitude, in which the osseous tissue, almost desti- tute of animal substance, generally yields under the slightest force, the acci- dent frequently eventuating in incurable injury. Bending of the bones had been incidentally observed by a considerable number of practitioners, in the last century, and, indeed, even prior to that period; b,ut the first systematic account of it was published in 1810, by Professor Jurine, of Geneva, Switzerland. In 1821, a short, but valuable article, illustrated by several graphic drawings, appeared on the subject in •the fourth volume of the American Medical Ilecorder, frora the pen of Dr. John Rhea Barton, of this city. More recently, attention has also been called to the affection by Professor Hamilton, in his Report on the Deformi- ties of Fractures, rrfade to the American Medical Association in 1855, and 'also in an article in the New York Journal of Medicine for November, 18.57. • I have myself met with this accident in nine cases, in children whose ages varied from three to eleven years, three being girls, and the remainder boys. Although it is most common in the ulna, radius, and clavicle, yet it also sometimes -occurs in other pieces of the skeleton, as the humerus, femur, tibia, fibula, and ribs. External violence alone is capable'of producing this •lesion. I am not acquainted with any cases in which it w.as occasioned by muscular contraction. In fact, considering that bending of the bones is exclusively confined to children, it is hardly possible that the accident could arise from such a cause; certainly not, unless there existed extraordinary muscular development with remarkable flexibility of the osseous tissue, a condition of things hardly compatible with a healthy state of tlie system. In the bones of the forearm, wdiich suffer more frequently than any qther, the injury usually originates frora force applied indirectly, as when, for example, a child, in the act of falling, instinctively throws out the arm to protect the body, and so receives the shock upon the hand, the concussion concentrating and exploding upon the radius, or the radius and ulna. In one. of my cases, the bend was produced by the body of the child being suddenly propelled against his forearm at a moment when the elbow was planted upon the floor, and the wrist lying upon a stool. Flexion of the clavicle is the result either of direct violence, or of force applied to the top of the shoulder, especially if the body be at the same time propelled in the opposite direction, as in the case of a fall. The seat of this lesion is variable ; in the long bones, as those, for instance, of the forearm, it usually occurs a short distance below their middle, but it may also take place higher up, or further down. The radius and ulna may both suffer synchronously, but very frequently one alone is affected, or, if both are implicated, they do not suffer in an equal degree". Judging from the cases of this accident that have fallen under my observa- tion, I am inclined to believe that it generally happens without any particular predisposition, either constitutional or local. In every instance of the kind, the subjects of the injury were in good health at the time of its. occurrence. What is the precise nature of this le'siou ? Is it really, as the name implies, INCOMPLETE FRACTURES, OR BENDING OF THE BONES. 949 a mere bending of the bones, or is it a flexion combined with partial fracture? These questions are easily answered. In very young subjects, as in children not more than a few years of age, and in the milder forms of the lesion, the osseous fibres are merely extended or stretched, so as to permit themselves to be drawn out of their natural course ; in cases of an opposite character, on the other hand, there is no doubt that, while some of the fibres are bent, others are both bent and broken. These conclusions are beautifully borne out by the experiments of Dr. Hamilton upon the bones of young chickens, which, from the fourth, to the sixth week, and consequently before the com- pletion of the ossific process, could be readily bent without fracture to an angle varying from twenty-five to thirty-five degrees; whereas, the bones of older chickens, thus treated, always partially broke, their fibres being inca- pable of withstanding the force used in flexing them. These partial fractures, sometimes called interperiosteal, from the fact that the fibrous envelop of the bones remains intact, bear a close resemblance, in the mode of their production, and the nature of the resulting injury, to the appearances presented by a green hickory stick, forcibly bent over the knee, but not to such an extent as to occasion any external sign of fracture, although it will be found, upon making a section of the wood, that many of its fibres have actually-been broken, while others, and perhaps the greater number, have merely been bent.' The symptoms attendant upon this accident are pain and deformity at the seat of the injury, loss.of power in the limb, and absence of crepitation. The pain.varies in degree, being sometiraes slight, at other times severe; swelling soon supervenes, and the part feels numb and heavy. A marked curvature, ge'nerally very gentle, but soraetimes quite abrupt, always exists at the affected part, and can seldom be completely effaced without the appli- cation of .very considerable force ; indeed, often not wjthout breaking the bone entirely across, especially if it was previously partially fractured. In the latter case, there is usually at the convexity of the curvature a slight depression, capable of receiving the point of the finger, its boundaries being formed by rough, sharp, bony fibres. Further than this there is no displace- ment, and under no circumstances is there any crepitation. The use of the limb is always greatly impaired, but not completely destroyed, as it commonly is in ordinary fracture. Finally, I may mention, as another highly important. and diagnostic sign, the great difficulty wdiich is so frequently experienced in restoring the parts to their proper.position. The treatment of these accidents must be conducted upon the same general principles as that of ordinary fractures. When the bones are merely bent, slight pressure and extension will usually suffice to accomplish restoration, the affected parts being compelled, as it were, to retrace their former steps. If flexion be conjoined with partial solution of continuity, the reduction will necessarily be more difficult, and may, in fact, altogether fail, owing to the manner in which the osseous fibres are interlocked with each other, and the inability which is experienced in disengaging them, so as to induce them to slip back into their proper position. However this may be, the attempts to remove the curvature by. extension and pressure should neither be too violent nor too long continued, lest they prove injurious. The object should be to restore as much as. we can by gentle meaus; what cannot fee effected in this manner, .may well be left to the operation of time, the'absorption of the broken and resisting osseous fibres, ahd the action <5f the muscles, which seldom fail to reinstate the parts, although from six to eight weeks may elapse before the final completion of the' cure. I have generally found-the use of leather splints well padded, and accurately shaped to the limb, of great ser- vice in bribing the bones into their proper relations. When the accident 950 DISEASES OF THE BONES AND THEIR APPENDAGES. is followed by undue inflammation, recourse must be had to the usual anti- phlogistic remedies, especially leeching and cooling lotions. There is a variety of partial fracture, known by the term fissure, which is peculiar to the bones of elderly subjects, no well-marked instance of it having ever been met with in infants and children. Such an occurrence, which is, in general, much more interesting in a pathological than in a practical point of view, is by no means uncomraon in the skull, especially along its base, where it is always .associated with severe, and frequently fatal, injury of the brain and its envelops. The fissures in many of these, cases are most exten- sive, involving the sphenoid, occipital, temporal, frontal, and perhaps even the ethmoid and parietal bones. In the other pieces of the skeleton the oc- currence is more rare; but examples are occasionally seen both in the long, short, and flat bones, as the result of external violence, generally directly applied, though sometimes indirectly. The accident is sometimes produced by gunshot injury. The lesion, luowever induced, consists essentially in a forcible separation of the osseous fibres, and exhibits itself in a great variety of forms ; the crack sometimes extending through the entire thickness of a bone, at other times merely through its outer table, and at other times, again,' involving both the compact and areolar tissues, but not passing completely through them. The length of the fissure varies, frora a few lines to a num- ber of inches, perhaps as many as six or eight, although this is exceedingly uncommon. The width of the crevice is generally very slight, perhaps barely sufficient to admit the blade of a penknife. In rare cases, as when it involves the extremity of a bone, it may gap somewhat, so as to give the part. an appearance as if it consisted of two fragments, firmly adherent at one end. Finally, the fissure may be straight, curved, or angular. Of the rarity of this lesion, as an uncomplicated occurrence, an idea may be formed when it is stated that there are probably not more than, three or four well-marked specimens of it in all the osteological cabinets of this city. As a conjoint lesion, it is occasionally met with iii compound fractures, espe- cially when caused by railway accidents. There are no signs by which the nature of the injury can be distinguished duting life; a circumstance which is the less to be regretted, because the treatment does not differ from-that of ordinary wounds, fractures, and contusions, with -which it is so generally associated. 5. DIASTASIS OR SEPARATION OF THE BONES AT THEIR EPIPHYSES. The extremities of the bones of young subjects are, as is well known, united to their shafts, or bodies, by means of cartilaginous matter, which, in some pf the pieces, and in some individuals, does not assume the osseous for.ni until after the twenty-first year, and occasionally, indeed, not'until even a later period. Up to this time, consequently, these junctions are liable to be severed, so as to allow the contiguous extremities to separate from each other, and it is this occurrence that constitutes what is technically called diastasis, as- seen in fig. 338. It is probable that this accident raay occur in all parts of the skeleton united in this way, although there are doubtless sorae in which it is more common than in others. Its occasional existence has been recognized, by dissection, in the humerus, radius, femur, and tibia, and there are few systematic trea- tises which do not allude to it as being* now and then met with in some of the other bones. The most common cause of diastasis is a wrench of the part, violent traction, or a severe fall. I am not aware that it has ever been pro- duced by muscular contraction ; and, on the other hand, it is rarely the result of direct violence, as, for instance, the kick of a horse, or the passage of the wheel of a carriage, such an accident more generally eventuating in fracture UNUNITED FRACTURES. 951 of the bones than in a separation of their epiphyses. The lesion may happen at any period of life, prior to the completion of ossification, but is most com- mon from the fifth to the fifteenth year. Its occurrence in middle-aged and elderly subjects is, for the reasons already mentioned, impossible, Girls are more prone to it than boys, owing, probably, to the fact that they are more fre- quently exposed to its exciting causes. The affection, like fracture, may be simple, compound, or complicated. Cases are noticed in which the diastasis is blended with fracture of the shaft of the bone, and it is by no means uncommon to find that small processes of bone are dragged away with the epiphyses. The symptoms of this lesion do not-differ essentially from those of fracture. Its existence may generally be suspected when an accident affecting a bone occurs in a young sub- ject, in the neighborhood of a joint; when the ends of the fragments are transverse, or nearly so; when the articular piece retains its position, while the other moves about; and lastly, when the crepitation produced by rubbing the ends of the fragments against each other is of an unusually dull, rough, grating character. Moreover, it will usually be- found that the parts, when once reduced, are less liable to be dragged asunder by the action of the muscles than in case of fracture. The prognosis is generally favorable, union taking place quite as promptly as in fracture. The treatment is also the same as in the latter accident. Diastasis of the fe- mur : reunited. 6. UNtNITED FRACTURES. Fractures occasionally refuse to unite, either in consequence of causes in- herent in.the part or system, or on account of mismanagement growing out of the surgeon's want of attention and skill, or else out of the patient's own misconduct. It is practically important that -a • distinction should be drawn Fig. 339. between a fracture that unites tardily and one that does not unite at all, or only through the medium of a fibrous, ligamentous, or fibro-cartilaginous tis- sue. Slow consolidation is by no means uncomraon; the parts may be loth to take on the requisite degree of ossific action, and the result may be that a fracture that is ordinarily repaired in four or five weeks, may, perhaps, be still imperfectly united at the end of twice that period. The process, of restoration is only held in abeyance, neither advanc- ing nor receding; by and by it begins again, and then often, proceeds with its wonted 'rapidity. Such cases are fre- quently very trying to- the surgeon's patience,' but they generally turn out well in the end, provided sufficient care has been taken to preserve the parts in their proper relations. In the ununited Ununited fracture of the bones of the leg. 952 DISEASES OF THE BONES AND THEIR APPENDAGES. . fracture, on the other hand, the process of consolidation is either completely prevented, or, after having progressed for some time, is at length permanently arrested. Under these circumstances, the ends of the fragments are gradually rounded off by absorption, and remain either entirely loose and disconnected, or they become adherent through the medium of fibrous, ligamentous, or fibro-cartilaginous matter. Sometimes an adventitious joint is formed, as in fig. 339, provided with a more or less distinct synovial membrane, thus per- mitting the ends of the bone to move upon each other with great facility. Want of reunion in a fracture may depend upon a great variety of causes, some of them resident in the parts themselves, others connected with the system. Thus, it niay be occasioned by the interposition of a clot of blood, or of a piece of muscle, tendon, or bone. An instance is mentioned where a fracture was prevented from becoming consolidated by the presence of a musket ball. Fragility, softening, and carcinomatous affections of the bones are usually enumerated as circumstances interfering with the reparative pro- cess, but it is not improbable that their influence has been greatly exag- gerated ; at all events, it is certain that in many cases of this kind, the frac- ture unites as readily as when the bones are perfectly healthy. Too much motion, the long-continued use of cold water, especially in persons of a nervous, irritable temperament, and tight bandaging, raay*also bring about this result. Some years ago, I saw a case in which, from the latter cause, the consolidation of a fracture of the thigh-bone was delayed for nearly a twelvemonth. The limb had become excessively atrophied from the long- contiuued and injudicious use of the roller, and it was not until after it had been entirely laid aside, and the man had been permitted to exercise upon crutches in the open air, that nature seemed to consider herself in a fit con- dition to commence the process of reparation, from wdiich she had been so long detained by this mode of treatment. Old age is no barrier to reunion, provided .the patient is in gc>od health at the time of the accident, and the fracture is not complicated. I have met with several cases of fracture of the humerus, in persons after the eightieth year, in whom the consolidation took place in the usual time. But the raost common local causes of all of tardy reunion, in injuries of this kind, are a want of accurate apposition between the ends of the.frag- ments and the existence of undue motion. Either of these-circumstances will inevitably interfere with the consolidating process, and in many cases effectu- ally prevent it, no matter in how favorable a condition the system may be for a cure. Hence, as stated elsewhere, the importance, nay, the absolute necessity, in every instance of fracture, of carefully guarding against these occurrences until the consolidating process shall be so far advanced as to en- able the fragments, so to speak, to take care of themselves. Fractures situated at or near the entrance of the nutrient arteries unite less rapidly than those situated further off, owing to the fact that they inter- fere more or less with the circulation and nourishment of the osseous tissue. It is easy to suppose that a laceration of these vessels, as occasionally hap- pens both in simple and compound fractures, might be a cause of non-con- solidation, especially when conjoined with other unpropitious circumstances. Statistics show that, when the supply of blood is cut off, to any considerable extent, so as to impose upon the periosteum the exclusive duty of nourishing the fragments, either one or both pieces will become,atrophied, their walls being visibly thinned, and their areolar structure rarefied. Want of union is soraetimes dependent upon the absorption of the ends of the fragments, or even of the greater portion of the fragments themselves. A very singular case of this kind came under my observation npt long ago, in a man aged 53 years. When eighteen years old, he received two simple fractures of the right humerus, at an interval of three months, one being UNUNITED FRACTURES. • 953 situated about the middle of the .bone, the other an inch and a half higher up. The first was repaired in the usual time, but the second refused to unite, the ends of the fragments becoming rounded "off, as in the formation of an artificial joint; the process gradually proceeding, the whole bone was finally absorbed, nothing remaining except its condyles and a little of its head. The period occupied in the absorption was about six years, the general health being all the while unimpaired. The muscles of the arm are well dev'eloped, and, when thrown into powerful action, are capable of diminishing the inter- val between the shoulder and elbow to the extent of several inches.' Although the man is unable to perform any of the usual movements of the member, he can readily raise a weight of up- wards of one hundred pounds, and Fig. 340. can apply his hand, to various pur- poses. The accompanying cut, fig. 340, represents the appearance of the limb during .the contraction of its muscles. f The principal constitutional causes v which interfere with the reparative process are, debility, whether frora loss-of blood, want of nutritive ac- tion, Or exhausting disease, as long-' Absorption of the humerus. continued fever ; a gouty, rheuma- tic, scorbutic, or syphilitic state of the system ; and loss of nervous influence, however induced. Another cause, but one which, I presume, seldom exerts much influence, is pregnancy. It is barely possible to imagine that, during this state, there may be such an abstraction of blood from the affected parts for the nourishment of the foetus as to retard, and, perhaps, even temporarily prevent, the formation of callus. In the few cases of this kind which have fallen under my observation, T have not, however, witnessed such an effect, and I am strongly inclined to believe that this influence has been greatly magnified, if, indeed, it is not almost wholly chimerical. The same remarks are. applicable to suckling. Another cause, probably much more efficient, as well as much more common, than the one just alluded to, is" the protracted and inordinate use of ardent spirits, weakening-the nutritive energies of the system, and rendering the blood and its vessels unfit for the performance of the important duties assigned to them in the reparative- process. Whatever the cause may be, great pains should always be taken to disco- ver it, with a view to its early and efficient rectification. Should it consist in debility, however induced, the patient must at once be put upon the use of nutritious food and drinks, as porter, ale, wine, or brandy.-aided, if neces- sary, by tonics, of which iron and quinine are generally the' most eligible. A gouty or rheumatic state of the constitution is best remedied by purga- tives, acid drinks, and colchicum. Tertiary symptoms should be met by iodide of potassium, either alone or in union wdth mercury,-the latter of which should sometiraes be carried to the extent of slight ptyalism. Debi- lity from drunkenness must be counteracted by the judicious employment of ardent spirits, such, if possible, as the patient has been in the habit of using previously to the accident. The local treatment must be regulated by the circumstances of each par- ticular case. The precise cause of the tardy or imperfect union must, if pos- sible, be clearly ascertained, and immediately remedied by appropriate mea- sures If it depends upon too much motion, greater quietude must be insured • any defect of contact must be redressed by a more accurate adjust- ment of'the ends of the fragments; cold-applications, if injurious, must be discontinued • and any extraneous intervening substance must be removed, 954 DISEASES OF THE BONES AND THEIR APPENDAGES. either by calling into requisition the agency of the absorbent vessels, by pressure and other means, or, as in the case of a piece of dead bone, by the knife and forceps. ' The cause of the defective union having been thus reme- died, the case will be likely, of its own accord, to proceed to a favorable termination, the ordinary principles of treatment being, of course, observed. The principal local remedies, besides those above mentioned, are : 1. Cuta- neous friction, either dry or moist, by means of the bare hand, or with a piece of flannel. If moist, various liniments, lotions, or unguents may be em- ployed, and often with decided benefit, inasmuch as they tend to excite capil- lary action in and around the ends of the fragments, thus promoting the for- mation of callus. * 2. Compression performed by splints of leather, or binder's board and the bandage ; or by an apparatus expressly constructed for the purpose, and in- tended to concentrate the pressure at the seat of the fracture; The compres- sion must, in all cases, be steady and persistent, as well as uniform and gentle. 3. Blisters and iodine may sometimes be beneficially employed. Their ap- plication is particularly indicated when the want of union is dependent upon undue vascular excitement, and is, of course, entirely restricted to cases of recent standing. 4. Friction of the ends of the fragments against each other, as recommended by Celsus, and practised by modern surgeons. It should be performed very gently, and be repeated every four, six, or eight days, according to its effects, care being taken to keep, the limb at rest in the intervals by an appropriate apparatus. 5. Acupuncturation with a long slender needle may be tried ; or a small incision may be made over the seat of the injury, and a heated wire thrust between the ends of the fragments. 6. Cauterization of the integuments over the seat of the fracture with some caustic alkali, as recommended and successfully employed, in 1805, by Dr. Hartshorne, of this city; or exposure of the ends of the bone, and rubbing them over with nitrate of silver, as practised by several modern surgeons. 7, Subcutaneous division of the ligamentous bands between the two ends of the fragments has occasionally been successfully practised. The operation is performed with an ordinary tenotome, care being Fig, 341. taken to cut the parts as thoroughly as possible, es- pecially over the extremities of the broken pieces. 8. The introduction of ivory pegs, as originally practised by Dieffenbach, from an inch and a half to two inches in length, conical in shape, and inserted into the ends of the fragments, previously pierced with a gimlet, seen in fig. 341. They must be forci- bly driven into the openings, and be retained until the consolidating process is well advanced. Excel- lent and rapid cures often follow this plan, as I have witnessed in several instances in my own practice. 9.. The seton, introduced into practice in 1802, by Dr. Physick, .is ordinarily, in obstinate cases, the most certain method. It should be passed between the ends of the fragments by a long, thin, flat needle, sharp and lancet-shaped at the point; or when this is impracticable, as near, the site of the fracture as possible, for experience has shown that this .mode of performing the operation is nearly as successful as the usual procednre. The foreign body is retained for a variable period, longer in some cases than in others, and generally until it has excited suppurative action. The patient is carefully watched; and if the pain and swelling become severe, the seton is UNUNITED FRACTURES. 955 at once withdrawn. Immediately after the introduction, the fragments are properly adjusted, and steps taken, if necessary, to maintain extension and counter-extension. In the first case in which this treatment was employed, the seton was retained many weeks, and the patient recovered the perfect use of his limb. The practice Of withdrawing the seton at the end of a few days, as advised by some, is,'I think, objectionable, for the reason that it will hardly have sufficient time, in such a case, to excite the requisite degree of inflammatory action. 10. Perforation of the ends of the bone by means of a peculiar instru- ment, fig. 342, an operation proposed, in 1853, by Professor Brainard, is sometimes serviceable. It consists in piercing subcutaneously the extremity of each fragment at several points, and cutting up the intervening tissue, with a view of exciting ossific action. The instrument is introduced in such a manner as not to wound any important structure, and is uot withdrawn until the bone has been deeply, and, if need be, even extensively drilled, compression being applied to prevent subcutaneous hemorrhage. The ope- ration is repeated once a week, or every ten days, until reunion has occurred, the limb being in the meantime kept quietly at rest in splints, and the treat- ment being in other respects conducted upon general principles. Fig. 342. iitf**^-* ■ Brainard's perforator, reduced one-half. Dr. Brainard's plan is always to begin the treatment with a small instru- ment, and to make only three perforations. The size of the former and the number of the latter are afterwards gradually increased until he succeeds in exciting more or less tenderness, pain, and heat in the parts, which are then kept up for some period. In favorable cases, a single operation may suffice ; in others,, it may be necessary to repeat it four, six, or even eight times. By carrying out these rules, Dr. Brainard states that he had, up to May, 1860, cured sixteen and then, closing the mouth, sees that the lower teeth rest fairly against the .upper. When the fragments overlap each other, they must Be drawn in opposite directions, when the slightest pressure will generally suffice to* effect their reduction. If any of the teeth are loosened, or partially forced from their sockets, and they are perfectly sound in other respects, they should by all means be. retained, being secured, if need be, to the adjacent ones, by 'a strong ligature, or a thin silver wire. It was formerly the custom to treat ■ such teeth as extraneous bodies, it being believed that they were incapable of re-adhesion; but raore enlarged observation has shown the fallacy of this opinion, and the practice would, therefore, be highly reprehensible. # The fracture being reduced, as may always be known by the evenness of the dental arch andof the inferior margin of the jaw, a piece of pasteboard, or What is preferable, of felt, is wet with hot water, and accurately adapted to'the base and sides, of the jaw, so as" to form a firm mould for it. This 966 DISEASES OF THE BONES AND THEIR APPENDAGES". being lined with wadding, and covered with a light compress, long enough to extend frora the angles of the jaw nearly to the chin, is now confined by a roller carried round the top of the head in the form of the figure 8, one por- tion of the bandage lying, in front of the ears, and. the other behind them. The lower jaw being thus pressed firmly against the upper, the bandage is next conducted across the chin and the occiput above the ears, so as to give the fragments proper support in1 front. This mode of dressing, which is as simple as it is excellent, I have employed for many years, and give it a decided preference over every other of which I have any knowledge. If there be any unusual tendency to anterior displacement, it may bo effectually coun- teracted by a stout adhesive strip, extending frora the chin along the lower part of the face to the side of the occiput. • The annexed cuts, figs. 347, 348, represent the bandages of Gibson and Barton, so much employed in this country. Their mode of application will readily be* perceived by an examination of the drawings. Fig. 347. Fig. 348. Barton's jaw bandage. * When there is no displacement of the fracture, as sometimes, though rarely, happegs, an equally simple, but less efficient, contrivance will answer the Fig. 349. Fig. 350. Pasteboard compress. purpose, as a pasteboard mould; fig.' 349, and a four-tailed bandage. The centre of the bandage being applied to the chin, the posterior tails are pinned to the front, and. the anterior to the back of the patient's night- cap. I bad recently under my charge a case of fracture of this bone, unattended with dis- placement, where a rapid aud perfect cure was effected without any dressing at all. • Professor Hamilton, in the treatment of fracture of this bone, employs an apparatus consisting of three straps, one of which, composed of firm leather, Hamilton's apparatus. FRACTURES OF THE HYOID BONE. 967 extends around the jaw and head in "the direction of the coronal suture, while the other two, made of strong linen-webbing, pass horizontally around the • head? above the ear, "the anterior being buckled to the forepart, and the pos- terior to the backpart of the vertical one. -The great advantage of this con- trivance, which is represented in*fig. 350, is the strong support it gives to the parts, thus effectually preventing displacement of the ends of the frag- ments. It was formerly customary, in bandaging fractures of the lower jaw, to fill up any irregularities that might exist between the two rows of teeth by the interposition of pieces of cork*; but the practice, if I mistake not, is no longer pursued by the scientific surgeon ; and yet it is easy to conceive of a case , where, in consequence of the loss of all the incisor; cuspid, and bicuspid teeth, ahd the»retention of some of the molar, some artificial support might become necessary for the proper maintenance of the fragments. In such a case the services of a skilful dentist should be called into requisition. In fracture of the neck or condyle of the jaw, the maintenance of the reduction .is always peculiarly difficult, on account of the action of the external pterygoid muscle. The most effective means of counteracting this disposition is to confine a thick, graduated compress behind the angle of the bone, the treatment being in other respects the same as in fracture of the body of the jaw.- . ' When the fracture is comminuted, it will sometimes be found exceedingly difficult, if not impossible, despite our best directed efforts, to keep the fragments on a level with each other, such being their constant tendency to displacement. To rectify this tendency, it may be necessary to connect the contiguous teeth of the adjoining pieces with delicate silver wire;. or, what is better, because more efficient, some of the teeth may be secured to a thin silver plate, interposed between them and the cheeks. Wounds, contusions, and hemorrhage, complicating these fractures, are managed upon general principles; inflammation is combated by the usual antiphlogistics ; loosened teeth and necrosed pieces of bone are removed as soon as they are detached; and the parts are kept steadily at rest, "renewal of displacement being guarded against by the most sedulous attention both ' of the patient and the surgeon. The food should consist of slops, as grated • cracker and milk, broths, gruel, and similar articles, and should be introduced into the mouth with a small spoon. The custom which formerly prevailed of conveying nourishment into the stomach- by means of a tube carried along the nose, has become obsolete, as well as the stiH more reprehensible practice of extracting dne of the front teeth, to afford room for feeding the patient. After the case has advanced for several weeks, a semi-solid, farinaceous diet may be allowed. FRACTURES OF THE HYOID BONE. Fracture of the hyoid bone is extremely rare. The cause of this immunity • is to be found in the great mobility of this bone, and in the protection which it receives from the lower jaw. The accident is usually occasioned by falls or blows, or by the pressure of the thumb and fingers in attempts at choking. An instance is mentioned where it was produced by muscular action, the patient having fallen violently backwards upon his head. Persons who com- mit suicide by hanging, occasionally break this bone with the rope. The fracture is generally seated in the large horns of the bone, sometimes in both, ■ at other times only in one. It is liable to be complicated with injury of the larynx lower jaw, and other parts, the skin being usually bruised and dis- colored The patient is unable to swallow, to articulate distinctly, and to move his tongue, except in the mos.t limited degree, and then not without 968 DISEASES OF THE BONES AND THEIR APPENDAGES. great suffering, and, perhaps, a sense of suffocation. Crepitation is generally sufficiently evident, especially during deglutition and when the index finger is placed in the throat in contact with the. smaller fragments, the correspond- ing finger resting upon the neck. The pain is very acute, and is aggravated by.the slightest motion. Sometimes the patient is conscious of a peculiar crushing sOund at the moment *of the accident. Occasionally thene is lacera- tion of the mucous membrane of the fauces, followed by pretty copious hemor- rhage, as in the interesting case reported by Professor Wood, of Cincinnati. Fracture of the hyoid bone, although not in itself necessarily dangerous to life, often becomes so in "consequence of its complications; but, even in the raost simple cases, it is generally exceedingly troublesome on account of the great mobility of the fragments, and the tendency in the supervening inflara- mation to be followed by severe swelling. Occasionally abscesses form, the detached piece becomes necrosed, and the neck is pierced with fistulous orifices, which are slow in healing. The accident has hitherto been noticed chiefly in-aged subjects, probably on account of the great brittleness of the bone at this period of life. In the treatment .of this fracture, attention must be paid to the position of the head, which should be inclined forward, and maintained in a state of the utmost quietude, by an appropriate bandage secured around the chest. If there be much displacement, readjustment should be attempted by means of the -finger in the throat while counter-pressure is made externally. Perfect silence should be enjoined. If there be much pain and swelling, leeches •should be applied to the neck, followed by satujnine and anodyne fomenta- tions ; the bowels should be freely evacuated by stimulating injections, and fever should be combated, if necessary, by bleeding at the arm. For the first few days, the patient should abstain as much as possible from food and drink; at alf events, he should take no more than what is just sufficient to sustain life. If he cannot swallow, a stomach tube must be used, but,-in general, this will not be necessary. After the swelling of the neck has measurably subsided, an attempt should be" made to keep the fragments in place by a compress and adhesive strips, though little, it must be confessed, is to be •expected from such a course. If any portion of the bone becomes necrosed, an early opportunity is sought to extract it. In ordinary cases, the fracture will unite in from six to eight weeks. . • . FRACTURES OF THE LARYNX. The cartilages of the larynx may be broken by external violence, as a blow, the kick of a horse, or the pressure of the thumb and fingers. The accident is most liable to happen in elderly subjects, after the partial ossification of these bodies, and.the one which is most apt to suffer is the thyroid. The fracture may be simple, comminuted, or complicated. The only reliable diagnostic symptoms are crepitation^ displacement of the fragments, and pre- ternatural mobility. The cOmmon-accompaniments are difficulty of articu- lation, breathing, and deglutition, loss of voice, cough, hemorrhage, and probably also emphysema, from an escape of air into the surrounding cellular tissue. Most of the Cases of this accident prove fatal, either soon after its occur- rence from* suffocation, or more or less remotely from the effects of inflam- mation. Fractures of the laryngeal cartilages, unless, attended with serious displace- ment, require little else than the ordinary antiphlogistic measures, with per- fect quietude of the head and neck. When there is extensive separation of the fragments, interfering with respiration, laryngotomy may be required, FRACTURES OF THE CLAVICLE. 969 both to afford an opportunity to readjust the broken pieces, and to prevent death by suffocation. . . FRACTURES OF THE CLAVICLE. The clavicle, owing to»the delicacy of its structure, its exposed situation at the top of the chest, and its connection with the shoulder and arm, is extremely liable to break. Of 2358 cases of fractures of different pieces of the skeleton, referred to by Malgaigne, 228 occurred in this bone, and of this number nearly three-fourths were observed in the male, thus showing a remarkable disparity in regard to-the relative frequency of the lesion in the two sexes. The accident is not peculiar to any particular period of life ; I have witnessed it in a child under six months of age ; and'Dr. W. Keller, of. this city, showed me a case last winter in which, it took place in the foetus in the womb, in consequence of a fall of the mother upon the wheel'of a carriage, at the eighteenth week of gestation. The child, at the time of my examina- tion, was several months old, and the seat of the fracture, which had involved the right clavicle, near its middle, was indicated by a marked forward angular projection of the ends of the fragments, which, however, were firmly united, the consolidation having been completed before birth. A similar case was lately shown me by Dr. .William B. Atkinson, the fracture having been pro- duced by a blow from a door 'upon the abdomen when the mother was gone . seven months in pregnancy. Fractures of this bone may be simple, compound, or comminuted.; unila- teral or bilateral; transverse or oblique ; partial or complete. A transverse fracture of the clavicle is among the rarest of accidents; as for myself, I have never met with an instance of it, either in the living subject, or in any of the specimens in our museums. . The bone nearly always gives way obliquely, the ends of the fragments being generally rather long and sharp, and often distinctly serrated. When very sharp, they sometimes project through the skin, or, at all events, press against it with so much force as to cause severe uneasiness, and great difficulty in maintaining apposition. It is very uncom- mon for the bone to break at several points; such an accident, in fact, can only happen from the application of direct force. Simultaneous fracture of . bothdavicles has been observed only in a few instances. 'I have two clavicles in my possession, from the same subject, which vere both-broken at the same point, but whether at the same time, I am unable to say. The seat of fracture is usually at or near the middle of the bone, where it. is.'thinnest and weakest. Of twelve preparations now before me, it is in eight about this point; in three it is towards the acromial extremity, and in one towards'the sternal. Fracture of either end is, I suppose, very uncom- .mon, as I have never met with an instance, either during life or after death. Great displacement generally attends fractures of the clavicle,4 as shown in fig. 351; .now and then, however, we see cases where the broken ends main- Fig. 351. • Fracture of tbe clavicle. tain their natural relations, as I have myself noticed in two instances. Such an. event can only occur when the fracture is incomplete, as sometimes hap- 970 DISEASES OF THE BONES AND THEIR APPENDAGES. • "Ti" 3 O pens in children, or when the periosteum is only partially divided, and the patient has taken care not to permit any dragging of the shoulder. As a general rule, the outer fragment will-be found to be drawn downwards, for-« wards, and inwards, by the weight of the limb and by the action of the deltoid, sraall pectoral", and subclavian muscles; the inner, on the contrary, is usually somewhat raised, by the. sterno-cleido- mastoid, but not nearly as much so as its extraordinary prominence would seem to indicate, its tendency to displacement in that direction being pretty effectually counteracted by the great pectoral mus- cle and the costo-clavicnlar ligament. These.appearances are well seen in fig. 352. In fracture of the extremities of the clavicle, the loss of apposition is usually very slight, its occurrence being prevented by the manner in which the bone is attached to the scapula and the complete oblique fracture,'near the middle of sternum. In comminuted fracture, the the clavicle. displacement is sometiraes so great as to render reposition impracticable, the mid- dle fragment being occasionally tilted perpendicularly up. The" accident is generally caused by indirect violence, as a fall upon the shoulder, in-which the sternal extremity of the bone is impelled* by the weight of the body, at the same time that the acromial end is thrust forcibly in the opposite direction by the object struck against. Xot unfrequently, however, it occurs from direct injury, as a blow or fall. Irt one instance I knew it to be produced by the kick of a gun, in shooting at a flock of pigeons. Child- ren often break their collar bones by tumbling out of bed, or rolling down a flight of stairs. When both clavicles are broken, one generally gives way by indirect, and the other, immediately after, by direct force. The symptoms of fracture of the clavicle are generally well marked. The shoulder has a singularly sunken appearance, being drawn downwards, for- wards, and inwards by the weight of the lirab and the .action of the muscles, especially the deltoid and small pectoral; the head and trunk are inclined towards the injured side; there is impossibility of rotating the arm, or of carrying the hand to the face ; and the patient commonly supports the elbow in order to take off the weight of the limb from the broken bone. Upon exa- mination, the seat of the fracture is generally readily discovered by the eye, the deformity b.eing nearly always extremely conspicuous; and the finger, as it traces theoutline.of the bone, cannot fail to detect any existing-irregularity. Crepitation is elicited by taking hold of the elbow and pushing the arm up- wards,, outwards, and backwards, in a direction opposite to that of the dis- placement. The same procedure will serve to efface the deformity, which, however, will be instantly reproduced upon the removal of the restraint. When the fracture is imperfect, or unattended with displacement, the diagnosis can only be established, as a general rule, by a careful digital examination, aided by the alternate elevation and depression of the shoulder. Although, in general, the patient is unable, in fracture of the clavicle, to carry his hand to the head, yet I have met with some very striking exceptions to this rule", both in children and adults! In a man, aged forty; whom I saw a few years ago with Dr. Dennis O'Reilly, the patient could execute this movement with quite as much facility as with the other limb. He could even swing it about without any pain or inconvenience. The fracture, caused by a fall on the edge of a doorstep, was situated towards the acromial extremity FRACTURES OF THE CLAVICLE. 971 of the bone, and was attended with marked displacement.- Children, accord- ing to my observation, are more subject to this anomaly than grown persons. My experience is that fractures of the clavicle are seldom cured without' raore or less deformity, wdiatever pains may be taken to accomplish the ob- ject. In some of my cases I have found it impossible, despite all the efforts I could command, to effect accurate restoration of the ends of the fragments. This difficulty will, I think, be raost likely to occur when the fracture is seated at or towards the acromial extremity of*the* bone, in which event the outer fragment is frequently, if not generally, thrown backwards in such a manner as to render it almost impossible to bring it to its natural position'. From the cases that I have seen of this fracture, as treated by other surgeons, and "from the numerous specimens of it to be found in our museums, I am satisfied . that a cure without deformity is a very uncommon result. It is gratifying, however, to know that deformity, even .when considerable,- does not, as a general rule, at all impair the usefulness of the limb. Union will, of course, be materially retarded, but iu time nature will succeed in rounding off the ends of the fragments, and in connecting them firmly together, either by an osseous clasp or a kind of bridge. When union fails to occur, the power of the arm is always weakened. In ordinary cases, consolidation takes place, in.the adult, In about five weeks, and in children, in eighteen or twenty days. In the reduction of fracture of the clavicle, all that is generally necessary is, to take hold of the elbow and to carry the arm upwards, outwards, and backwards, a procedure which rarely fails to effect approximation of the ends of the fragments. If anything more is required, the fingers may be "passed along the broken bone, so as to assist in moulding the parts into proper shape. During the treatment the indication is to maintain the shoulder in the position here adverted to ; and for this purpose it will be necessary to support the limb in such a manner as to bring the elbow against the antero- lateral aspect of the chest, while the forearm rests against the front, the fin- ' gers lying across the opposite clavicle. To confine them in this position, . the best dressing is a qumber of adhesive strips, of appropriate Jength, to reach around the limb and shoulders, so as to .form, in the first place, a kind of immovable sling, and, secondly, to secure the arm to the side of the trunk. ■ When this dressing, which is mare easily applied than described, is carefully put on, it answers the object much better than any of the nurnerous contriv- ances that have ever been invented for the cure of this fracture. The strips, which should be from an inch and a half to two inches in width, may be so arranged as to make a'certain degree of pressure, through the medium of a compress, directly upon the seat of the fracture, or, if this be deemed unne- cessary,' the seat.of fracture may be kept under constant surveillance by letting it remain uncovered. The dressing, if properly applied, need not be renewed oftener than once or twice during the treatment, if, indeed, at all. If the patient be an adult, and the skin be covered with hair, the surface should be previously shaved. When there is a tendency on the part of the shoulder to sink forwards and inwards, it should be counteracted by a wedge-shaped pad' in the axilla, the large extremity being directed upwards, and confined by suitable tapes to the opposite shoulder. In general, however, I have not found it necessary to resort to such an expedient. Next to the adhesive strip dressing, which I have used and recommended for some years pa'st, in the treatraent of fractured clavicle, I prefer a. very simple contrivance, somewhat after that of Velpeau. - It consists of a wedge- shaped pad, aud an ordinary roller, carried round the limb, shoulder, and trunk so as to confine the parts in the position already indicated. Ihe dif- ferent turns of the bandage should be secured to each other by a large num- ber of oins which thus serve to keep them effectually in place. I seldom use less than from thirty to forty', and I find that, when this is done, the bandage 972 DISEASES OF THE BONES AND THElJt APPENDAGES. may be worn with great advantage for several successive weeks, without the slightest derangement. In warm weather, however, it should be removed at least as often as every ten days for the sake of cleanliness, especially if the patient perspire much. * An ingenious apparatus for the treatment of.fracture of the clavicle has beeu devised by Dr. R. J. Levi's, of this city, which, combining most of the principles of that of Dr. Fox, so long and so extensively used in this country,' commends itself by its simplicity, lightness, efficiency, and cheapness. It con- sists of a short, firm, axillary pad, supported by two straps which are buckled to a broad supporting band. From the front of this band, which crosses the upper part of the back/and descends on the anterior portion of the chest, giving a firm surface of support, is suspended a sling in which the elbow is sustained. On the back of the. sling, behind the elbow, is fastened a strap which crosses the back obliquely, and coming in front on the sound side, .is buckled to the front end of the supporting band. In adjusting the apparatus, the pad is first placed in the axilla by passing the arm through the opening between the straps above the pad.' The wide band is then thrown across the shoulders, the elbow placed in the sling, and the long strap attached to the back of the sring carried across the back and finally buckled at its front attachment to the wide supporting band. In removing the apparatus from- the patient, it is only requisite, to loosen the front attachment of the latter strap, which will allow the sling to drop from the'elbow. '• The extra bucklej which is noticed at the front end of the wide supporting band, comes into use when the apparatus is reversed for the opposite shoulder. . The apparatus of Dr. Levis may be made of any strong material, as drill- ing, webbing, or soft leather, and its different pieces may be attached together with buckles,- or, if more convenient, with buttons, or tapes. Fig. 353 ex- hibits the various parts of the apparatus, .and fig. 254 a front view of its application. Fig. 353. . Fig. 354. The French surgeons were formerly much in the habit of using the stellate or figure-of-8 bandage, represented in fig. 355. It consists of a wedge-shaped FRACTURES OF THE CLAVICLE. 973 pad and a-long roller, carried alternately round each shoulder, after which the arm and forearm are secured to the side and front of the chest in'the usual manner. The bandage of Desault, once, so much employed in this country, has fallen into deserved neglect. Boyer's apparatus for fracture of the clavicle is represented in fig. 356. Fig. 355. • Fig. 356. Figure-of-S bandage. ■ Boyer's apparatus. Dr. Dugas, of Georgia, is in the habit of treating fractures of this bone without a.pad, simply with a triangular piece of thick, unbleached muslin, to each angle of which is attached a band- age from three to four yards in • length Fig. 357. by three inches in width. The apparatus, which is described at length in the Southern Medical and Surgical Journal for 1852, is applied in such a manner as to form a sling for the elbow and forearm,-at the same time that the arm is firmly secured to the side. When both clavicles are simultaneously fractured, the treatment, should be con- ducted upon the same general principles as when one of these bones alone is broken. Some of our practitioners have derived im- portant aid, under such circumstances, from the use of a yoke, inveqted by Dr. Huntoh, the end of the splint being furnished with holes, and allowed to project several inches beyond the shoulders, thus affording excel- lent points of supp'ort for the tapes of Fox's apparatus. The annexed drawing, fig. 357, represents this apparatus as modified by T)aV Sunton's " yoke splint," modified by Day. 974- DISEASES OF THE BONES AND THEIR APPENDAGES. FRACTURES OF THE SCAPULA. Fractures of the scapula are extremely uncommon. Of 1,902 cases of frac- tures of different pieces of the skeleton, treated at the Middlesex Hospital, Londqn, only 18, according to Lonsdale, occurred in the shoulder-blade. At the Hotel-Died, at Paris, the scapula, in 2,358 cases, was broken only in 4. 'On the contrary, a remarkable disproportion of such cases sometiraes occurs in the .hands of particular surgeons. Thus, Dr. Dugas has met with four cases of this accident, and Dr. Bulloch,.of Savannah, with not less than six, although neither has seen an unusual 'number of other fractures. The in- jury may show itself in various forms and directions, and may occupy either of the two processes of the scapula, its neck, its body, or its inferior angle. a. The acromion process, fig. 358,'being the most exposed portion of the scapula, is more frequently broken than any other part of this bone, the ac- cident being usually caused by a blowupon the top Fig. 378. ^f the shoulder, or by violence applied directly to the process.itself. It may also be produced by force transmitted along the humerus by a fall upon the elbow or palm of the hand. There is reason to believe that what is sometimes regarded as a frac- ture of this process is nothing but a separation of its epiphysis, which frequently fails to coalesce with the rest of the bone until late in life. I have seen quite a uumber of examples of this kind, and there is not a cabinet, however small, that does not fur- nish similar proofs. The osseous consolidation is . occasionally postponed until after the age of forty. The fracture is'generally somewhat oblique, and its signs are so peculiar as to be characteristic. The natural rotundity of the shoulder is destroyed ; Fracture of the acromion pro- ,, » . • -i -i , i . , cess . , the outer fragment is drawn down by the weight of the arm, which hangs motionless by the side of the body; the head of the humerus can be felt in the axilla; there is a de- pression at the situation of the fracture; the distance between the shoulder and-the top of the sternum is diminished; and a distinct crepitus may be detected on pushing up the arm in contact with the displaced fragment. In addition to these symptoms there is acute pain at the seat of the injury; the lirab cannot be raised,by its own efforts; and the patient inclines his'head towards the affected side, and supports the forearm as in fracture of the cla- vicle. Fracture of the acrornion process is distinguished from dislocation of. the • humerus into the axilla by the circumstance that, in the former, the limb is movable, but fixed in the latter; that the signs'*of the accident are easily effaced by elevating the arm, but immediately recur when the surgeon lets go his hold, whereas, in .dislocation, the reduction always-requires a certain de- gree of* force, and does not relapse when it has been effected; in the former, moreover, there is usnally^crepitus, but not in the- latter. In tracing the spine of the scapula, the finger, as it approaches the acromion process, will sink down if there be fracture, whereas the spine will be unusually prominent if there be dislocation. The union is usually ligamentous instead of osseous, owing to the difficulty which is experienced' in preserving the contact of the fragments. This dc- currence wdll be more likely to happen when the tip of the acromion is broken off than when the fracture is seated near its root. The leading indications in the treatment of this lesion are, first", to secure FRACTURES OF THE SCAPULA. 975 Fracture of the neck of the scapula; ac- cording'to Sif-A. Cooper. the arm and forearm firmly to the.anterolateral part of the chest; and, se- condly, to raise the humerus against the top of the shoulder-joint, so that its head shall serve as a splint for the broken process. For this purpose, the same bandage is used as for fracture of the clavicle, but the axillary pad is dispensed with, lest the broken piece should be pushed too far outwards. 'b. In fracture of the \ieck of the scapula, fig. 359, the coracoid process and glenoid cavity are detached from the rest of the bone in an oblique di- rection* The accident' is one of great rarity, so much so, that many surgeons . have doubted the possibility of its occur- rence.. It can be produced only by great direct violence, though one case is known where it was caused by muscular con- traction in a young lady, in the act of throwing her necklace over her shoulder, the bone having doubtless been exceed- ingly brittle from some organic defect. The symptoms are always well marked. The acromion is unusually prominent, the head of the humerus is felt in the axilla, the shoulder has a flattened appearance, the limb is lengthened, the coracoid process is thrown down below the clavicle, between the deltoid and pectoral'muscles, severe pain and numbness are experienced in the axilla, and a distinct crepitus is perceived on rotating the arm upon the scapula. The accident bears, at first sight, consi- derable resemblance to dislocation of the humerus into the axilla; but from this it is always readily distinguished by the facility with which the parts may be restored to their natur.al situation, by the immediate return of the symp- toms when the limb is left to.itself, and by the existence of crepitus. From fracture of the neck of the humerus'it raay be known by the circumstance that, in the latter, the shoulder retains its rotundity, and that the limb, instead of being lengthened, is shortened ; the acromion also "is much less prominent, . In two cases of this, accident,^observed by Dr. Dugas, the fracture, pro- duced by a blow upon the shoulder from a falling tree, was instantly followed by paralysis of the limb and cessation of* puliation in.all its arterial trunks ;. a consequence, evidently, of injury done to the axillary vessels and nerves. Treatment having been neglected, no union took place, and the arms have never regained their functions. . . This fracture is retained with difficulty, and is liable to be followed by stiff- ness of the shoulder-joint, atrophy and paralysis, of the muscles of the arm, and other disagreeable symptoms. It is managed in the.-same manner as fracture of the clavicle, a pad being placed in the axilla, the dbow being kept well raised, and the scapula thoroughly steadied until reunion has oc- curred." If the parts are much contused, leeches, fomentations, and other antiphlogistics may be required. Passive motion should be instituted at the end of three weeks, and renewed every few days afterwards. Consolidation may be expected in two months. • • . „' It is not improbable that the edges of the glenoid cavity may occasionally be broken off, either by direct force, or in consequence of the sudden and violent propulsion of the head of the humerus. It is remarkable, however, that the existence of such a lesion has never been demonstrated by dissection. Is it not likely that some of the bad forms of luxation of the shoulder-joint, in which the reduction is maintained with great difficulty, and which are so 9.76 DISEASES OF THE BONES AND THEIR APPENDAGES. liable to terminate in permanent anchylosis and ruin of the articulation, are Cases of this description ? The subject is worthy of greater attention than it lerto received. In the annexed cut, fig. 360, from Air. Fergusson, the fracture extends i the glenoid cavity. le coracoid process is spmetimes broken in ence of a severe fall or blow, generally a short ! from its tip, the fracture "being usually ac- Fic. 361.. Fracture of the glenoid cavity. Fracture of the coracoid process. companied with evident contusion of the soft parts, and similar lesion of the acromion, clavicle, or humerus. The accident, which is of very rare occur- rence, is characterized by inability to Taise and adduct the arm, by. preter- natural mobility, by depression of the detached fragment by the conjoined .action of the small pectoral, two-heade*d flexor, and coraco-brachial muscles, and by the detection of crepitus on moving the arm upon the shoulder, the finger being placed between the deltoid and great pectoral muscles. The adjoining sketch, fig. 361, taken from a preparation in Professor Neill'-s col- lection, affords an illustration of a well-marked specimen of fracture of the coracoid process. The treatment consists in confining the arm and forearm to-the anterior part of the chest by means of a bandage and sling, care being taken to keep the elbow well -raised, so as to fix the top* Of the scapula, and support the broken part. By this procedure, the pectoral and flexor muscles of the arm ■ are relaxed, and prevented from acting injuriously upon the tip of the cora- coid process. Violent inflamraation, occasionally.terminating in profuse suppuration, and even in death, is apt to follow this accident, owing to injury inflicted upon the pectoral muscles and the axillary vessels, nerves, and glands. The matter being deep-seated, has great difficulty in reaching the surface, and is, there- fore, disposed\o burrow extensively among the surrounding structures. The proper remedy is an early and free incision at the most dependent, portion of the abscess. d. The body of this bone, fig. 362, rarely suffers from fracture, and then onlv from great direct violence, causing at the same time serious irfjury in the soft parts. In one case, recorded by a foreign writer, the accident is said to have been produced by muscular action. The fracture exhibits no regularity in regard to shape, is often multiple, and is rarely attended with displacement. Fracture of Ihe body of this bone occasionally, extends through its spine, so as to divide it into two nearly equal vertical parts, as. in a case which I saw, in 1860, with Dr. Rohrer. Tfoe patient was a strong laboring raan, age,d thirty-seven, who, in a fall from a scaffold, struck his right shoulder Fig. 3GO. has hitl copied througl c. T conseqi distanc FRACTURES OF THE RIBS. 977 Fig. 362. violently against the corner of a plank, fracturing the scapula through its spine and body near its centre. Five days had elapsed when I made my visit. The parts were then much swollen and ecchymosed, the top of the shoulder was de- pressed and forced forward, and there was a marked irregularity between the ends of the fragments, the outer being drawn downward and forward, so as to form with the posterior a kind of triangle, thus ^---------~-^^, with distinct crepitation upon the slightest motion. The man was unable to put his hand to his head, but could easily touch the opposite shoul- der. He experienced great pain at the time of the accident. To steady the shoulder-blade, which is the leading indication in the treatment of this ac- cident, two large, narrow, and moderately thick compresses should be placed along its axillary and vertebral borders, and confined by a broad roller carried round the upper part of the trunk; or, instead of this, they may be secured by means of large adhesive strips. The arm and fore- arm are then fastened to the anterior part of the chest, as in fracture of the clavicle. In the case above described, apposition was easily maintained by a modifi- cation of Desault's apparatus. e. Fracture of the inferior angle of this bone is occasionally met with; it is marked by preternatural mobility, by displaceraent of the smaller fragment by the action of the great serrated muscle, and by acute pain at the seat of the injury. The diagnosis may readily be established by fixing the top of the scapula and moving the lower angle; if they follow each other, it will be an evidence that there is no fracture, and conversely. The treatment is the same as in fracture of the body of the bone. The ordinary situation of fracture of the body of the scapula. FRACTURES OF THE RIBS. The central ribs, frora their exposed and fixed position, are much more liable to be broken than the upper and lower; the former being safely pro- tected by the collar-bone, the scapula, and numerous thick and strong mus- cles, while the latter, from their great shortness and mobility, can readily glide out of the way of any injury that might otherwise affect their integrity. However this may be, they usually yield at their more prominent points, in an oblique direction, a transverse fracture being here, as elsewhere, an unu- sual occurrence. The accident is most frequent in elderly subjects, children and young persons seldom suffering. The causes are twofold, external vio- lence and inordinate muscular action. The first produce their effect either in a direct or an indirect manner; most commonly in the former, as when the ribs are struck by a fall or blow, or when the body is traversed by the wheel of a carriage. In the second case, the ribs, being impelled by forces ope- rating upon their extremities, break at or near their middle, as when, for example, the back of the chest is pressed against a wall by a railroad car. When these pieces are acted upon directly, their curvature is diminished; but increased when the violence is applied indirectly. I recently attended an old lady who had the eleventh rib of the left side fractured by her grand- daughter a stout girl of fourteen, by throwing her arms round the body, in a friendly embrace, on going to bed. In 1837, a number of persons met with VOL. I.—62 978 DISEASES OF THE BONES AND THEIR APPENDAGES. severe injuries of this kind, by being severely squeezed in a crowd in the Champs de Mars, in Paris. A rib has occasionally been broken by mere muscular contraction in the act of coughing, but such an occurrence is unu- sual, and implies an abnornal condition of the osseous tissue. The number of ribs broken at any one time is variable. The largest num- ber I have ever met with was eight; sometimes, however, it is still greater. In a specimen in my collection, frora the body of a woman, aged upwards of seventy, who threw herself out of a second story window, there are not less than fifty-nine fractures, twenty-seven on the right side and thirty-two on the left. The fracture may occur simultaneously upon both sides, as in the case just mentioned; and it may be either simple, or complicated with other injury, as rupture of the intercostal artery, wound of the soft parts, and laceration of the pleura and lung. A fracture of the more superficial ribs is often easily detected simply by placing the hand upon the part where the violence is supposed to have been inflicted, and requesting the patient to cough. The bones being thus obliged to undergo a sudden motion, the lesion, if it exist, wdll be almost sure to show itself by the occurrence of crepitation and preternatural mobility. If, however, the fracture be placed under cover of a large quantity of muscular and fatty matter, as it will be in certain situations in robust and corpulent subjects, the surgeon may find it very difficult, if not impossible, to detect it. Should this happen to be the case, the examination should be repeated again and again, until the diagnosis is satisfactorily determined. The difficulty will be increased if only one rib be broken, or if the broken bone retain its normal position ; on the other hand, the diagnosis may be established at a glance if the injury be exteusive, and attended with marked displacement, as when it has been inflicted by a fall, or by the kick of a horse. Finally, the patient, as he takes a deep inspiration, is occasionally sensible of a peculiar cracking noise at the site of the fracture. The pain which attends the fracture of a rib is generally very acute, and, wdthout being strictly limited to the seat of the injury, is always more severe there than anywhere else; it is exasperated by the respiratory movements, and is commonly so violent as to compel the patient to breathe entirely with the aid of the diaphragm. Every attempt at a full inspiration, coughing, or sneezing, is followed by exquisite suffering. In very aggravated cases, the pain resembles that of pleurisy, and is accompanied with intense thoracic oppression. If the lung has been wounded by a spicule of bone, or the pro- jecting end of the broken rib, there will probably be spitting of blood, if not hemoptysis, and, perhaps, also emphysema. In the latter case, the air may fill the cavity of the chest, causing a hollow sound on percussion, and total extinction of the respiratory murmur, attended with great increase of dys- pnoea. Should the air escape into the subcutaneous cellular tissue, as when there is injury of the costal and pulmonary pleurae, it will form a diffused tumor, soft and crackling, and at once indicative of the nature of the case. More or less copious hemorrhage will be present when there has been lace- ration of an intercostal artery, the blood sometimes passing into the chest, but more generally escaping externally. The ribs being firmly connected to the costal cartilages in front, and to the vertebras behind, it is impossible for them to undergo any shortening when they are fractured, or for the ends of the fragments to overlap each other, as in fracture of the long bones. Derangement, however, may take place in almost any other direction, although the angular displacement is by far the most common, and this may be either outwards or inwards, figs. 363 and 364, according to the manner in which the injury was inflicted, the latter being usually produced by direct violence, the former by indirect. It is FRACTURES OF THE RIBS. 979 seldom, however, that more than one end of the bone is displaced in this direction at the same time. The Miitter cabinet contains several specimens in which one of the fragments projects above the level of the others. Fig. 363. Angular displacement outwards. Fig. 364. Angular displacement inwards. Fractures of the ribs are not always devoid of danger, even when they are perfectly simple, or apparently free from all complication. Their number may be so great as to cause severe shock, or such an amount of local and constitutional disturbance as to produce alarming illness and even death. The danger is generally greater, all other things being equal, in fracture of the upper ribs than in fracture of the middle and lower, because a greater degree of violence is generally required to produce it. A fracture complicated with injury of the lung and pleura must be looked upon as a serious occurrence, as it is sure to be followed by raore or less inflammation, if not by hemorrhage and pneumothorax. An escape of air beneath the skin is a matter of no consequence, except as indicating serious lesion within the chest. Hemor- rhage from a wouud in an intercostal artery is usually rather troublesome than dangerous. The following case, which fell under my observation in August, 1854, strikingly illustrates the danger of fracture involving a number of ribs, with- out any very serious complication. Mrs. Hall, of Monmouth, Illinois, a tall, slender woman, aged fifty-four, fell while the railroad cars were in the act of running off the track, against the'top of one of the seats, breaking eight of the ribs on the left side. The second third fourth and fifth bones were fractured in front, about two inches 980 DISEASES OF THE BONES AND THEIR APPENDAGES. and a half from their cartilages, while the eighth, ninth, tenth and eleventh, had given way behind, within a short distance of the spine. There was no displacement of any of the fragments, excepting the posterior one of the tenth rib, which projected slightly inwards towards the chest, and pierced the pleura. Excessive pain, dyspnoea, crepitation, and preternatural mobility, marked the accident. The cough was violent, and the patient was unable to lie in bed. The ordinary treatment was pursued, but without any material benefit, and the woman died at the end of the fourth day, exhausted by her suffering. The left side of the chest contained about three ounces of coagu- lated blood, evidently furnished by the wounded pleura, but there was no sign of inflammation, except at the seat of the upper fracture, where the serous membrane was a little roughened by lymph and slightly ecchymosed. The lung was free from disease. The other organs were sound. Fracture of the ribs, without complication or displacement, is best ma- naged by encircling the chest with a broad bandage, drawn sufficiently tight to compel the patient to perform respiration chiefly by the diaphragm; the intercostal muscles, and consequently, also, the ribs, being rendered perfectly passive. The bandage should be from eight to ten inches in width, and long enough to extend at least twice around the body. The ends being fastened by two pieces of tape, a scapulary is attached to prevent the cloth from slip- ping. Or, instead of this, the chest may be surrounded with broad strips of adhesive plaster, arranged so as to overlap each other partially, and drawn with sufficient firmness to keep it perfectly motionless. Female patients may wear, with great advantage, their usual corsets, a triangular piece being cut out in front and below to allow due play to the diaphragm. In addition to the bandage, I usually employ a thin, flat compress, as a small folded napkin, to give greater support to the broken bone. Similar dressings will answer when there is outward displaceraent of the fragments, only that it may be necessary to employ a somewhat thicker com- press ; but how are we to proceed when the end of the broken bone is driven inwards towards the chest, perhaps into the pleuritic sac and the lung? Should it be let alone, or ought we to follow the practice of the older sur- geons, and make an attempt to elevate it with the finger, the gimlet-screw, or the trephine ? It is evident that counter-pressure by means of thick compresses applied to the extremities of the rib can be of no use. If there be a wound, it might be easy enough to insinuate a small lever, and raise the bone, if not to its proper level, at least out of harm's way. As for myself, I should certainly not meddle with the case, even if the depression were very considerable, unless the symptoms were most urgent, and not then until I had given a fair trial to other means, as the bandage and ordinary antiphlo- gistics, especially the lancet and full doses of anodynes. If relief did not soon follow, or if the suffering, instead of diminishing, rapidly increased, and it was perfectly obvious from the violence of the pain, cough, and expectora- tion, that a piece of rib had been forced into the substance of the lung, I should then, I think, not hesitate to make an attempt to raise the offending fragment, or, failing in this, to remove it altogether. Cases requiring such heroic measures must be exceedingly rare, and hardly deserve formal mention in a work of this kind. Wounds, contusions, and hemorrhage, consequent upon these accidents, must be treated upon general principles. If air collect within the chest in sufficient quantity to cause excessive respiratory embarrassment, it should be let out with a delicate trocar, introduced through a valve-like opening in the skin. Pain and cough are relieved in the usual manner. If the local distress be urgent, leeches may be used, followed by the application of a large opiate plaster. The patient observes the semi-erect posture in bed, and remains FRACTURES OF THE STERNUM. 981 within doors until he feels that he can exercise with impunity. If his bandage become insupportable, he must not lay it aside, but simply slacken it. The annexed drawing, fig. 365, affords an illustration of the manner in which the ribs are some- times tied together by bony Fig. 365. matter after fracture. It was taken frora a specimen in my collection. Cases occasionally occur where the rational symp- toms of fracture of the ribs exist, but in which the cha- racteristic signs are absent. Under such circumstances, the rule is to treat the pa- tient precisely as if the bones Were really broken. Fractured ribs united by osseous matter. FRACTURES OF THE COSTAL CARTILAGES. Fracture of the costal cartilages is so uncomraon that a long time elapsed before surgeons were willing to believe it a possible occurrence. That it does take place, however, is a fact fully established by modern observation ; and, what is remarkable, experience has shown that it is not always necessary for these bodies to be ossified before they can be broken, although this is usually the case. The accident is invariably produced by external violence, either directly or indirectly applied, and is observed chiefly in elderly subjects. The fracture is usually single, and the pieces which are most liable to suffer are the fifth, sixth, and seventh, owing probably to their great length and to their exposed situation. The direction of the fracture is commonly somewhat oblique ; the ends of the fragments often overlap each other, the posterior passing in front or behind the anterior, which, from its connection with the sternum, serves as the fixed point. The same symptoms which serve to denote a fracture of the ribs will serve to point out one of the costal cartilages. The accident may be simple or complicated, but, in general, it is comparatively free from danger. The broken ends are united through the intervention of a clasp or ferule of bone, in which the cartilaginous tissue remains unchanged. The reduction and maintenance of this fracture are often very difficult, but by a careful observ- ance of the rules laid down in speaking of fracture of the ribs, the surgeon will usually succeed in effecting a cure in six or eight weeks. Malgaigne ad- vises the use of a broad truss for keeping the fragments together, the_ pad making direct, but gentle pressure upon their extremities. In obstinate cases, the ends of the fragments might be united by the silver wire. FRACTURES OF THE STERNUM. This bone may give way in almost any portion of its extent, but more commonly near its middle, the direction of the fracture being generally some- what oblique. A few instances of longitudinal fracture of the sternum have been observed. Blows, kicks, and falls are the ordinary causes of the acci- dent Chaussier relates a case where it was occasioned by violent muscular contraction during labor, and several examples of a similar nature have been recorded by more recent observers. In 1858, Dr. Rohrer, of Chestnut Street had the kindness to show me a case, in a large, heavy, muscular man, a^ed forty-seven who met with a transverse fracture of the upper part of 082 DISEASES OF THE BONES AND THEIR APPENDAGES. this bone, from inordinate contraction of the sterno-cleido-mastoid muscles, in jumping, while intoxicated, from a shed eleven feet high upon the earth below. The heels striking the surface obliquely, threw the body violently backwards, the head and neck coming in contact with the edge of a board, which projected several inches above the pavement. The fracture no doubt occurred in consequence of the effort which the man made to regain his equilibrium. The ends of the fragments either preserve their natural relations, or, if there be any displacement, it is in the direction of the thoracic cavity; in which case the broken bone may lacerate some of the contained viscera, cause effusion of blood into the anterior mediastinum, and perhaps induce emphy- sema by wounding the lungs. When the fracture is attended with displacement, it may usually be de- tected at a glance, or by merely passing the finger over the line of injury. Grating, sometiraes audible at a considerable distance, and increased at every respiratory effort, is generally present. The pain is excruciating; recumb- ency is, for a time at least, impracticable; and there is great dyspnoea, along with cough, spitting of blood, and other symptoms of internal injury. In Dr. Rohrer's case, above mentioned, there was, even several days after the accident, a marked depression at the site of fracture, with consider- able irregularity of the ends of the fragments, which was much increased when the patient sat up in bed. During recumbency, when he coughed hard, the hand, placed over the seat of the injury, could distinctly feel the frag- ments ride over each other, the upper evidently moving more freely than the lower. It seemed as if their edges were beveled off obliquely, that of the lower piece from above downwards, and from before backwards, and that of the upper in the opposite direction. Two or three times, as the man coughed, a distinct grating noise was heard. Percussion upon the spine, immediately opposite the fracture, had also the effect of displacing the ends of the frag- ments, and a similar result followed when firm pressure was made upon the anterior surface of the fragments. When Dr. Rohrer first saw the case, the upper fragment was thrust backwards towards the thoracic cavity, fully one inch behind the level of the other; but it was easily restored to its natural situation by bending the chest backwards over a thick pillow. The pain at the seat of fracture was comparatively slight; but the suffering in the back of the neck and head was very distressing. There was neither cough nor emphysema, and the fever that followed was slight. The prognosis of fracture of this bone varies according to the mildness or severity of the accompanying lesion. When the thoracic organs have sus- tained much violence, the patient may die frora shock, hemorrhage, or em- physema; or, if he be so fortunate as to survive the immediate effects, he may perish from the secondary consequences of inflammation of the lungs, abscess of the mediastinum, or disease of the bone itself. In the Mutter Museum at the Jefferson College is a skeleton in which a fracture of the sternum, near its middle, had undergone perfect reparation, although not without considerable deformity from the want of accurate apposition. Evi- dence of fracture exists in a number of other bones, and there must also have been a remarkable predisposition in the individual to the development of ex- ostoses. The treatment of fracture of the sternum is in great measure restricted to the application of a compress and bandage, to afford support to the chest, and assist in securing the quietude of the intercostal muscles. If there be any serious internal complications, local and general bleeding, active purga- tives, antimonials, and anodynes, may be required, aided, perhaps, by medi- cated fomentations. If the fracture be simple, no attempt should be made to rectify depression of the offending fragment, unless it is perfectly certain FRACTURES OF THE VERTEBRAE. 983 that it acts as a cause of compression of the heart or lung. In such a case, and also when there are loose pieces of bone projecting into the chest, restoration should be effected at all hazard, and that with the least possible delay. To accomplish this, the patient may lie across a table, upon a kind of double inclined plane, in order to extend the spine, and afford the muscles that are attached to the exteemities of the sternura an opportunity of drawing the ends of the broken bone asunder. While this is being done, pressure should be made upon the parts in a direction opposite to that of the displacement, at the same time that the lungs are, if possible, thoroughly distended with air. Or, this failing, the bone, the body being still in this position, may, perhaps, be raised by a small, delicate elevator, used subcutaneously, if a wound was not previously made. If this also prove unsuccessful, I should not hesitate, in view of the urgency of the case, to apply the trephine, or to remove a sufficiency of bone with a Hey's saw. A similar proceeding may become necessary when matter forms in the anterior mediastinum, or when a portion of the sternum is assailed with caries or necrosis. FRACTURES OF THE VERTEBRAE. The vertebrae are so compactly constructed, so strongly articulated, and so thickly covered by muscles as to render their fracture a matter of great difficulty. The most common causes are violent blows or falls, giving rise at the same time to severe injury of the soft parts. Occasionally, but very rarely, the lesion is produced by contre-coup, as when a person falls from a great height and alights upon his feet, the force being transmitted along the extremities and the pelvis to the spinal colnmn, where, concentrating itself upon a particular bone, it breaks its substance or severs its ligamentous connections. Any part of such a bone may give way, its body, plates, and processes being all liable to yield under the influence of the causes here men- tioned. The symptoms and effects of this lesion must be considered with reference to the different divisions of the vertebral column, as the cervical, dorsal, and lumbar, each possessing certain peculiarities growing out of its relations with the spinal cord and the nerves which are detached from it. In fracture of the cervical vertebrce, the symptoms vary according to the situation of the affected bone. Thus, if the lesion be above the fourth piece, or the principal origin of the phrenic nerve, and the spinal cord is at all compressed, the diaphragm will be paralyzed, the respiration will be more or less embarrassed, and death will follow, either immediately or within a short time after the accident. If, on the other hand, the fracture is seated below this point, there will be paralysis, to a greater or less extent, of the superior extremities, difficulty of breathing, relaxation of the anal sphincters, incon- tinence of urine, and tympanitic distension of the abdomen. If the injury done to the soft parts is not very severe, recovery may follow, but in most cases death takes place in from three to five days. In fracture of the dorsal vertebrce, the upper extremities will be free from paralysis, unless the injury is seated very high up, when they may participate in this affection with the sub-diaphragmatic portions of the body. The bowels, in either case, will be torpid and distended with gas, and the bladder will be'unable to expel its contents. The patient seldom lives longer than a fortnight although in some rare cases life is prolonged for several months. In this event the bowels and bladder may partially regain their original tone, but the urine soon becomes loaded with phosphatic matter, and the lining merabrane of the organ suffers from chronic inflammation, adding thus greatly to the patient's distress. When the lumbar vertebrce are broken, the lower extremities are generally deprived both of volitiou and sensibility, the feces pass off involuntarily, and 984 DISEASES OF THE BONES AND THEIR APPENDAGES. the bladder is unable to contract upon its contents. Life usually lasts longer than in fracture of the dorsal vertebras, the paralysis not extending so high up, and consequently not involving so many important organs. In the ma- jority of cases, the patient dies in five or six weeks; but sometimes, though rarely, he survives a much longer time, his bladder, meanwhile, suffering as in fracture of the other divisions of the spine. The symptoms here enumerated may follow fracture of any portion of a vertebra, except, perhaps, that of the spinous process, where the suffering is generally comparatively slight, unless the lesion is complicated with serious mischief of the spinal cord. Fracture of the spinous processes of the vertebras occasionally occurs inde- pendently of the bodies of those bodies, as seen in fig. 366, the usual exciting cause being a blow, fall, or kick. Preternatural mobility and lateral dis- placement, with more or less contusion and discoloration of the soft parts, are the most reliable phenomena. Fig. 366. Fig. 367. Fracture of the spinous process. Fracture of the vertebral arches. Fracture of the arches of these bones, of wdiich the accompanying cut, fig. 367, affords a good illustration, is often comminuted and attended with de- pression of the fragments, some of which may be driven into the substance of the spinal cord, crushing and pulpifying it. It is generally produced by violence directly applied, and is not unfrequently quite as dangerous as a fracture of the bodies of the vertebras. The transverse processes of the vertebras can only be broken, as a general rule, by excessive force, as the passage of a ball, or a fall frora a considerable height. Hence the result of such accidents is commonly very unfavorable. The diagnosis of fractured spine is usually rather a matter of inference than of positive conviction. Its most important elements are the mode of pro- duction of the injury, and the paralysis of the extremities, but it should be recollected that this symptom may depend entirely upon lesion of the spinal cord, unconnected with fracture of the vertebras. Owing to the small size of these bones and the manner in which they are covered in by the muscles of the back, it will generally be impossible to detect either crepitation, deformity, or preternatural mobility. All these phenomena may, however, be present in fracture of the spinous processes. Dissection, after an injury of this kind, will usually reveal more or less displacement of the broken bone, which is sometimes quite comminuted, laceration of the connecting ligaments, and injury of the spinal cord, with more or less extravasation of blood in the spinal canal and the surrounding parts. The cord is compressed, bruised, pulpified, perhaps nearly completely FRACTURES OF THE VERTEBRAE. 985 Fig. 368. Fracture of the vertebrae. severed, pieces of bone sometimes being imbedded in its substance, as shown in fig. 368. The prognosis of these accidents may be inferred from what has been said respecting their symptoms and effects. If the patient escape immediate de- struction, he will almost certainly succumb under his suffering at no very remote period; or, if his life should be spared, he will be doomed to carry on a miserable, bedridden existence, palsied and other- wise crippled in the exercise of some of his more important functions. In the treatment of this accident, very little is to be done in the way of restoring displaced fragments, all such attempts being not only uncertain, but, even if successful, likely to aggravate the danger by the additional mischief that is inflicted upon the spinal cord. The same remark is applicable to the opera- tion of cutting down upon the injured part, and removing the offending portion of bone with the trephine or saw, as proposed by the late Mr. Henry Cline, of London, and practised by him and other surgeons. In all the cases, amounting probably to ten or a dozen, in which this procedure has been em- ployed, including those of Dr. John Rhea Barton and Dr. Goldsmith, no par- ticular benefit has followed ; a circumstance that might have been expected when it is recollected how seriously the spinal cord is generally injured by the depressed fragment. The operation, although not without difficulty, on account of the great depth at which the offending bone is situated, may be executed by any competent surgeon, with but little loss of blood; and, I must confess that, notwithstanding the want of success which has hitherto attended it, I should feel very much tempted to resort to it, if the symptoms were such as to render it certain that the lesion was accompanied by depres- sion. Whether an operation be performed or not, it is the duty of the surgeon to adopt prompt measures for the prevention of inflammation ; with this view- blood is taken freely from the arm, and also by leeches from the seat of the injury; the bowels are relieved by purgatives, or stimulating enemas, and pain is abated by full doses of anodynes, combined, if there be much fever, with antimonials. The bladder is carefully watched, and the urine, if re- tained, is drawn off regularly twice or thrice a day, instead of allowing the catheter to remain permanently in the bladder. The patient should be kept on his back, upon an air-bed, his head resting upon a low pillow, and his position being as seldom changed as possible. Great care is taken that he is not turned upon his face for any purpose whatever, as he might be almost instantly asphyxiated while in this situation, from the imperfect descent of the diaphragm, caused by the pressure of the abdominal viscera, on account of the paralyzed condition of the abdominal muscles, and their consequent inability to offer any resistance to the weight of the body. After the lapse of five or six weeks, the back and limbs should be frequently rubbed with stimulating liniments, and a large issue should be established in the vicinity of the injury with the Vienna paste or the actual cautery. Along with these means, trial may be made of small doses of strychnine, in union with iron and quinine. . ., e . . When the lesion is confined to the spinous processes, the fragments must be moulded into shape, and retained by two long, thick compresses, stretched along the side of the spine, and secured with a circular bandage, fastened by 986 DISEASES OF THE BONES AND THEIR APPENDAGES. a scapulary. If the broken pieces, however, be much shattered, so as to pre- clude the possibility of their reunion, the best plan will be to remove them. Fracture of the odontoid process, although a very uncommon occurrence, is sometiraes met with, and, as might be supposed, generally proves promptly fatal from injury done to the spinal cord. Now and then, however, a remark- able exception is found. Thus, in a case related by Professor Willard Par- ker, the patient survived the accident five months, at the end of which time he suddenly expired from displacement of the process, during some inad- vertent movement of the head, a result favored by the destruction of the occipito-axoid ligament. The dissection showed that the odontoid process had beeu completely broken off, and that its lower extremity had been turned backwards towards the spinal cord, as in fig. 369. The patient was a man, forty years of age, who had been thrown violently from his carriage, alighting upon his head and face, about fifteeu feet off. After recovering from the immediate effects of the accident, he was able to resume his business as a milkman, which he followed, diligently and uninterruptedly, every day for four months. He complained, how- ever, constantly, from the time of the accident, of pain in the occipito-cervical region, and was always obliged to support his head, which he was incapaci- tated from rotating. The only visible deformity was a protuberance of the neck, just below the base of the occiput, to the left of the median line, with a corresponding indentation. Fig. 369. Fracture of the odontoid pro- cess of the axis. A. Broken surface. B. Odontoid process. FRACTURES OF THE PELVIC BONES. a. The innominate bone may give way in various parts of its extent, but the one which is most apt to suffer is the upper crest, owing probably to its exposed situation. The acetabulum is sometimes broken by a severe blow upon the hip, or by a counter-stroke, as when a person falls upon his knee or foot, thereby driving the head of the femur into the pelvis. In the adjoining cut, fig. 370, from a preparation in the possession of Profes- sor Neill, the fracture runs in a semicircular direction through the acetabulum. In young subjects, the in- nominate bone is occasion- ally separated at the aceta- bulum into its three primitive pieces. Whatever may be the site, form, or extent of the fracture, it can happen only through the agency of direct mechanical violence, which, at the same time, generally seriously compromises the soft structures, both outside and inside the pelvis. The most frightful accidents of this kind that have fallen under my observation have been the result of railroad injury, caused by the body being jammed in between a car and a wall, literally crushing the bone, aud fatally implicating the bladder and other organs. Fracture of the acetabulum. FRACTURES OF THE PELVIC BONES. 987 The symptoms of this accident will necessarily vary according to the seat and extent of the fracture. When the bone has given way at the cotyloid cavity, the nature of the case may usually be recognized by the circumstance that the head of the femur is drawn upwards, and the great trochanter some- what forwards, so that the limb is diminished in length, and the foot inverted. When the head of the thigh bone is impacted in its new position, the limb may be firmly fixed, as in dislocation, but, in general, it will be found to be more or less movable, and to afford a distiuct crepitus when an attempt is made to rotate it. b. Iu fracture of the pubic and ischiatic bones, the corresponding limb is either somewhat shortened, or it retains its natural length ; the fragments are pushed either directly downwards, for- wards towards the femur, or backwards Fig. 371. towards the acetabulum ; the patient is unable to sit, stand, or walk; and on placing one hand upon the ilium, and the other upon the pubes, crepitation may usually be perceived. A well character- ized fracture of the pubic and ischiatic bones is delineated in fig. 371, from a preparation in the collection of Professor ■IN Gill. Fracture of the pubic and ischiatic bones. c. Fracture of the crest of the ilium is characterized by more or less displacement, preternatural mobility, and crepi- tation ; the pain is severe, and progression impracticable. The nature of the accident is sometimes rendered apparent by the existing deformity and by slight manipulation. Besides the above symptoms, denotive of fracture of different parts of the innominate bone, there is always more or less contusion of the external soft parts, and not unfrequently, also, serious injury of the pelvic viscera, followed by loss of motion of the inferior extremities, retention of urine, and other distressing affections. The prognosis should, therefore, be very guarded, as such accidents are generally fraught with danger, death often occurring in a few days from inflammation or extravasation of urine, or at a later period from abscess, phlebitis, and other mischief. Owing to their peculiar character, it is usually found very difficult to re- duce these fractures, or to prevent relapse after this has been done. To effect restoration, our main reliance must be upon pressure, while the maintenance is best accomplished by well arranged compresses, secured by a body bandage. When no displacement exists, all such dressings may very properly be dis- pensed with. In either case, the utmost quietude is enjoined; the patient must lie upon his back, his shoulders being elevated, and the thighs flexed, to relax the muscles about the pelvis; inflammatory action is promptly dealt with, and the bowels are relieved by stimulating purgatives and enemas. The bladder is carefully watched, retention of urine being relieved by the catheter. d. The sacrum may be broken by falls, blows, gunshot violence, and similar injury. The fracture is generally discoverable, especially when there is dis- placement, by mere manual examination, as the patient lies upon his abdomen. It is attended with severe pain at the affected part, and great difficulty in walking, accompanied, when there is lesion of the sacral nerves, with paralysis of the lower extremities, retention of urine, and involuntary discharge of the feces. The danger attending this accident is always considerable, on account of the mischief done to the soft parts; hence, even if the patient survive the immediate shock of the injury, he may perish afterwards from the effects of inflammation of the pelvic viscera. 988 DISEASES OF THE BONES AND THEIR APPENDAGES. When there is displacement of the fragments inwards, reposition may be attempted by the insertion into the rectum of a stout bougie, a lithotomy scoop, or a vesical sound, care being taken not to do any injury to the mucous membrane ; or, if the displacement be very slight, the bone may be left in its new situation, as no harm can be caused by so doing. Backward displacement may be easily remedied by pressure with the finger, relapse being prevented by a compress and a T bandage. Recovery is promoted by rigid recumbency and antiphlogistics. e. The coccyx is sometimes broken by a fall, by a kick upon the buttock, and by the passage of the child's head in labor. The accident is most com- mon in elderly subjects, in whom the joints of this bone have been destroyed by a deposit of osseous matter. The characteristic signs are preternatural mobility, acute pain, and crepitation on introducing the finger into the rectum. During labor, the occurrence of the accident is sometiraes rendered evident by a sense of yielding and a peculiar noise perceived by the attendant as he is engaged in supporting the perineum. If displacement exist, it is remedied by pressure upon the surface and counter-pressure with the finger in the rectum. It is very important, especially in the female, that the coccyx should be preserved in a continuous line with the sacrum, otherwise serious deformity of the pelvis may ensue, interfering with defecation and parturition. After the reduction has been effected, the parts should be supported with a com- press, confined by adhesive strips ; perfect quietude and lateral recumbency should be observed; and the bowels, without being acted upon at all fre- quently, should be maintained in a strictly soluble condition. 2. SUPERIOR EXTREMITY. FRACTURES OF THE BONES OF THE HAND AND FINGERS. The symptoms of fracture of the bones of the thumb and fingers are so obvious that anything like a formal account of them is quite unnecessary. The treatment is best conducted by a leather, felt, or gutta-percha splint, accurately moulded to the shape of the member and the palm of the hand, to which it must be well secured by appropriate rollers. The metacarpal bones are sometimes broken by machinery, and I have met with two instances in which the fourth and fifth of these pieces had given way under a blow of the fist, the part struck being, in one of the cases, the face, and in the other the forehead. There was marked displacement upon the back of the hand, from the projection of the anterior fragment, with distinct crepitus and swelling of the soft parts, but hardly any pain. The treatment consisted in the use of a well-padded tin case for the palm of the hand, ex- tending from just above the wrist, and of a short, narrow splint for its dorsal surface, firm pressure being made with it over the seat of fracture. Union occurred in a month, with no apparent deformity. The carpal bones are never broken, except by direct violence, which always seriously implicates the soft parts, not unfrequently necessitating removal of the hand. The nature of the accident is usually apparent from the attendant deformity, the excessive pain, loss of function, and crepitus on manipulation. Reposition of the fragments having been effected by pressure and counter- pressure, retention is secured by means of two splints, either of binder's board or wood, long enough to extend from the middle of the forearm to the ends of the fingers, the hollow of the palm being well padded, and the limb sup- ported in a sling. FRACTURES OF THE SHAFTS OF TnE RADIUS AND ULNA. 9S9 FRACTURES OF THE SHAFTS OF THE RADIUS AND ULNA. Fig. 372. Fig. 373. The radius and ulna may be broken conjointly by direct violence, or, as more frequently happens, by a counter-stroke, as when a person falls upon the hand, and the force is concentrated by transmission upon the forearm. The fracture, although it may occur at any point, is most common in the inferior half of these bones, and rarely takes place at the same level, what- ever may be its cause. In general, too, it is oblique, and not transverse, as is usually supposed. The nature of the accident is commonly sufficiently apparent from the angularity of the frag- ments, seen in fig. 372, and their preter- natural mobility, to say nothing of the facility of eliciting crepitus on rotating the hand. The patient experiences an inability to supinate and pronate the limb, the fore- arm is in a state of semi-flexion, and acute pain is felt at the seat of the injury. The chief danger in this fracture, as it ordinarily exhibits itself, is from the tend- ency of the ends of the fragments to sink inwards into the interosseous space, and to become united by a common callus, thereby materially impeding the usefulness of the limb, by destroying the functions of supina- tion and pronation. With ordinary care, however, such an accident is not likely to happen, and, in most cases, the consolida- tion is completed in frora thirty to thirty- five days, without any deformity, or ultimate inconvenience. The vicious union here mentioned is well shown in fig. 373, from a preparation in my collection. The fracture having been adjusted in the ordinary manner, the forearm is bent at a right angle with the elbow, and enveloped by a roller, extending from the fingers up- wards. Two thick binder's board splints are next applied along the anterior and posterior surfaces of the broken bones, aud secured with the remainder of the bandage. They should be a little wider than the limb, and long enough to reach from just below the elbow to the extremities of the fingers, both being well covered with wadding, and accurately moulded to the parts. The hand and forearm are then suspended in a broad sling, and confined to the chest in such a manner as that the thumb shall look directly upwards. In my own practice I have, of late years, entirely dispensed with the com- presses upon which so much stress has been laid by practitioners for counter- acting the tendency which the ends of the fragments have to approach each other at the interosseous space. I am satisfied that they are not needed for this object and that all the compression that can be required, at least in ordinary cases, can be effected by the two splints, which are always employed in the treatment of fracture in this situation. The bandage, too, has received a great deal of unjust blame in these cases, it being alleged that, if applied directly to the surface, it will force the bones together, and thus bring on the result adverted to in the foregoing paragraph. It would unquestionably be Mal-approximation of the ends of the frag- ments in fracture of the ulna and radius. Fracture of the shaft of the ra- dius,with vicious union. 990 DISEASES OF THE BONES AND THEIR APPENDAGES. easy enough to produce such an effect, but it need hardly be added that this would be an abuse, and not a proper use of the bandage, its appropriate office being to afford equable support to the muscles of the broken limb for the purpose of preventing swelling and spasmodic action. Whenever it causes such an amount of compression as to force the fragments towards each other, it cannot fail to excite pain and inflammation, if not still worse conse- quences. It is the manner, then, in which the application is made, and not the application itself, that is objectionable in the treatment of this fracture. As to the splints, they should be carefully moulded to the shape of the limb, a narrow interval being left between them at its radial and ulnar borders. When the binder's board splints cannot be obtained, light pieces of wood may be used. When the fracture is multiple, consisting, for example, of three fragments, the intermediate one having lost its support may have a tendency to sink in towards the interosseous space. To counteract this disposition, a thick, narrow pad may be placed along the mesial border of the loose piece, in an opening in the anterior splint, so as to enable the surgeon to make the pres- sure more firm and direct. But even here such an expedient will rarely be necessary, if the parts have been moulded into position prior to the applica- tion of the apparatus. Fig. FRACTURES OF THE ULNA. Fractures of the ulna may with great propriety be divided into those which take place at its body, its inferior extremity and its two principal processes, the olecranon and coronoid. 1. Shaft.—The body of the bone is most commonly broken in the lower half of its extent, in an oblique direction, as exhibited in fig. 374, from causes acting directly upon the forearm. The acci- dent, may, however, be produced by a counter-stroke; and one instance is known where it was occasioned by muscular action in wringing clothes, the patient being a stout, healthy girl of eighteen. The fracture is evinced by a marked depres- sion at the inner border of the forearm, by the mobility of the fragments, and by the crepitus on rotating the hand. The lower fragment alone is generally displaced, being drawn over towards the interosseous space by the inferior pronator mus- cle, while the other, in consequence of its firm connection with the humerus, remains stationary. An exception to this is seen in the adjoining figure. Great care is necessary in the treatment of this fracture, lest the upper end of the lower fragment retains the vicious position into which it is forced at the time of the accident, and is induced ultimately to become soldered to the inner margin of the radius. To prevent this occurrence, the hand should be permanently inclined towards the thurab, the means for doing this being two splints, the extremities of which are rendered somewhat sloping from behind forwards, in a direc- tion opposite to that of the splints employed in the manage- ment of fracture of the corresponding end of the radius. Such an expedient will be much more efficient than the use of the long, thick, and narrow compress, generally recommended for that purpose. The head of the ulna is sometiraes broken off, either separately, or along with the head of the radius. The circumstance is easily detected by the mo- bility of the part, by the disabled condition of the wrist-joint, by the severity Fracture of the shaft of the ulna. FRACTURES OF THE ULNA. 991 of the pain, and by the concomitant distortion. The treatment is conducted with two splints, aided, if necessary, by two compresses applied directly over the seat of the fracture. 2. Olecranon Process.—Fracture of the olecranon, seen in fig. 375, is caused either by direct violence, or by the inordinate action of the three-headed ex- Fig. 375. Fracture of the olecranon process. tensor muscle, attached to its upper extremity. Situated at various points of its extent, the fracture may be transverse or oblique, single or multiple, simple or complicated. The symptoms are, semiflexion of the limb, impossibility of extending the forearm, a hollow at the back of the elbow, fig. 376, and a movable promi- Fig. 376. nence at the postero-inferior surface of the arm, along with more or less pain and swelling. The interval between the two fragments varies from one and a half to two inches, and may be aug- mented or diminished at will by moving the forearm. The radius may be ro- tated upon the ulna, and crepitus may be elicited by the approximation of the extremities of the broken bone. Sometimes the very tip of the olecranon is severed, and then there is no separa- tion of the fragments. The same thing may happen when the fracture is oblique, or transverse, provided it is not below the ligamentous expansion of the extensor muscle. The union of this fracture is generally fibro-ligamentous, as seen in fig. 377, from a specimen in my collection. The cause of this kind of union is Fig. 377. Fracture of the olecranon process. Fracture of the olecranon process united by fibrous matter. threefold; first, the want of proper nourishment of the upper fragment; secondly, the difficulty of maintaining accuracy of apposition ; and, lastly, the accumulation of an inordinate deposit of synovial fluid, all, but espe- cially the first, interfering with the healing process. I have, in a few in- stances, seen osseous union ; but such an occurrence is extremely rare, and is not at all likely to happen if there be any considerable separation of the fragments, or when the fracture extends through the lower part of the pro- cess. The period required for the repair of the injury varies from six to eight weeks, and many months generally elapse before the patient regains a good use of'his limb. When the lesion is of a complicated nature, violent inflammation of the elbow-joint may arise, sometimes ending in permanent anchylosis. 992 DISEASES OF THE BONES AND THEIR APPENDAGES. The treatment consists in maintaining the limb in the extended position, by means of a wooden splint, long enough to reach from the fore part of the middle of the arm to the same point of the forearm, as represented in fig. Fig. 378. Apparatus for fracture of the olecranon process. 378. A roller having been applied from the fingers upward, the sraall frag- ment is drawn into its proper place, where it is confined by a few long adhe- sive strips and a compress, the whole being firmly secured by carrying the roller round the joint somewhat in the form of the figure 8 ; or, instead of this, the arm is bandaged from the shoulder downwards, so as to obtain a more perfect control over the extensor muscle, the great agent in effecting displacement. Passive motion is instituted at the end of three weeks, and frequently renewed, to prevent anchylosis. If the fracture is associated with severe injury of the soft parts, leeches, fomentations, and other antiphlogistic measures must be employed. 3. Coronoid Process.—A considerable number of cases of fracture of the coronoid process of the ulna, exhibited iu fig. 379, have been reported, both Fig. 379. Fracture of the coronoid process. in systematic treatises and in medical periodicals, but it is very questionable whether even a minority of them should be considered as true examples of that lesion. I have myself never met with the accident in the living subject, and I am not aware that a solitary specimen of it exists in any of the osteo- logical collections, private or public, in the United States. Professor Ham- ilton, who has investigated this subject with his usual care and ability, is very decidedly of the opinion that most of the published cases of this acci- dent are unworthy of acceptance, either because they were badly observed or imperfectly reported, and because the existence of scarcely any of them has been verified by dissection. Some years ago, an instance of reputed fracture of the coronoid process occurred in a young man, a patient in the Louisville Hospital; but, although the symptoms were such as are usually described as characteristic of that lesion, I am by no meaus satisfied that it really was of that nature. In the case of a boy, about nine years of age, treated by Dr. A. A. Scott, of Missouri, by whom the particulars have been kindly communicated to me, the coronoid process is stated to have formed a distinct prominence upon the anterior and inferior surface of the humerus, a short distance above the joint, movable from side to side, the olecranon being at the same tirae displaced slightly backwards, and the forearm somewhat flexed. The accident was caused by a fall upon the hand while the arm was forcibly extended. If we may credit the reported cases of this fracture, it is evident that it takes place mostly in young subjects. It has generally been supposed that it may be caused by inordinate contraction of the anterior brachial muscle; FRACTURES OF THE ULNA. 993 but if any one will take the trouble to examine this muscle at its lower ex- tremity, he will find that it is impossible for it to produce this effect, since the only connection which it has with this portion of the ulna is at the very base of the coronoid process, all the rest of the prominence being entirely . free, and therefore beyond the reach of the influence of the anterior brachial. Such an accident might possibly occur in this way if the coronoid process were, like the olecranon, an epiphysis, but this is not the case. Hence the most reasonable conclusion is that fracture of this prominence is always pro- duced either by direct injury, as by the passage of the wheel of a carriage, or, as probably more commonly happens, by force applied to the hand, im- pelling the ulna and radius violently upwards against the lower extremity of the humerus-. In whatever manner the fracture is produced, the symptoms are not gene- rally so clearly marked as one might at first suppose. That this is the fact is sufficiently evident frora a study of the reputed cases of the accident, in which the diagnosis has generally been attended with unusual difficulty. The •ulna, having lost its purchase in front, will necessarily be drawn backwards . and upwards by the action of the three-headed extensor muscle, so that the accident will present all the appearances of a dislocation of the bone in this direction, the prominence of the olecranon being characteristic. The patient is unable to flex the limb, and the detached portion of bone can be felt just above the elbow, where it may be readily grasped and moved about, espe- cially soon after the accident, before any swelling has come on. By bending the forearm at a right angle* with the arm, and drawing down the fragment of bone, crepitation might possibly be elicited, but this must, in any event, be very faint and indistinct. The accidents with which this fracture is most liable to be confounded are fracture of the humerus and dislocation of the ulna and radius backwards. The union qf this fracture *is universally considered as taking place by fibro-ligamentous tissue, and there is no doubt that this is the fact, as appears sufficiently evident when we reflect upon the small size of the detached piece of bone, the difficulty of keeping it in place, its imperfect nourishment, and its close connection with the joint; circumstances which are so many impedi- ments to the formation of osseous matter. In young subjects, and under pro- per management, a cure may generally be looked for in four or five weeks. The treatment is quite simple, being conducted with a view to the thorough Fig. 380. • relaxation of the flexor, muscles of the arm.' For- this purpose, the forearm, after having been carefully bandaged from the fingers up as far as the elbow, and the arm from the shoulder down- . wards, in the opposite direction, is placed at a right angle, as seen in fig. 380, in a tin-case or suitable splints, and supported in a sling, care being taken to prevent the radius and ulna . from slipping backwards, away from the condyles of the humerus. The fulfil- ment of this indication will generally be materially aided by the USe Of ad- Apparatus for fracture of, the coronoid process. ' hesive strips, carried around the joint in the same manner as in fracture of the olecranon. Passive motion should be instituted at the end of three weeks, and perseveringly renewed from time to time, lest anchylosis ensue. vol. I.—63 994 DISEASES OF THE BONES AND THEIR APPENDAGES. FRACTURES OF THE RADIUS. 1. Shaft.—Fracture of the body of the radius may take place independ- ently of that of the ulna, as shown in fig. 381, and is the more frequent accident of the two; its most common seat is the inferior half of the bone, Fig. 381. Fracture of the shaft of the radius. and its ordinary cause a,fall upon the palm of the hand. Dr. Packard, of' this city, has reported a case of fracture*of the upper portion of the radius, caused by violent muscular exertion in driving a pair of horses. The symptoms are usually well marked, there being more or less deformity, preternatural mobility, inability to perform the motions of pronation and su- pination, and the detection of crepitus upon rotating the hand. The ends of the fragments have a singular tendency to approach the interosseous space, and hence, if the case be not judiciously managed; there is apt to be permanent distortion, with partial loss of function of the limb. One of the evil conse- quences of this tendency is the want of osseous union, or the formation of a false joint within two and a half or three inches'of the wrist. I bave seen a ■ number of well-marked exanjples of this kind, and I know of.no fracture where an unskilful surgeon may show his ign6rance to greater disadvantage. The limb, being bandaged in the usual manner, is steadied by two splints, extending as far forwards as the extremities of the fingers, the hand being inclined inwards towards the ulna, and maintained in a state midway between pronation and supination. For .this purpose, the ends of the splints should be shaped somewhat like the handle of a pistol, as this arrangement will afford an opportunity of bearing upon the radius in such a manner as to force the lower fragment outwards in contact with the superior, thereby counter- acting the tendency above alluded to. If this point be strictly attended to, the cure can hardly fail to be perfect. Ordinarily consolidation may be looked for in four weeks. 2. Superior Extremity.—-This bone is occasionally broken at its superior extremity, the fracture detaching its rounded head,' or extending through its neck. It is very rarely that the bone gives way at the bicipital tubercle. The injury could hardly be produced in any other way than by direct violence. Owing to the manner in which the parts are enveloped by the muscles, the symptoms are usually indistinct, and the diagnosis is, consequently, rather difficult. The usual symptoms are deformity just below the*'elbow-joint, caused by •the flattening of the muscular prominence in that situation; the projection* of the upper end of the lower fragment in front of the limb being drawn thither by the two-headed flexor muscle, impossibility of executing the func- tions of rotation^and the rapid supervention of severe swelling. To render the diagnosis certain, the best plan is to grasp the head of the radius with the thumb and index finger of one hand, and to rotate the forearm with the other. If there be fracture, its existence will be rendered evident by the head of the bone refusing to obey the motions of the inferior fragment. By adopting this manoeuvre, it will hardly be possible to mistake the nature of FRACTURES OF THE RADIUS. 995 the case, unless there be so much swelling as to prevent the bone from being felt, in which event the examination must be repeated when the tumefaction has measurably subsided. * In the treatment of fracture in this situation, the limb is placed at a right angle with the arm, in a state midway between pronation and supination, and the same splints are employed as in fracture of both bones of the forearm, care being take*n to extend them as high up as possible, in order that they shall afford adequate support to the upper fragment. When there is great disposition in the pronator muscle to draw the lower fragment over towards the interosseous space, a compress may be used, but not otherwise. The annexed drawing, fig. 382, from a preparation in my collection, ex- hibits a rare form of fracture, in which a portion of the head of the radius has been chipped off, and permanently united to the contiguous border of the coronoid process of the ulna. The specimen was obtained in the dissecting-room, and nothing is, therefore, known of its history. Inferior Extremity.—The frequency of fracture of the lower extremity of the radius, its liability to be confounded with, dislocation of the wrist- joint and the imperfect recovery of the functions of the hand which so often follows it, sufficiently attest the importance of the subject, and afford a* satisfactory reason for the extraordinary attention that has been accorded to it by modern surgeons. Among those who have particularly interested themselves in elucidating the question, I am happy to mention Dr. John Rhea Barton, who, in a short, but graphic paper, published in the Philadelphia • Medical Examiner for 1338, was- the first-to de- rractureof the head of the radius. scribe, with any degree of accuracy; the nature and treatment of fracture of this bone at the radio-carpal articulation. In 1814, Dr. Colles, of Dublin, gave an account of a fracture which he had repeatedly found at the distance of about an inch and a half above the joint, and raore recently the whole question- has been examined anew by some of the French-and British surgeons, particularly Mr. R. W. Smith, of Dublin. Two circumstances powerfully contribute to the production of this fracture, namely, the large amount of spongy substance entering into the composition of the inferior extremity of this "bone, and the peculiarity of its connection with the wrist-joint. The relative quantity of this matter in its lower and . middle portions, and also the difference in their compact structure, are very striking. These appearances, which are sufficiently conspicuous even in young- subjects, are remarkably prominent in elderly persons, in whom the spongy substance of this part of the bone is generally exceedingly rarefied and infiltrated with oily matter, while the compact is often merely a thin crust, hardly as thick as an egg-shell, and scarcely less brittle. The peculiar mechanism of the wrist-joint cannot fail to strike the surgeon. From the intimate manner in which the radius is articulated with the scaphoid and semilunar bones, any shock received, upon the palm of the hand is readily communicated to it, causing it, if the force be at all severe, to give way under its influence ;■ whereas' the ulna, which has no such close relation, generalfy escapes without injury. Fracture of the lower extremity of the radius may happen at'any period of life, but is most common in middle aged and elderly subjects. As the result of indirect violence, I have not seen an instance before the eleventh year. Respecting the site, direction, aud extent of fracture of this part of the 996 DISEASES OF THE BONES AND THEIR APPENDAGES. Fig. 383. JIultiple fracture of the lower extre- mity of the radius. radius, the greatest possible diversity exists. Generally the injury is situated low down, within a short distance of the joint, or within the joint; but the line of fracture^s often considerably higher up, as an inch, an inch and a quarter, and even:an inch and a half,, at the junction, or even beyond thd junc- tion, of the lower extremity of the bone with its shaft. Sometiraes the seat and direction of the fracture correspond to the line of union of the'epiphysis. In regard to its direction, the fracture is generally oblique, extending frora above down-. wards, and from the dorsal to the palmar sur- face. Of forty-seven cases analyzed by Mons. Goyrand, of Aix, forty-diree were of this de- scription, the degree of obliquity varying much in different instances,.the fissure being some- times almost horizontal. The fracture of the lower end of the radius is frequently multiple, or comminuted ; indeed, I am inclined to believe that this form of in- jury is more comraon than the simple. In the annexed drawing, fig.. 383, from a preparation in the pathological collection of the New York Hospital, there are four fragments, and in seve- ral cases I have seen as many as five and six. Occasionally there are two fissures, one trans- ' verse, or nearly so, and the other vertical, detaching the head of the bone from its shaft. In Barton's fracture, the lesion always extends through the articular surface of the bone, affecting more particularly its posterior margin, and is frequently attended with separation of the styloid process. Fracture in this situation may.be complicated, first with fracture of the styloid process of the ulna, or of the head and shaft of that bone; secondly, " with dislocation of the wrist-joint; and, thirdly, with seriqus injury of the soft parts. Some years ago I attended, along with Dr. Chenowith, a young man in whom this bone was split in two by a transverse and oblique fissure, the larger fragment being completely detached, and thrown forwards and inwards over the ulna, whence, as it was impossible to replace it, I removed it by incision. A good recovery took place with hardly any impairment of the functions of the wrist-joint. In my private collection is a specimen.of transverse fracture of the lower extremity of the radius, extending into the joint, and detaching the head of the bone by several small, vertical fissures. In this case I had an opportunity of dissecting the parts in consequence of the removal of the forearm, above its middle, by another surgeon, several weeks after the occurrence of the accident. The hand and wrist were, much swollen, and infiltrated with pus, which was also freely diffused through the sheaths of the flexor tendons, while the cellular tissue along the inner part of . the-palm contained a good deal of blood. The joint was filled with'matter, and the scaphoid and semilunar bones, as well as the ulna, which was dis- located backwards, were almost completely divested of cartilage.* The ends of the broken, pieces are sometimes impacted in this fracture, the superior being driven into the cancellated structure of the inferior; buf such {fn occurrence, although said to be common, is, if I may judge frora the cases that I have had an opportunity of examining, quite infrequent. When the force causing the impaction is very great, the inferior fragment may literally be crushed by the superior. The accident nearly always results from a fall upon the hand, in'which the patient, stretching out the limb, receives the shock upon the palm, whence it FRACTURES OF THE RADIUS. 997 is transmitted to the inferior extremity of the radius. Occasionally, though much more rarely, the fracture takes place by a fall upon the back of the hand. The lesion is also produced by direct violence. The most conspicuous symptom of this, fracture is the singular deformity of the hand, giving the lirab the appearance of a dislocation of the wrist-joint, as exhibited in fig. 384. This is owing tO the fact that -the lower fragment Fracture of the lower extremity of the radius. along with the carpus is drawn upwards and backwards, from an inch to an inch and.a half above the joint, by the action of the extensor muscles of the thumb, while the upper fragment forms a slight projection on the palmar aspect of the forearm. Immediately above the posterior prominence is'a well-marked depression, which gradually slopes off towards the ulna, and is generally sufficiently large to receive the little finger. These appearances are always very striking when the limb is held in a situation midway between pronation and supination, and are easily effaced by extension and counter- extension, although they are promptly reproduced when these forces cease to act. The lower extremity of the forearm has a rounded form, from the increase of its antero-posterior diameter; the fingers are usually flexed, and the patient is unable to supinate the hand, which is, moreover, completely powerless; the pain is excessive, and considerable swelling soon arises, espe- cially along the palmar aspect of the limb. Crepitus may usually be detected by pressure just above the wrist-joint. With these phenomena before him, a ■surgeon must be exceedingly stup'id if he does not speedily detect the nature of the! injury. Instead of being thrown backwards, the inferior frag- ment is sometimes forced in the opposite direction, forming a projection in front of the forearm, beneath the flexor tendons. Another tumor, more conspicuous, aud consisting of the lower extremity of the inferior fragment qf the radius, occupies the dorsal surface; it extends across the entire breadth of the limb, and is bounded above by a well-marked furrow, more dis- tinct internally than externally. The accident, which is exceedingly rare, closely simulates dislocation of the carpus forwards, but may readily be distinguished from it by the presence of crepitus, and the facility with which the symptoms can be made temporarily to dis- appear under slight manipulation. The adjoining sketch, fig. 385, represents a fracture of the inferior extremity of the-radius, complicated with luxation of the ulna. The signs of both injuries are characteristic. The drawing was taken from a private patient. . The prognosis of this fracture is greatly influenced by the nature of the case and the manner in which it is Fraclure of the lower end managed. If, as occasionally happens, there is no dis- 0f the radius.- 4029894073 998 ' DISEASES OF THE BONES AND THEIR APPENDAGES. placement, or serious complication, consolidation may be looked for in frora twenty-five to thirty days, without deformity or permanent impairment of function. "Under opposite circumstances, nothing but the utmost care and circumspection will be likely to insure a successful cure. In any event, the patient must not expect to regain the complete use of his wrist and fingers for several months,.as there is a great tendency, in almost every case of the kind, in the resulting inflammation to extend to the synovial membrane of the digital articulations and of the sheaths of the tendons. This fact should al- ways be explained to the patient at an early stage of the treatment, other- wise the surgeon may be unjustly censured for what he cannot possibly avoid. Among the various contrivances for maintaining the contact of the frag- ments, I may mention, as an excellent one, that devised by the late Dr. Henry Bond, of this city, which I can recommend, from my own experience, as well calculated to fulfil every indication that can be presented by such an injury. It consists,-as shown in figs. 386 and 387, of two splints, one of medium- . Fig. 386. Bond's splint, being the part for the back of the forearm. sized binder's board, and the other of thin, light wood, furnished with a block and edges of thin sole-leather, about an inch in height, the whole pre- Fig. 387. The same, for the front of the forearm and hand. senting somewhat the appearance of a shallow trough. They are Ipng enough to reach from a short distance below the elbow to within an inch of the knuckles of the metacarpal bones, the block of the latter resting in the hollow of the palm, and both being well padded with wadding. Having encircled the thumb and each finger with a narrow bandage, the better to control the resulting swelling, and the fracture having been adjusted by pressure and extension, a roller is next passed around the limb as high up as the superior part of the forearm, special care being taken that it shall not produce the - slightest constriction anywhere. The splints are then placed in their proper position, and fastened in the usual manner. If there be any tendency to displacement, which, however, rarely happens after the first few days, a nar- row, square compress, not more than a third of an inch in thickness, is laid over the projecting fragment, to give greater concentration and effect to the pressure of the apparatus opposite to the seat of fracture. Sometimes it is found necessary to use a compress on each side of the wrist; but such is the accuracy with which the palmar splint fits the parts that this portion of the dressing may generally be altogether dispensed with. There is no use,-in any FRACTURES OF THE RADIUS. 999 case, of an interosseous compress, as there never is any tendency in the frag- ments to inward displacement. The advantage of the apparatus of Dr. Bond is that, while it maintains the thumb perfectly at rest, and consequently pre- vents its extensor muscles from disturbing the fragments, it permits the patient to move his fingers ab^ut freely in front of the block ; a circumstance of no trifling importance in an accident so liable to be followed by inflammation of the sheaths of the tendons. The hand and forearm are, of course, supported in a sling. In the absence of Dr. Bond's apparatus, a good dressing may be made of two thin pieces of wood, or stout binder's board, a little wider than Fig. 388. the forearm, well padded, and of the same length as the preceding, care being taken, in applying- them, to fill up the hollow of the hand and the intervals between the splints and lirab with cotton. It will also be well, in this case, to give the anterior extremities of the splints a sloping inclination from above downwards, so as to put the extensors of the thumb slightly upon the stretch, as seen in fig. 388. A very simple but efficient method of treating fractures of the inferior extremity of the radius was recently suggested by Dr. John Swinburne) of Albany, New York. It consists in confining the forearm upon a single splint, stretched along its posterior aspect from the elbow to the metacarpo- phalangeal joints, and composed of a thin piece of wood, the width of the limb, and provided with two compresses, one of which fills up the concavity of the carpus, while the other supplies the deficiency in, the straight line of the arm above. The splint is secured with adhesive strips, the application being commenced at the elbow, and then continued, at intervals of several inches, down the limb to the hand, which, the displaced parts having been previously adjusted, is firmly fastened in such a manner as to allow perfect freedom to the thumb and fingers. The annexed cuts, figs. 389, 390, and Fig. 389. Dressing for fracture of the lower end of the radius. Fig. 390. Fig. 391. Dr. Swinburne's apparatus for fracture of the radius. 391 afford a good idea of the apparatus and of the appearance of the limb after its application. The above dressings will answer equally well, whatever may be the charac- 1000 DISEASES OF THE BONES AND THEIR APPENDAGES. ter of the displacement, whether backwards or forwards. Passive motion is instituted at the end of a fortnight, proper support being given to the frac- ture while this is being made. The proceeding is afterwards repeated every other day, until the end of the fourth week, when the apparatus may gene-" rally be discontinued, the bandage alone being used* If the joints of the fingers are stiffened, they should receive special attention%at each dressing. FRACTURES OF THE HUMERUS. Fractures of the humerus are of frequent occurrence, and are of great practical importance, from the difficulty which so often attends their diag- nosis and treatment. They may take place in the shaft of the bone, at its surgical neck, at its head within the capsular ligament, and at its condyles. 1. Shaft.—The simplest fractures of the,humerus are those which occur in its shaft, as they are raost easily detected and treated, and least liable to be followed by deformity and loss of function. Caused occasionally by direct violence, they more frequently result from falls upon the palm of.the hand, in attempts to save the body from raore serious injury. In several instances that have come under my observation, and which-are alluded to in another part of this section, the accident was produced by muscular contraction ; in one case, while the patient was in the act of throwing a chip. The fracture is .usually oblique, a transverse one, properly so termed, being exceedingly uncommon. A complicated fracture of the shaft of the humerus is occasion- ally met with, as a consequence of the explosion of firearms, the contact of machinery, or the passage of the wheel of a carriage. The symptoms of fracture of the humerus in this situation are usually cha- racteristic, the deformity, preternatural mobility, and crepitus being well marked. In general there is some shortening, but the amount of this varies very much, according to the obliquity of the fracture and the development of the limb; in ordinary cases, it is very slight, the weight of the arm being sufficient to counteract the action of the muscles, at least to a considerable extent. The direction of the displacement is regulated by the line of frac- ture ; if this is below the insertion of the deltoid, the inferior fragment will be drawn inwards, but outwards if it be above that point. However this may be, any deformity that is present is easily effaced by extension and counter-extension. The limb .is completely powerless, and is always sup- ported by the patient at the wrist. The treatment of this fracture is very simple, the only apparatus necessary being two splints, and a roller applied from the fingers up. The splints may consist of two stout pieces of nnoiled sole-leather, or binder's board; one extending from the axilla to within an inch of the internal condyle, and the other from the shoulder-joint to the corresponding point of the outer condyle, the two, when applied, nearly meeting each other. By soaking them in hot water,'they may be accurately moulded to the shape of the limb, and, when this is done, it is impossible to conceive of anything better adapted for the treatment of such a case. The forearm and hand are, of course, supported in a sling, and, for the sake of greater security, the arm may be fastened by a few turns of a bandage to the side of the trunk, though this is not at all essential. Special care is taken notto raise the elbow, as a certain degree of weight is necessary to prevent overlapping of the fragments. This mode of dressing fractures of the shaft of the humerus I have practised for many years, and it requires no argument to show its superiority over the old four- splint apparatus, still, used by many surgeons. If the lesion be simple, re- union will generally occur in a month. 2. Inferior Extremity.—Fracture of the condyles may be caused by a fall upon the point of the elbow, by a blow, or by the passage of the wheel of a 'FRACTURES OF THE HUMERUS. 1001 carriage. I have repeatedly known it to be produced by a fall upon the palm of the hand, the limb being at the time in an extended position. The accident may be simple, or, as not unfrequently happens, complicated with serious mischief to the joint and soft parts. Both condyles may be bcokeh, or one only may be affected. In the former case, a longitudinal fracture usually extends some distance along the centre of the bone, and then termi- nates, probably at a distance of an inch and a half to two inches above the joint, in an oblique or transverse fissure in the lower portion of the shaft of the humerus, thus producing three fragments. Not unfrequently, however, there is a separation merely of one of these prominences, the fracture being then usually directed obliquely downwards into the joint. In a third series of cases, the sraall projection over the inner condyle is broken off, either ob- liquely or perpendicularly, without any involvement whatever of the articu- lation. . , The symptoms of fracture of this portion of the humerus vary according to circumstances, as might be expected from a consideration of. the structures of the elbow-joint. When both condyles are severed just above the articula- tion, the radius and ulna project backwards, a hollow exists at the .bend of the arm, the forearm is slightly flexed, and the distance between the elbow and wrist is sensibly diminished.' When the fracture involves both the con- dyles and the inferior extremity of the shaft of. the bone, there will be, in ad- dition to these phenomena, an increase in the width of the beud of the arm, and an app*earanee of greater flattening. The accident, whether accompanied by this occurrence or not, is liable to be mistaken for dislocation of the radius and ulna backwards; but the diagnosis may generally be readily determined by the fact that the symptoms which mark the former lesion promptly dis- appear on extending the limb, and that crepitus may be produced when the forearm is rolled upon the humerus. When the inner condyle alone is detached, as exhibited in* fig. 392, the Fig. 392. . Fraeture of the internal condyle; . • ulna projects backwards, but resumes its natural position on extending the limb; the condyle forms a tumor at the back part of the elbow ; crepitus is perceived on bending the forearm; and, if the forearm be extended, the humerus will advance in front of the ulna as the latter recedes. A fracture of the external condyle, shown in fig. 393, is characterized by 393. Fracture of the external condyle. the existence of a turaor at the outer and back part of the elbow, by crepi- tation on rotating the radius, by the supine position of the hand, by inability to move the ioint, and by the constant semiflexion of the forearm...... When the tubercle over the internal condyle is broken off, the diagnosis is easily established hy the great-mobility of the fragment, the ready production 1002 DISEASES OF THE BONES AND THEIR APPENDAGES. of crepitus, and the other ordinary signs of fracture. Tbe accident is usu- ally caused by a fall upon the elbow, and is unaccompanied by any displace- ment of the bones of the forearm. Whatever may be the nature or extent of these fractures in the vicinity of the elbow-joint, there are always severe pain and complete inability to move the limb. Considerable swelling soon follows, and effusion rapidly takes place within the articulation, .obscuring the characteristic features- of the injury, and rendering the diagnosis proportionately difficult. When such a state of things exists, leeches, fomentations, and other antiphlogistic mea- sures may be necessary before the parts will be sufficiently toleraqt of the requisite .manipulation. The inferior extremity'of the humerus occasionally gives way just above the condyles, generally in a more or less oblique direction, as seen in fig. 394. Such an occurrence may, unless great^care be taken, be readily confounded Fig. 394. Fracture of the lower end of the humerus. with dislocation of'the ulna and radius backwards, which its symptoms, at first sight, closely resemble. The signs of distinction are, the mobility of the limb, and the facility with which the parts can be restored to their natural position, followed by the immediate return of deformity upon discontinuing the extension. The accident, which should be treated on the same princi- ples as fracture of the shaft of the humerus, is extremely liable to be fol- lowed by stiffness of the joint. In chHdren, prior to the completion of the ossific process,, there is some- tiraes a separation of t\\e epiphysis of the inferior extremity of the humerus, induced by falls upon the hand or elbow. The symptoms resemble those of fracture in this situation in the adult, there being an unnatural projection at the back of the joint, caused by the retraction of the lower fragment along with the bones of the forearm, and the ready production of crepitus on ex- tending the limb. The accident is treated as if it were a fracture. I kuow of no fractures which I approach with more doubt and misgiving than those of the inferior extremity of the humerus, involving the elbow- joint. I-know of none which are more liable to be followed by severe in- flammation of the synovial membrane, extensive effusion, anchylosis, and deformity. Even in the more simple forms of these injuries, and where the treatment has been most skilfully conducted; there is generally great risk of an unfavorable result; at all events, a long tirae will be sure to elapse before there will be anything like a good -use of the articulation. The prudent sur- geon will, therefore, inform his patient, at the commencement of the attend- ance,.of the nature and probable consequences of the case. From five to six weeks is the average period necessary for the reunion. The nature of the deformity, in badly-treated*fracture of the condyles of the humerus, may exhibit itself in quite a variety of ways, depending upon FRACTURES OF THE HUMERUS. 1003 the peculiar mode of treatment. Sometimes a posterior projection remains, caused by the displacement of the lower end of the bone backwards; not unfrequently the limb has a strangely twisted appearance, either in the direc- tion of pronation or supination; occasionally it is permanently flexed or extended; and sometimes, again, the limb is greatly increased in breadth. Most practitioners, I believe, are agreed upon the propriety of treating these fractures with the limb in the flexed position. I know of but few that pursue the opposite plan, and the arguments which they have adduced iirits favor have by no means convinced me that it is at all equal to the other me- thod. It is but just to say, however, that I know nothing of its comparative merits from experience, inasmuch as I have never, in a solitary instance, adopted it, having always been satisfied with the rectangular position. To maintain the limb in this situation*, I have long been in the habit of employ- ing a light and well-shaped tin-cafce, extending from the axilla to the meta- carpo-phalangeal articulations. This, being properly lined with wadding, affords an admirable support to the limb, and effectually prevents displace- ment of the fragments, whatever may be their size or number. Great care should be taken to protect the inner condyle from pressure, otherwise it may become seriously inflamed, if not ulcerated. To obviate this occurrence, a small gap may occasionally be made with advantage in the case, opposite this ledge of bone. A case made of gutta percha, felt, thin wire, or sole- leather, answers quite as well as one of tin, and is even superior to it,.inas- much as it admits of more accurate adaptation to the irregularities of the limb. The forearm is supported in a sling, in a state midway between'supi- nation and pronation. There are no fractures which, require more constant vigilance after their adjustment than those about the elbow-joint. The dressings should, therefore, be examined for some time, from day to day, in order that they may be changed whenever they become either too tight or too slack, and especial pains must be taken that the bandage, in the first instance, is applied very loosely, due allowance being always made for the resulting swelling. If sorae time have elapsed since the occurrence of the injury,, and the pain and tumefaction are very severe, measures should be used to reduce the inflam- mation before the limb is put up. Passive mo'tion is commenced at the end of two weeks, and repeated every forty-eight hours until all danger of anchy- losis is passed. As soon as the fracture is sufficiently repaired to bear the change, the rectangular apparatus is taken off, and a more obtuse one substi- tuted in its place. Fig. 395. Complicated fracture of the elbow. Fractures of the elbow are often of a complicated character, fig. 395, espe- cially when caused by railway injury, or falls from a great height, penetrating 1004 DISEASES OF THE BONES AND THEIR APPENDAGES. the joint, extensively lacerating the soft parts, and, perhaps, comminuting the bones. Such accidents are always fraught with danger, both to limb and life, and usually promptly require araputation. Even .supposing that the limb could occasionally be saved under such circumstances, the patient's re- covery will be extremely tardy, and when, at length, he does get well, it will be found, as a general rule, that the joint will be worse than useless, only serving as a hindrance; 3. Superior Extremity.—The superior extremity of the 'humerus includes the hemispherical head of this bone and its two necks, the anatomical and surgical; the former being the narrow, constricted portion between the head and its tuberosities, and the latter all that portion which intervenes between these, prominences and the insertion of the broad dorsal muscle, its length varying'from an inch and a half to two inches, according to the stature of the individual, a. Fracture of the Head.—Fracture of the head of the humerus is an ex- tremely uncommon occurrence, so much so, indeed, that its possibility was for a long time a matter of controversy among surgeons. The cases, how- ever, that have been reported by Bichat, Astley Cooper, Dorsey, Gibson, R. W. Smith, Malgaigne, aud others, have effectually dispelled all doubt upon the subject. I saw, myself, many years ago, in a- patient of Dr. George McClellan, an instance of the kind, which had been mistaken by the attend- ants for a fracture of the acromion process, and the true nature of which was not detected until several years after the occurrence of the accident, when the man, wdio was upwards of forty years of age, died of another disease, and an opportunity was thus afforded of examining the parts. The fracture had extended obliquely from above downwards .through the head.of the bone; and, although it had become perfectly consolidated, there were several rough prominences which, while they unmistakably indicated the seat of the injury, greatly impeded the movements of the shoulder-joint. The accident had been caused by a fall from a carriage. In a specimen in my private collection, obtained from the body of an insane woman, upwards of seventy years of age, whose skeleton presented the appearance Qf having been broken in numerous place's, the head of the humerus is completely detached from the anatomical neck, the articulating surface, which retained its smooth and polished aspect, being tilted over the great tuberosity against the posterior surface of the bone, to which it is firmly and Inseparably united by osseous matter, the fracture having evidently hap- pened a long time before death. Directly opposite to the prominence thus formed, on the inner surface of the humerus, is another large projection* fully an inch in length, having the character of a stalactitic exostosis. The bicipital groove is completely effaced. The whole bone is extremely light, its weight being hardly two ounces and a half. The annexed cut, fig. 396, conveys a good idea of the distinguishing features of this remarkable, if not unique specimen. Fracture with detachment of the head of the humerus. When the head of the humerus is completely detached from the tubercles along the anatomical neck, it-must necessarily act as a'foreign body, speedily perishing from the wan.t of nourishment. In some cases, however, it is en- FRACTURES OF THE HUMERUS. 1005 abled to preserve its vitality, although imperfectly, by remaining in connec- tion with the rest of the bone through the intervention of a few bands of fibrous tissue. b. Fracture'of the Anatomical Neck.—In children, prior to the completion of ossification, the.head of the humerus is occasionally separated from the shaft of the bone, very neai? the point of attachment of the capsular ligament, or at the .anatomical neck. The accident is generally caused by a fall on the elbow, or by violence applied to the shoulder, and is very liable to be mistaken for other injuries. In old persons, the' head of the bone, fig. 397, is sometimes not only broken ■ off, but thrown down into the axilla, where it forms a distinct tumor that can easily be felt by the hand, but .which does not obey the movements of the arm. Such an accident always seriously complicates the case. Intra-capsular fracture of the humerus is occasionally impacted, the upper fragment being propelled into the inferior. The occurrence, \vhich is extremely uncom- mon, is met with exclusively in old subjects, laboring under atrophy and great fragility of the osseous tissue. The head of the bone can be felt in the glenoid cavity, there is a slight hollow below the acromion, the axis of the arm is direeted inwards towards the coracOid pro- cess, and the elbow is somewhat separated from the trunk. Crepitation is either very faint or entirely want- ing. The length of the humerus is diminished, but generally in so slight a degree as to render it unavailing in a diagnostic point of view. c. Fracture of, the Surgical Neck.—Fracture of this portion of the .humerus is uncommon, but may take place, from the same causes as fracture of the shaft of the bone; sometiraes from a fall upon the hand or elbow, sometiraes from direct violence,«and sometiraes, although rarely, frora muscular action. The injury is always attended with marked displacement, forming an import- ant feature in its history. The superior fragment, yielding to the influence of the spinate muscles of-the scapula, is generally drawn outwards and slightly Fig. 398. Fracture of anatomical neck of humerus. Fracture of the surgical neck of the humerus. forwards, while the inferior one is directed inwards towards the side of the trunk by the pectoral, broad dorsal, and large teres muscles, attached to the inner border of the bicipital groove. At the same time that this portion of the humerus is dragged inwards, it is usually'somewhat raised by the joint agency of the muscles that pass from the scapula to the forearm ; the extent of the displacement, however, is commonly trivial, inasmuch as the weight of the limb is almost sufficient to counteract its occurrence. The diagnosis of these different fractures is not always so easy as might, at first, be supposed. Their character is often greatly obscured by the swell- ing, and the consequent difficulty of making a thorough examination. In genera], there is marked deformity at the shoulder-joint, the deltoid muscle is flattened, the arm is twTsted-'upon its axis, and, if the injury is situated on 1006 DISEASES OF ME BONES AND THEIR APPENDAGES. the outside of the capsular ligament, there is usually slight shortening of the humerus, with distinct projection of the upper end Of the lower fragment. If extension and counter-extension be made, so as to draw the parts in place, crepitation will be elicited, followed by a recurrence of all the previous symp- toms the moment the surgeon rdinquishes his hold. In all cases of ddubt, it will be a good plan to grasp the head of the humerus firmly with the thumb and fingers of one hand, while with the other we seize the elbow and move the arm on its axis. If fracture be present, it will almost be sure to be de- tected by the crepitation produced by the manoeuvre, whereas, if there be a dislocation, no noise will be perceived, and there will also be little or no mobility. When the head of the bone is fractured, and thrown off the glenoid cavity, the symptoms will be of a compound character, the crepita- tion and abnormal mobility co-existing with flattening of the deltoid muscle, extraordinary saliency of the acromion process, and a.remarkable fulness in the axilla, caused by the presence of the displaced bone, at the same, time that the upper extremity of the inferior fragment projects prominently up- wards and inwards. Treatment..—Fractures of the superior extremity of the humerus must all be treated uponthe same general principles as fractures of the shaft of the bone. The limb being bandaged from the fingers up, Fig. 399. two splints, broad and hollow, made of unoiled sole- leather, binder's board, gutta-percha, or gum sheeting, are applied, one on the outside, and the other on the inside of the limb, the former being long enough to ex- tend from the external condyle to the top of the shoulder, which it should cover well in, since it is of paramount importance to give firm support to the broken parts, as in fig. 399. The inner splint should be carefully padded at its superior extremity, in order that it may not chafe the skin ©r exert any disagreeable pressure upon the axillary vessels aud nerves. Xo cushion will be required for the axilla. The aroi is carefully secured to the side of the chest, and the forearm is supported in a sling, but the e\bow is left free, in the hope that its weight will tend to prevent "overlapping of the frag- ments. Passive motion is instituted at. the end of the third week, and firm union may reasonably be expected in a fortnight more. A long time, however, will elapse Welch's shoulder splint, before the joint will completely regain its functions, if, • indeed, it evd' does. Permanent lameness will almost be inevitable, if the fracture be intra-capsular and comminuted, owing to the difficulty of readjusting the fragmepts. When fracture of the superior extremity of the humerus is complicated with dislocation, the proper plan, of course, is to restore the displaced bone to its natural position before an attempt is made to readjust the ends of the fragments. The operation, however, will necessarily be one of extreme diffi- culty, on account of the shortness of the superior piece, which thus deprives the surgeon of the advantage of a suitable lever. His whole reliance must, therefore, be upon well-directed pressure and counter-pressure, while the patient is fully under the influence of an anaesthetic, complete muscular relax- ation being of paramount importance to success. When the operation fails, it has been recommended to let the dislocated head of the bone remain in its unnatural situation, and to bring the upper extremity of the lower fragment in contact with the glenoid cavity, in the hope that, in time, as the bone be- comes rounded off, it will contribute to the restoration of the motion .of the limb. Such an idea, however, it seems to me, must be perfectly delusive; for FRACTURES OF THE HUMERUS. 1007 it is impossible to see how, under such circumstances, nature could make anything like a good or useful joint. Instead, therefore, of pursuing such a practice, I should not hesitate; if a case of the kind were to present itself to me, to cut down upon the dislocated bone, and push it back into its natural position. The broken pieces being placed in contact, and the wound care- fully closed, I should not apprehend any bad results from inflammation and ' its consequences. Excision of the head of the humerus is seldom followed by serious effects; and, although the two cases are not exactly parallel, yet I should neither expect to lose my patient, nor make him a stiff joint. Fractures of the surgical neck of the humerus are occasionally impacted, the upper extremity of the inferior fragment being forcibly driven into the cancellated structure of the lower end of the superior fragment. Such an occurrence.is most common-in old subjects, after the age of fifty-five, in con- sequence of interstital absorption of the osseous tissue, and may be'produced either by a blow upon the shoulder, or, what is more common, by a fall upon the elbow. The extent of the impaction varies from a few lines to half an- inch or more. As the bone retains its continuity, the symptoms of the acci- dent are usually very obscure, there being neither mobility nor crepitation, unless the fragments are unlocked by being forcibly pulled asunder. Never- theless, there is generally some deformity, perceptible upon firmly grasping the humerus, and an alteration in the axis of the limb, which often looks as if it were twisted, together with severe pain, and- usually also more or less contusion of the soft parts. If the impaction be extensive, there will, in addition, be'some degree of shortening of the arm, or a slight diminution in the distance between the shoulder and elbow. These circumstances, conjoined with the fact that the patient has received a severe injury, that there is loss of motion in the joint, and that all the symptoms of dislocation are absent, afford sufficient evidence of the probable nature of the* case. The impacted fracture requires no special treatment on its own account. Experience and common sense alike dictate the propriety of letting it alone. Nothing, certainly, can be gained by pulling the fragments forcibly asunder, except mischief and trouble. Instead, then, of such interference, the surgeon contents himself with supporting the limb, and combating inflammation by leeching, fomentations, and other means ; taking care, in due time, to institute passive motion, lest anchylosis should arise. d. Great Tuberosity.—Fracture of this portion of the •humerus, although uncommon, is probably not quite as infrequent as is generally supposed, the obscurity of its symptoms rendering it extremely apt to be mistaken for other lesions in and around the scapulo-humeral articulation. The accident is liable to occur at almost any period of life, except, perhaps, in early child- hood, and is always caused by a fall or blow upon the forepart of the shoulder, the force being concentrated upon the upper extremity of the humerus so as •to separate the large tubercle from the hemispherical head and shaft of the bone. The existence of the fracture is denoted by considerable flattening of the deltoid muscle, by a remarkable increase in the width of the upper portion of the arm, which is' nearly double what it is in the natural state, and by the presence of two osseous prominences, one of which, consisting of the detached tuberosity, is situated at the superior and outer part of the joint, and the other, formed by the head of the humerus, at the upper and inner part. • The acromion is abnormally salient, and the arm is separated from the side, but can be approximated to it without difficulty, and in fact readily pronated in every direction by the surgeon. The most important diagnostic signs are the great increase in the breadth of the articulation, the refusal of the thumb to sink into the glenoid cavity, as it always does in dislocation of the shoulder, the preservation.of the length of , the limb and the production of crepitation upon rotating the humerus by seizing 1008 DISEASES OF THE BONES AND THEIR APPENDAGES. it just above the elbow while the surgeon encircles the head of the humerus with both hands. Another important evidence is the fact that the deformity is readily effaced by manipulation,*but instantly reappears when it ceases. Reparation, generally of *an osseous character, is effected in from four to six weeks, according to the age of the patient, and the amount of the result- ing inflammation, which is always very considerable, in consequence of the concomitant contusion of the soft parts. Owing to this circumstance, the motions of the'joint usually remain imperfect for many months; and in not a few cases, even when the greatest vigjlance is exercised, they are never completely regained, owing tO a redundancy of callus and the formation of osseous excrescences around the articular surfaces. Iu the treatment of this fracture, one of the leading indications is to neu- tralize the action of the muscles which are attached to the tubercles of the humerus, the larger one receiving the insertion of the two spinate 'and the small teres, and the lesser the subscapular, which necessarily tend to draw the fragments away from each other, the subscapular being materially aided in this by the action of the broad dorsal, the great pectoral, and the short •head of the flexor of the arm. To accomplish this object, the limb is put up in two leather splints, the inner one of which is nicely padded above to prevent undue pressure upon the axillary vessels and nerves, while the outer one should be bent well over the top of the shoulder. No cushion will be neces- sary, especially if the precaution be used of securing the arm and forearm pro- perly to the chest. The elbow is carefully supported in a sling, but not so firmly as to push the head of the bone too high up towards the acromion process. For the first five or six days after the accident, leeches and fomen- tations may be required, and passive motiort should be instituted in three weeks. 3. INFERIOR EXTREMITY. FRACTURES OF THE FOOT. Fractures of the bones of the foot do not require any special notice, as their management is conducted upon the same principles as that of fractures of the hand. From the fact that they are generally complicated, the treat- raent must be largely antiphlogistic, and the surgeon will have cause to con- gratulate himself if he is not occasionally obliged to amputate the foot, or exsect sorae of its bones. It need hardly be added that any loose and dis- placed fragments should always be promptly removed, even when there is no external wound, and when it might be perfectly easy to effect replacement; for such pieces" would not only be likely to act as fpreign bodies, but they might, in the event of vicious reunion, seriously interfere with the wearing of a boot. •" The calcaneum, or heel-bone, notwithstanding its exposed situation, the* importance of its functions, and the manner in wdiich it-lies beneath the tibia and fibula, is seldom the subject of fracture. Direct violence is the most common cause of the accident, which is often attended with severe lesion of the neighboring structures, both soft and hard. Falling from a great height, in which the person alights upon his heel or foot, is the manner in which it commonly happens. The bone being thus forcibly acted upon, on the one hand, by the weight of the body, and, on'the other, by the resistance ©ffered • by the surface struck, yields at its weakest point, breaking, perhaps, into several pieces. More rarely the accident is produced by the inordinate contraction of the muscles of the calf, as in dancing and leaping; but in this case it is only the posterior extremity of the bone that suffers, its tip being the part generally torn off. The amount of displacement varies according to circumstances, being necessarily very slight when the fracture extends across the body of. FRACTURES OF THE FOOT AND TIBIA. 1009 the bone, whereas it is always very considerable when it involves its back part, on account of the action of the gastrocnemial muscles, which, exerting their influence through the tendo Achillis, sometimes draw up the posterior fragment from an inch and a half to two,, three, four, and even five inches Authors speak of an impacted fracture of the calcaneura, but such an occur- rence must be extremely uncommon. The signs of this fracture are always sufficiently characteristic when the posterior portion of the bone is broken off, the hollow at the heel, the pro- tuberance at the lower and back part of the leg, and the impossibility of extending the foot, being unmistakable evidences of the nature of the acci- dent. Upon bringing down the upper fragment in contact with the inferior, crepitus raay be obtained, though it will be very faint if the tip only of the bone has been detached. The diagnosis will be more difficult when the fracture extends across the body of the calcaneum ; for then there will be no displaceraent, the latter and interosseous ligaments keeping the posterior fragment in position. In general, however, it may be determined by the history of the case, and by making pressure upon the calcaneum in different directions, thus eliciting crepitation if fracture actually exist. A fracture of the calcaneum frora the laceration of its fibres is usually slow in uniting on account of the difficulty of keeping the fragments in contact, the muscles of the calf constantly tending to separate the upper from the lower. For this reason, the union will frequently, if not generally, be ligamentous instead of osseous, and a long time will, therefore, be required for the com- plete restoration of the functions of the foot. When the fracture is caused by direct violence, the repair is effected in the ordinary manner. When there is much contusion of the soft parts, it may be necessary to use antiphlogistics for moderating the inflammation, before applying permanent dressings. The nature of these dressings must depend upon the presence or absence of displacement. In the former case, the chief obstacle to the cure is the contraction of the gastrocnemial muscles, which must, therefore, be effectually controlled until the consolidation has advanced sufficiently to enable the upper fragment to maintain its position independently of extrinsic aid. The least objectionable contrivance for fulfifliag this indication is a short splint, of stout tin, well padded, and adapted to the shape of the limb, the anterior part of which it should cover from the middle of the leg as»far nearly as the toes. When tin cannot be obtained, wood, sole-leather, or binder's board, may be used. The object of this splint is to maintain the leg and foot in a permanently extended position, for in proportion as this is effected will be the relaxation of the muscles of the calf. To maintain the upper fragment in place, the leg and foot may be bandaged in opposite directions, adhesive strips and a compress having previously been applied around the heel and sole. This position should be continued for at least six weeks, or until there is reason to believe that the connecting medium is firmly established. The apparatus of Petit, formerly so popular in the treatment of this form of fracture, should not be used, as it is anything but a suitable contrivance, the tendency of the cord and slipper being .to displace the upper fragment, and to irritate the soft parts about the heel. In the other variety of fracture, as there is no displacement, all that is necessary is to subdue inflammatory action, and to keep the foot and leg in a quiet and relaxed position wdth a tin case, or two light side splints, the limb lying upon its outer surface over a pillow. FRACTURES OF THE TIBIA. The tibia, like other long bones, is liable to give way at various points of its extent, but raore frequently below its middle than anywhere else. A VOL. i.—64 1010 DISEASES OF THE BONES AND THEIR APPENDAGES. fracture of its condyles is unusual, and its occurrence is always denotive of great direct violence. Occasionally the bone is broken near its upper ex- tremity, from an inch to an inch and a half below the knee. The internal malleolus is sometimes detached by a twist of the foot, by a fall upon the sole of the foot, or by direct injury. Most fractures of the shaft of the tibia are oblique, very few, if any, trans- verse ^nevertheless, as the fibula retains its integrity, there is seldom any considerable displacement, the sound bone acting as a splint to the broken one. It is not often, however, that the fragments com- pletely retain their apposition ; in general, there is some degree of separation, which may always be easily detected, even when there is considerable tumefaction, by passing the finger along the tibia, and tracing its outline. If there be a fracture, it wiR manifest itself by an abnormal depression at sorae particular point, or by an unnatural projection, sufficiently obvious to establish at once the nature of the case. The amount of this projection is often very great, especially when the upper fragment is very long, sharp, and oblique, in which event it is gene- rally extremely prominent, and with difficulty prevented from piercing the skin. The annexed drawing, fig. 400, from a preparation in my collection, conveys a good idea of this form of injury. For the reason just mentioned, there will usually be an absence of crepitation, or if there be any evidence of this kind, it will be very faint and unsatisfactory. The fracture, if perfectly free from com- plication, will commonly unite in from four aud a half to five weeks. Fracture of the internal malleolus is met with in various forms. In sorae cases, the process is broken off at, or close to, its connection with the lower end of the tibia; in others, near its free extremity ; but the most common site«or* the lesion is about the centre of the process. Its direction is nearly always-oblique; rarely, if ever, strictly transverse or perpendicular. Occasionally the process is broken at several points, thus constituting a comminuted fracture. Finally, cases occur, although rarely, in which the fracture coexists with fracture of the lower extremity of the fibula. The diagnosis is easily established by the position of the foot, which is always turned upwards and inwards, as if it were partially dislocated, and by the facility with which the de- tached piece of bone can be moved about with the thumb and finger; a procedure which also readily elicits crepitation. The most simple contrivance for the treatment of fracture of the tibia, is.a tin case, fig. 401, accurately shaped to the limb, provided with a foot-piece, and reaching a few inches above the knee. A band- age is applied in the usual manner, and any tendency to displacement is easily counteracted by means of a compress, arranged so as to bear gently and equably upon the ends of the fragments. I have never found it necessary to employ any other apparatus than this, no matter where the tibia was broken. When the fracture involves the malleolus the foot-piece will Tin case. effectually prevent displacement. In fracture of the Oblique fracture of the tibia. FRACTURES OF THE FIBULA. 1011 superior extremity of the tibia, extending into the condyles the plan usuallv adopted is to place the leg and thigh in The straight positioA, s£ to comiS the condyles of the femur to support the broken bone, extension and counter extens.orrbeing made with two long splints. Such a contrivance, however will be altogether unnecessary, if we employ the tin case, especially if it be made sufficiently long to embrace the inferior third of the thigh, thereby completely counteracting any tendency on the part of the muscles of the limb to draw Fig. 402. Dr. Welch's splints. the upper fragment backwards into the popliteal space. An efficient appa- ratus for these fractures will also be found in Dr. Welch's splints, fig. 402; 403. Dr. Bauer's splints. and in the wire splints of Dr. Bauer, fig. 403, the latter being particularly valuable on account of their light, airy, and pliable character. FRACTURES OF THE FIBULA. Fracture of the fibula is, relatively considered, a sufficiently common occur- rence, its frequency being due apparently to the slender form of this bone, to its superficial situation, and, above all, to the important part which it plays in the formation of the ankle-joint. The accident may take place at any por- tion of the bone, but is most common, by far, fh the inferior fifth of its extent, owing to its intimate connection with the astragalus, which, constituting the pivot of the foot, readily receives and.transmits the various shocks to which the latter is so continually exposed. Of fractures of the shaft and head of the fibula, no particular description is necessary, since they are always easy of detection, and since the treatment does not differ materially from that of 1012 DISEASES OF T5E BONES' AND TnEIR APPENDAGES. » similar injuries of the tibia. But it is different wdth fractures of the inferior fifth of the bone, where, as just stated, the lesion is most common, and where, from being usually associated with other mischief, it is extremely liable to be followed by deformity and permanent lameness. For these reasons, fractures in this situation require to be studied with more than ordinary care. Fractures of the fibula are much more common on the right side than on the left. Iu 207 cases collected by Dupuytren, more than two-thirds involved the right leg. The statistics of Malgaigne show that it is most frequently met with between the ages of twenty-five and fifty, and that men are more than four times as liable to it as women. Of 104 cases examined by this author, not a single one occurred before the fifteenth year. The causes of fractures of this portion of the fibula can be properly appre- ciated only by a careful examination of their mechanism. The tibio-tarsal articulation, being a hinge-joint, admits chiefly of flexion and extension, its lateral movements being restrained by the two malleoli, and the ligaments by which the bones of the leg are connected with those of the foot. Hence, the latter cannot be turned outwards or inwards to any considerable extent with- out producing a fracture of the former, the site of injury being determined by the particular inclination of the limb. Thus, when the foot is forcibly ab- dueted, its inner edge resting on the ground, the upper surface of the calca- neum will be pressed violently against the external malleolus, in a direction parallel to the fibula, wdiich will, consequently, yield at its weakest point, which is about an inch and a half above the joint, at the part sometimes called the ngck of the bone. In most cases there is a rupture of the deltoid liga- ment, if not also a fracture of the internal malleolus. When the foot is for- cibly adducted, the astragalus becomes the immediate cause of fracture, for this bone, turning upon its antero-posterior axis, escapes frora the arched cavity formed by the tibia and fibula, and, pressing against the outer malleo- lus, breaks the fibula nearly at the same level as in the preceding case, the direction of the fissure being usually somewhat oblique. The external lateral ligament is either torn or violently stretched. The most ordinary cause of this fracture is a fall upon the foot, in which this portion of the limb is forcibly inclined laterally, at the moment the weight of the body impels the bones of the leg forcibly against those of the foot, ren- dered stationary by the resistance offered by the ground. The fibula raay also be broken across by violence applied directly to the part, as a blow, or the passage of the wheel of a carriage. Of 207 cases of this accident recorded by Dupuytren, 120 were the result of forcible adduction, and 60 of forcible abduction, the rest being caused by direct violence. However the fracture may be induced, the superior extremity of the inferior fragment is always thrust inwards against the tibia, while the inferior ex- tremity of the superior fragment, either remains fixed, or Fig. 404. inclines in the same direction. The latter usually happens when the injury is direct, the former when it is indirect. The inferior extremity of the fibula is sometimes broken almost vertically; such an occurrence, however, must be ex- tremely uncomraon, and I have seen but two instances of it, both of them being specimens in the Mutter collection. In one, represented in fig. 404, the bone looks as if it had been split, the fissure extending upwards, almost in a straight line, fully an infch and a half; the posterior, longer, and larger' fragment being pushed considerably backwards, so as to form with the other an intermediate triangular space. In the other bone the fracture is also vertical, but the separation Fracture of the IS much leSS. fibula. The symptoms of fracture of the lojtver extremity of the FRACTURES OF THE FIBULA. 1013 fibula vary according to the circumstances of the case. When this bone alone is severed, the chief signs will be slight eversion of the foot, a depres- sion at the site of injury, and some change, usually not very conspicuous, in the contour of the ankle-joint. When the internal malleolus is broken off, or when the tibia has given way a short distance above the articulation, these characters will exist in a more marked degree, and point out unerringly the nature of the lesion. The foot will be so much abducted as to present the appearance of being dislocated outwardly; the width between the two mal- leoli will be much increased; the hollow at the line of fracture will be quite deep; and the external margin of the foot will be considerably elevated, while the internal will be proportionately depressed. Upon taking hold of the foot, it will be found that it is unusually movable, and that it can easily be restored to its natural relations, but that the moment we cease our grasp it will return to its former position. In performing these manipulations crepitus is very easily felt; and, upon tracing the outline of the lower portion of the bone, the finger will usually sink in at the seat of fracture, owing to the fact, pre- viously mentioned, that the upper end of the lower fragment always falls over towards the tibia. A good deal of ecchymosis is often present, and a con- siderable amount of swelling quickly follows, obscuring the characteristic fea- tures of the injury, and embarrassing the diagnosis. The only accident with which fracture of the inferior extremity of the fibula is liable to be con- founded is a sprain of the ankle-joint, from which, however, it may always readily be distinguished by the great distortion which attends it, and by the presence of crepitus. A simple fracture of the fibula in the inferior fifth of its extent will, if pro- perly treated, usually unite in a month, without any deformity of the limb, although even then a considerable time will elapse before the ankle-joint will perfectly regain its functions. When the injury is complicated with rupture of the ligaments, fracture of the corresponding portion of the tibia, or other serious lesion, the repair will be much slower, and there will be danger, unless the case is managed with the most consummate skill, of permanent deformity and lameness, the former manifesting itself in an everted condition of the foot and in increased width of the ankle-joint. The material point in the treatment of fracture of the fibula in this sitaation is to-maintain the foot in a position the reverse of that which it assujnes in consequence of the injury. To accomplish this object, which is designed to draw away the upper extremity of the lower fragment from the tibia, and to restore it to its proper relations, the limb, after having been enveloped in the ordinary bandage, with the precaution of not compressing it opposite the site of fracture, is placed in a tin case, the foot being directed permanently in- wards. The requisite inclination may easily be imparted by means of a piece of roller, or a few adhesive strips, carried around the instep and heel, and attached to the inside of the leg. Or, instead of this, the fracture may be treated with Dupuytren's apparatus, fig. 405, consisting of a light wooden Fig. 405. Dupuytren's apparatus. splint and a wedge-shaped cushion ; the former reaching frora the upper third of the leg to about three inches below the sole of the foot, and the latter from 1014 DISEASES OF THE BONES AND THEIR APPENDAGES. the same point to a level with the ankle. The lirab being bandaged in the sarae cautious manner as in the former case, the apparatus is stretched along its inner surface with the tapering end of the pad upwards, and secured, first above, and then below, the roller being passed around the foot and ankle in such a manner as to turn the internal margin of the foot upwards and in- wards. The lirab may afterwards be kept in the extended position, or, what is preferable, be placed, half bent, upon its outer surface over a large pillow. The parts are diligently watched, the dressing being changed as occasion may seem to require, and passive motion instituted at the end of the third week. FRACTURES OF BOTH THE TIBIA AND, FIBULA. Fractures of both bones of the leg are sufficiently common, particularly in young and middle-aged subjects, and are deserving of special attention, on account of the difficulty of their management, and their liability to be fol- lowed by deformity and lameness. Much diversity obtains in regard to the seat of these fractures, as well as concerning their direction, and the nature and extent of their displacement. In twenty-two specimens, contained in Dr. Mutter's collection and my own, I find that in ten the tibia and fibula were broken at their inferior extremity, the line of separation in none of them extending beyond three inches above the joint. In four the tibia gave way at its lower third, and the fibula at frora two to three inches and a half from its head, or junction wdth the upper end of the tibia. In six of the cases the tibia was broken from two to three inches above its inferior articulating surface ; in two of these the fibula had yielded at its middle, and in the remaining four at different points of its ex- tent. In only two cases had both bones been broken at the same level; in one of these the fracture occurred at the middle of these pieces, and in the other a little below that place. In the twenty-two cases the tibia had been broken only twice above its middle ; whereas, the fibula had given way above this situation in six cases; In sixteen of the cases the seat of fracture of the tibia was either at the ankle-joint, or below the middle of the bone, generally in its inferior fourth or third. In ten cases of fracture of the fibula the seat of the injury was either at the joint, or within the first three inches from its articulating extremity. From the above examinations it follows: first, that the tibia and fibula rarely break on the same level; secondly, that both bones are most liable to yield either at the ankle-joint, or, at all events, within the first three inches above that joint; and thirdly, that the fibula is more frequently fractured at its superior extremity than the tibia. An examination of these specimens has supplied me with some other inte- resting facts. Thus, I have found that the fracture in nearly all was more or less oblique, the line of separation in fifteen specimens of broken tibia ex- tending from above downwards, and from without inwards. As a natural consequence of this occurrence, the superior extremity of the inferior frag- ment projected outwards towards the fibula, which it touched in several of the preparations, on account of a want of proper adjustment during the treat- ment ; the lower extremity of the upper fragment, on the contrary, projected inwards, and had apparently generally been much the sharper of the two. The fibula, in most of the specimens, afforded evidence of having been broken across more abruptly than the tibia, but still with a considerable degree of obliquity in almost every instance that I inspected. Indecent fracture of the tibia, complicated with fracture of the fibula, the inferior extremity of the upper fragment is generally remarkably sharp, and, in consequence, often protrudes through the integuments at the time of the- injury, the same cause that produces the lesion forcing it across the soft FRACTURES OF BOTH THE TIBIA AND FIBULA. 1015 parts. Or, if it is not pushed out at the moment of the accident, it often escapes afterwards, through ulceration, induced by the pressure which it exerts upon the soft parts. The obliquity of fractures of the tibia is often very extraordinary, and there are few cases in which it does not become a .source of great suffering to the patient, and of annoyance to the surgeon, on account of the trouble that is experienced in keeping the fragments in their proper relations. A rare form of fracture of these two bones is represented in fig. 406, from a specimen in my collection. The tibia, it will be perceived, is broken, off ■ Fig. 406. Fracture of the tibia and fibula at the ankle-joint. just above its articulating surface without affecting the internal malleolus, while the fibula has given way about an inch and a quarter above the joint. The foot is characteristically everted. In fig. 407, also Fig. 407. ^ from a specimen in my possession, the fracture embraces both the extremity and the malleolus of the tibia; the fibula being broken off a few lines above the joint. Fig. Fig. 408. Broken articulating surface of the tibia. 408 exhibits the appearance of the broken articulating surface of the tibia. The causes of fractures of both bones of the leg are Fracture of the bones of either direct or indirect, just as when these pieces suffer the leg at the ankle-joint, separately. A very common mode in which the acci- dent happens is a fall upon the pavement, as when an individual slips in consequence of the presence, of ice, or when, as he is rapidly walking, the foot is suddenly caught in a hollow, or between two hard resisting objects, so as to throw the whole weight of the body upon the leg. Another way in which the lesion is produced is a fall from a consider- able height, as when a person is precipitated from a scaffolding. Jumping out of a carriage under full speed often produces fracture of the tibia and fibula. In many cases, the injury is occasioned by direct violence, as by the passage of the wheel of a carriage, the kick of a horse, the caving in of a sand bank, or the fall of a heavy stone. The symptoms of the injury, however induced, are generally well marked, if -not positively unmistakable. In nearly every case the liifib is shortened « 1016 DISEASES OF THE BONES AND THEIR APPENDAGES. from one and a half to three inches, and there is also, generally, great de- formity in its diameter, both depending upon the overlapping.of the fragments, which, as already stated, is frequently very extraordinary. Besides, upon making extension and counter-extension, it is generally easy to elicit crepi- tation. When the fracture is very oblique, the lower end of the superior, fragment may usually be felt iraraediatdy beneath the integuments, forming a sharp, prominent projection in front of the limb, or at its inner aspect. Sometimes the soft "structures are much bruised and ecchymosed. Another remarkable symptom, one which, indeed, is seldom absent, is a spasmodic , twitching of the limb, coming on soon after the accident, and frequently lasting for several weeks, much to the annoyance and distress of the patient. When the fracture is situated just above the ankle, the foot will usually be a good deal everted, causing an appearance of dislocation outwards, as ex- hibited in fig. 409. The prognosis of fracture of both bones of the leg may be gathered, in part, from what precedes. In the more simple Fig. 409. forms of the injury, attended with but little obliquity, a good cure can generally be effected in from four to five weeks. If, however, the ob- liquity is uncommonly great, it willt be found extremely difficult, if not impossible, to effect consolidation in a manner altogether unexcep- tionable, however skilfully and zealously the treatment raay be conducted. More or less de- formity will almost be inevitable, either in the length or in the diameter of the limb; owing tp the remarkable tendency which, the ends of the fragments have to overlap each other, and which it is often impossible to counteract successfully, whatever means may be adopted for the pur- pose. Old fractures of the tibia and fibula, like those Fracture of the lower end of the of the bones of the forearm, are occasionally tibia and fibula. connected by a bridge of callus, or of new os- seous matter, which does not, however, so far as can be determined, impair their usefulness, as must always necessarily be the case with the latter. I have several times met with this occurrence when the lesion was confined to one-of these bones, and I am not able to say whe- ther one is more liable to give rise to it than the other. Moreover, it does not seem to be necessary to its production that there should be an^ approxi- mation of the ends of the opposite fragments, as it may take place when they are perfectly straight, although the former condition no doubt acts as a pre- disposing cause. Fractures of both bones of the leg, if attended with shortening of the limb, require to be treated by extension and counter-extension, steadily and persistently maintained throughout, otherwise, as just stated, deformity will alraost be inevitable. If, on the other hand, the fracture be transverse, or nearly so, such a procedure raay of course be dispensed with, the object being attained by confining the leg in a tin case, or fracture box, care being taken to keep the great toe constantly on a line-with the inner border of the pa- tella, the surest evidence that there is no rotation of the ends of the frag- ments upon each other. Any tendency to forward, backward, or lateral dis- placement is generally easily counteracted by means of compresses and short . splints. The limb may then be placed in an easy position upon a slightly inclined plane, made of a bolster or pillow, or it may be suspended by acord FRACTURES OF BOTH THE TIBIA AND FIBULA. 1017 and pulley to the tester of the bed, as raay be found raost agreeable or con- venient. . Counter-extension may be made when the fracture is oblique, by means of a box provided with a foot-board, and two lateral splints, one extending to the perineum, and the other to the axilla, as I have generally myself preferred; or with the contrivance of Dr. Neill, consisting of a box, reaching as high as the middle of the thigh, the counter-extension being made with adhesive Fig. 410. Dr. Neill's apparatus for fracture of the leg. strips, passed through holes at the upper part of the apparatus, and tied on the outside, as exhibited in fig. 410. The use of the gaiter, fig, 411, in the treatment of fractures of the leg and thigh, attended with shortening and deformity, cannot be too pointedly con- demned, as it is almost impossible, in any case, however carefully watched, Fig. 411. Fig. 412. Application of the gaiter. Application of the handkerchief. to prevent chafing, and other inconvenience. A similar remark is applica- ble, only more forcibly, to the handkerchief, fig. 412, at one time so much employed for this purpose. Both appliances are most villainous, and should therefore be proscribed, especially as an admirable substitute may always be found in the adhesive strips, secured to the sides of the .limb, fig. 413, and tied at the bottom of the foot-board. Fig. 413. Application of adhesive strips for making extension. The annexed cut, fig. 414, represents the method of treating oblique fractures of the leg, recommended by Dr. Swinburne. A narrow, delicate snlint and foot piece are fastened by means of adhesive plaster, while counter- extension is made from the knee by strips of the same material looped about the limb below the joint. A strong cord is then passed through this loop, 1018 DISEASES OF THE BONES AND THEIR- APPENDAGES. and thence on through a hole in the side splint, opposite the lower part of the thigh, iu order to afford the requisite degree of tension. If, after the apparatus has been applied, the lirab is not sufficiently steady, adhesive strips must be used, as represented in the engraving. Fig. 414. Dr. Swinburne's mode of treating fracture of the leg. Suspension of the leg may sometimes be advantageously practised, both as it respects the comfort of the patient and the welfare of the fracture. It may be done according to the method recommended, many years ago, by Professor , N. R. Smith, of Baltimore, or the very simple contrivance of Mr. Salter, of England, depicted in fig. 415, representing the limb surrounded by the appa- Fig. 415. Salter*s apparatus for suspending the leg. ratus and slung to the tester of the bed. The case in which the le*g rests is made of light metal; and the whole contrivance is so arranged as to admit of lateral motion, and also of sliding up and down, simply by the rolling of the pulley-wheels upon the horizontal bar. The apparatus of Dr. Smith may be used for fractures of any of the long bones of the lower extremity, whether simple, compound, or complicated. It consists, as is seen in fig. 416, of two pieces, united by a hinge, after the fashion of a double inclined plane, one corresponding with the thigh, and the other with the leg, the latter supporting a shoe, which is attached by a thumb- screw, and is so arranged as to be rotated outwards or inwards, thereby ele- vating or depressing the toe, as may be deemed most desirable. The two pieces are supplied with side boards, joined by bows of iron beneath; and they are so constructed, both at the knee and at the foot, that they may be elongated or shortened at pleasure. Moreover, a short crutch, movable and well padded, is secured to the inner and upper extremity of the thigh portion, in order to prevdit injurious pressure upon the perineum. Another piece, COMPLICATED FRACTURES OF THE LEG. 1019 well padded, movable, and composed of iron, is appended to the superior' and outer part of the apparatus,-and is fastened round the trunk by a strong band. The thigh and leg rest on slings attached to the side-pieces, the latter being confined in the apparatus by its own weight, aided by a bandage, Fig. 416. Dr. N. R. Smith'j suspending apparatus or double inclined plane. while the former is supported in front by a well padded, flexible splint. The whole contrivance is suspended to the ceiling, or the tester of the bed, by a single cord, attached below the knee, near the centre of gravity of the limb and apparatus. The cord ascends with a slight obliquity from the trunk, so as to effect the requisite extension, by making gentle traction on the limb, which is completely grasped by the apparatus, and consequently firmly held by it. In this manner, the member is compelled to obey all the accidental and necessary movements of the body, thus obviating all strain and tension at the seat of fracture. COMPLICATED FRACTURES OF THE LEG. Fractures of the leg are not unfrequently complicated, whether involving both bones or only one, as in fig. 417. In the latter case, the tibia, much more frequently than the fibula/is the piece that is most liable to suffer. Fig. 417. Complicated fracture of the leg. Such accidents are produced in various ways; sometimes by violence applied to the foot as when a man jumps out of a second story window, or falls from a scaffolding; but more generally by direct force -as the passage of the wheel of a carriage a blow from a stone, or the kick of a horse. When produced 1020 DISEASES OF THE BONES AND THEIR APPENDAGES. • by these and other similar causes, the lesion is usually situated in the inferior portion of the leg, towards the ankle-joint, which is not unfrequently pene- trated. Fractures of the leg, occasioned by railway violence, are always of a comminuted character, the bones being extensively crushed, and the soft parts severely lacerated and contused, if not actually pulpified. Hemorrhage, both venous and arterial, often sadly complicates such injuries, and, along with the shock, sometimes proves speedily fatal, the system, perhaps, never fairly reacting after the accident. Complicated fractures of the leg, of a very bad character, are also frequently produced by machinery in rapid motion, and by gunshot violence. Sometimes, again, especially when there is unusual brittleness of the osseous tissue, the bones are frightfullynbroken by causes so trivial as to surprise us ho\r they could have induced such a result. In whatever manner complicated fractures of the leg may happen, the ends of the fragments, particularly those of the tibia, are extremely liable to pro- trude at the wound; the latter often in such a manner as to render it very difficult to effect replacement, owing to its being tightly gjrt by the edges of the opening in the integuments, and also to the great length which so fre- quently distinguishes it. The symptoms of such accidents are always suffi- ciently characteristic, since there is usually not only great deformity, but likewise, as just stated, exposure of the ends of the broken pieces. Never- theless, although no difficulty can attend the diagnosis, under such circum- stances, so far as the existence of fracture is concerned, yet the surgeon should always institute a most careful and searching examination, with a view of ascertaining the real condition of the soft structures, the welfare of which is often much more deeply interested than that of the bones them- selves. The first object, in every case of the kind, should be to determine what should be done ; whether an attempt should be made to save the limb or to cut it off. As a general rule, it may be stated that when—if I may use an antithetical and apparently contradictory expression—the complicated fracture is simple, that is, without any serious lesion of the soft parts, an effort should always be made to preserve the limb, especially if the patient be young and robust, and the bone not comminuted, although perhaps bro- ken at several different points. It is true, such cases sometimes terminate unfavorably, both as it respects limb and life; and it should also be borne in mind that the injury sustained both by the soft and the osseous tissues may • be much greater and more serious than the eye and hand can possibly detect. The dangers, too, from tetanus, pyemia, erysipelas, secondary hemorrhage, and profuse and exhausting suppuration, are not. to be overlooked by the surgeon in his laudable endeavors to save a patient from mutilation ; nor is he to forget that such lesions, especially when seated near the ankle-joint, are extremely liable to be followed by anchylosis. When the bones are severely comminuted, the soft parts terribly lacerated, or the ankle-joint extensively opened—in shortj when the limb has been frightfully bruised, torn, and crushed—no one would hesitate to use the knife the moment sufficient reaction has taken place to enable the system to with- stand the additional shock. The case eten then is frequently a bad one, the patient often rapidly sinking from exhaustion, or soon after from the effects of pyemia. • When an attempt is made to preserve the limb, the first indication is to arrest hemorrhage ; the second, to coaptate the ends of the broken bone; the third, to place the limb in an easy, comfortable, retentive apparatus; and the fourth, to moderate the resulting inflammation. These intentions are to be fulfilled in conformity with the general principles laid down finder the head of general observations on fractures. If the ends of the fragments are unu- ' sually long and sharp, and disposed to protrude despite of the ordinary pre- cautions, the best plan will be to retrench them ; being careful, however, to FRACTURES .OF THE PATELLA. 1021 cut off as little as possible. The edges of the wound are accurately approxi- mated by suture and collodion, every precaution being used to exclude the atmosphere. The best fracture* appa- ratus is the wooden box', fig. 418, so Fig. 418. much used in this city, both, in* private and hospital practice, .consisting of four pieces, one corresponding with the back of the leg, and two with its sides, the fourth being intended for the foot. The latter, projecting nearly perpendicularly, is provided with two mortise holes, for the reception of the extending bands. The two. lateral pieces are secured each Fracture-box. by two hinges to the back boa'rd, so as to admit of being opened or shut at pleasure during the application and removal of the dressings. The limb, enveloped in the bandage of Scultetus, is carefully laid into the box,.previously closed, and partially filled with coarse bran, which is afterwards piled on until the whole leg and the spaces on each side of it are completely covered in. The advantage of the bran, thus used, is that it -affords not only easy, equable, and comfortable support to the bro- ken bones, but also that it readily absorbs the discharges, and prevents the deposit of the ova of the fly, so common during the hot months of this and other countries. Substitution is effected whenever the substance becomes soiled and caked. For a knowledge of this mode of treating compound frac- tures of the leg, the profession is indebted to Dr. John Rhea Barton, and there is no question that it is one of the most valuable improvements that have been introduced into the management of this class of injuries at the pre- sent day, whether it be viewed merely with reference to the comfort of the patient, the safety of the limb, or the convenience of the surgeon. Fig. 419. • Compound fracture of the leg, dressed. The necessary extension and counter-extension are .easily effected by adhe- sive strips. For the first week or ten days, leeches and cold water-dressi-ng will generally be required. . Should suppuration arise, the raost soothing ap- plication will be a linseed poultice. A very comraon mode of dressing compound fractures of the tibia alone is by M'Intyre's screw splint, represented in fig. 419, well padded, and ex- tended ; an opening being left in the bandage opposite the wound. FRACTURES OF THE PATELLA. Fracture of the patella, figs. 420 and 421, although comparatively an un- common event, is of great practical importance, from its proximity to the knee-joint and'the imperfect manner in which it is usuallyrepaired. It may extend th'rouo-h the bone in any direction, transversely, obliquely, or verti- 1022 DISEASES OF THE BONES AND THEIR APPENDAGES. cally, the frequency of the occurrence being in the order here stated. When the fracture is comminuted, the fissures often exhibit the most irregular arrangement. Fig. 420. Fig. 421. Transverse fracture of the patella. Oblique fracture of the patella. Fig. 422. The causes of the accident are two,»external violence, and muscular action. The transverse, fracture is nearly always produced by the lat- ter, or by the joint agency of the two, while the oblique and vertical are invariably the result of direct injury, as a fall, blow, or kick. In the latter case, consequently,' there is frequently severe contusion, of the soft parts, and sometimes the knee- joint is even' laid open. The trans- verse fracture is produced by falls in wdiich the leg is strongly flexed upon the thigh, while the body is thrown suddenly and forcibly backwards, thereby putting the extensor muscles powerfully upon the stretch, the line of fracture usually taking place just abo've the middle of the bone. Jumping out of a carriage, and falling backwards upon the ground, is one of the nfost com-, mon ways in which the accident is occasioned. Circus-riders and ballet- dancers sometiraes break this bone in the act of leaping in the exercise of their profession. The symptoms of fracture of the patella are generally well marked. In the transverse form of the lesion, the nature of the accident is at once detectable by the change in the contour of the knee, by the inability to extend the limb, and by the displacement of the upper frag- ment, as seen in fig. 422. In many cases, the person is conscious, at the moment of the injury, of something having given way, and perhaps he may have even heard the peculiar characteristic snap. If he attempts to get up and walk, he will be almost sure to fall, from his inability to extend the leg and support the weight of the body upon it. The dis- placeraent is usually considerable, the superior fragment being drawn "Upwards upon the fore ftart of the thigh by the extensor muscles. The height to which it may be carried varies according to the extent of the destruction of the ligamentous connection of the tendon of these muscles. When the separation is com- plete, it may amount to two and a half, three, and even four inches, while under opposite circumstances it may not exceed six, eight, or ten lines. The distance between the two fragments is always increased b'y bending the leg. The front of the knee has a flattened appearance, and upon passing the finger over it its point will be found to sink down abruptly as it were into the joint. The lower fragment is stationary, but the upper is easily moved, and may, by thorough extension of the limb, be brought down into its normal situation, so as to enable us to detect crepitus. If some time has elapsed since the occurrence of the accident, cousiderable swelling may be present, obscuring somewhat the diagnosis. In respect to its mode of union, the transverse fracture of the patella holds the same relation as a similar injury of the- olecranon. In both cases the nutrition of the fragments is seriously impaired by the laceration of the ves- Fracture of the patella. FRACTURES OF THE PATELLA. 1023 Fig. 423. sels, and in both great difficulty is experienced in maintaining coaptation. Hence it is a law that the union' takes place by ligament and not by bone. In all the cases of this fracture that I have been able to examine, both in the living subject and in museums, I have not met with any in which the consolida- tion was completely osseous. A'few such cases, however, have been described by surgeons. In the inferior animals, it is not uncommon, if care be taken to keep the ends of the bone accurately in contact: When the interval be- tween the broken pieces is very considerable, as, for example, when it amounts to two inches, the union is established by the aponeurotic tissue which natu- rally covers the patella, and which, in this case, extends from one fragment to the other, the plastic matter which is poured out in consequence of the injury riot being capable of becoming organized and converted into ligamentous matter. Whatever may be the nature of the connecting medium, it is im- portant that it should be as close and perfect as possible; for it is found that the joint will always be weak and unprotected precisely in proportion to its length and thinness. The annexed cut, fig. 423, represents a sketch from a specimen of fracture of this bone in the cabinet of Pro- fessor Pancoast. It will be seen that the patella is broken into three pieces, the superior one being drawn up in front of the thigh, far away from the joint, and nearly four inches from the inferior, which consists of a mere little strip, hardly two lines in width, correspond- ing with the lower edge of the bone. No union followed, owing, doubtless, to bad management or neglect, and the consequence must have been a very imperfect use of the limb. The treatment of transverse fracture of the patella is attended with serious difficulty on account of the trouble experienced in controlling the action of the extensor muscles, whose tendency is constantly to draw the supe- rior fragment upwards away frora the lower. To coun- teract this tendency, therefore, constitutes the chief indication of the treatment. This can be effected only by maintaining the leg steadily and faithfully in a com- plete state of extension, the thigh being at the same time flexed upon the pelvis, and the body kept in -the semi-erect posture. In this manner, the extensor mus- cles are thoroughly and effectually relaxed. The most efficient contrivance for1 insuring this position of the limb is a strong, well padded tin case, long enough to reach from the middle of the thi'gh, to the corresponding point of the leg, a roller having previously been applied from the toes upwards, and another from the groin downwards. The superior fragment, having been brought into place, is next confined by numerous adhesive strips, carried around the bone above and below the joint,^ and connected afterwards by vertical and transverse pieces. The dressing is completed by the application of a long, thick, and rather narrow compress, extended around the upper border of the patella, and confined by the two rollers passed around the joint in the form of the figure 8. Managed in this way it is hardly possible for the fracture to suffer the slightest displacement, or to conceive of anything better calculated to fulfil the end in view. The tin case maintains the limb in the extended position, the adhesive strips and compress retain the upper fragment in contact with the lower, and the two rollers, applied in opposite directions, aid powerfully in controlling muscular C° When a suitable case cannot be procured, the object raay be attained by Old fracture of the pa- tella, showing the sepa- ration of the fragments. 1024 DISEASES OF THE BONES AND THEIR APPENDAGES. the use of a wooden splint, well padded, and stretched along the posterior part of the thigh and leg. The adjoining drawing, fig. 424, represents tfce mode of dressing transverse fractures of the patella, pursued by Professor Hamilton, and also, with slight modifications, at the Pennsylvania Hospital. Fig. 424. Apparatus for fracture of the patella. The plan is an excellent one, and seldom fails to effect a good Cure; often with hardly any interspace between the ends of the fragments. The letters require brief explanation : a is the bed ; b, floor of the splint; c, foot-piece, provided with holes and side-pins; d, inclined plane, constructed so that it raay be raised or lowered at pleasure ; e, cushion, thicker under the knee than at either, end ; /, roller, not completely applied, to secure the lirab to the inclined plane; g, adhesive strips,.laid over a compress, and crossed under the splint, those from above passing through a notch in the board behind the knee; h, h, ends of the compress. As anchylosis is one of the occurrences most to be dreaded after this fracture, passive motion should be employed as soon as there is reason to believe that the union is sufficiently advanced to admit, of it. This will usually be by the end of the third week. It should afterwards be repeated, at first every other day, and then every day, until all risk of this accident is passed. The limb must not be used for the ordinary purposes of progression for three or four months, experience having shown that, if it be exercised too early, the connecting bond will become gradually raore and more elongated, and thus materially interfere with the restoration of tfte functions of the joint. At'tbe expiration of four weeks, the tin case may be taken off, and a leather splint substituted, the patient walking about upon crutches. A portion of the patella may be broken off obliquely, and, Suffering no material displacement, may readily unite by bony matter, as any other frac- ture. A similar result generally follows when the fissure is vertical, with little or no separation of the fragments, the tendency to which is very slight, as the broken pieces are not influenced by muscular contraction. The prog- nosis is, therefore, other things being equal, always favorable, although, owing to the proximity of the knee-joint, a considerable period will usually elapse before there will be perfect restoration of the functions of the limb. The signs of these fractures are sometiraes very obscure, especially if there be much swelling of the soft parts. In general, however, the nature of the case may be determined by the impaired motion of the knee-joint, by the fixed character of the pain, and by making pressure upon the patella in oppo- site directions. The limb, having been enveloped in a bandage, should be kept at rest in FRACTURES OF THE SHAFT OF THE FEMUR. 1025 an elevated and extended position until there is a complete subsidence of in- flammation, when the starch dressing should be applied, the patient being permitted to move about upon crutches. . If the fracture be vertical, or nearly so, it will be necessary to support the fragments by means of two compresses, stretched along the lateral borders of the bone, and confined by adhesive strips and a roller. When the fissure is very oblique, the displacement may be such as to demand a course of treatment similar to that necessary in a transverse fracture. When the patella has once been broken transversely, it is exceedingly liable to a recurrence of ihe accident from comparatively slight muscular contrac- tion. The judicious practitioner should, therefore, always put the patient upon his guard in this respect. The fracture may occur at the same point, but generally it takes place a little higher up. Finally, when one patella has • been broken, the other is apt to suffer in the same manner, pwing to the im- perfect use of the affected limb, and the consequent liability of the patient to fall. FRACTURES OF THE FEMUR. Fractures of the femur deserve the most'attentive study; for not only are they of frequent occurrence but they present themselves under every possible variety of form, and there are no injuries of the kind which,-to use the lan- guage of Pott, " so often lame the patient and disgrace the surgeon."" Any portion of the bone-may give way, and hence it is customary, in treating of the subject, to speak of fractures of the shaft of the femur, of its condyles, and of its superior extremity, or of its neck, and of its trochanters. 1. FRACTURES OF THE SHAFT. The shaft of the femur may be broken in any portion of its extent, but there are three points which are particularly obnoxious to fractured These points are the upper fourth of the bone, the middle, and the inferior fourth, the relative frequency of the accident being in the order here stated, although it is generally asserted that the bone yields more frequently at or near its middle than anywhere else. This idea, however, accords neither with the results of my observations upon the living subject, nor with my examinations of specimens of fractured bones'in different collections. The relative differ- ence, however, is, no doubt, very, slight. A brief account of the lesion, as it occurs at these several points, will suffice to place the subject in a proper ' practical light, and serve to prevent those sad mistakes, often so disastrous both to the patient and the attendant. • Fractures of the Upper Fourth of the Shaft___The most common site of fracture of this portion of the bone is from two arid a half to three inches and a' half below the small trochanter; the line of fracture is almost always oblique, extending from behind forwards, and from above downwards, being frequently from an inch and a half to two inches in length. A transverse fracture here is an exceedingly rare occurrence. It is also very uncommon to see the bone give way just below the small trochanter, and it is worthy of note that, when it does break at this point, it is generally complicated in its character, or associated with extra-capsular fracture, properly so termed: The symptoms of fracture seated in this portion of the femur are generally so obvious as to indicate-at once the nature of the injury, the characteristic signs consisting of great shortening and angular deformity. The shortening varies from two to four inches, and usually exists in full force immediately after the receipt of the injury. The superior portion of the limb is remark- ably distorted, being convex on its external surface, with a corresponding vol. T.—65 1026 DISEASES OF THE BONES AND THEIR APPENDAGES. concavity internally, occasioned By the overlapping of the ends of the broken bone, the upper nearly always lying in front of the lower,-and both being usually directed somewhat outwards. In *ten specimens of fracture of the upper fourth of the shaft of the femur, now before me, I find that in all, ex- cept one, the upper fragment is in front of the lower, the reverse being the case in the other. In these ten specimens the superior piece is drawn for- wards and outwards in six; in two it is tilted upwards and inwards; and in two it is raised up and in a straight line with the lower, or without any lateral deviation whatever. The distance of the fracture from the small trochanter ranges from two inches and two-thirds to three inches and a quarter. Iu the six specimens in which the superior fragment is directed forwards and outwards, the. lower fragment is also inclined outwards in four, the junction between them being such as to give the bone more or less of an arched appearanpe, the convexity being external and the concavity internal. ■ In the two specimens in which the upper end is directed forwards and in- wards, the lower end, in one, is inclined inwards also, and in the other jt is straight, or in a line with the superio'r fragment. In seven of the eight spe- cimens in which the displacement is lateral, the inferior, fragment is more or less strongly everted, and, consequently, the knee and foot, during life, must have been in the same position. The fractures, so far as can be determined, were all oblique, the line of disjunction, in nine, extending from behind forwards, and from above downT wards, one only being in the opposite direction, and in this the lower frag- ment lies in front of the upper, overlapping it four inches. The distance at which the ends of the bone are separated anteriorly, varies from half'an inch to an inch and three-quarters. The angle which the -superior fragment forms with the inferior, does not, in any of the ten specimens, exceed 45°, while in most it falls considerably short of this. I have been thus particular in giving the results of these examinations, on accoqnt of their practical bearing upon fractures of the superior extremity of the shaft of this bone. Sir Astley Cooper, and those who have adopted his views, have evidently formed very erroneous ideas, not only as regards the extent and direction of the displaceraent of the upper fragment, but also of its causes. Thus it has been asserted that" the upper end often overlaps the other almost at a right angle, which is-not the case in any of the specimens that I have examined ; on the other hand, it has been alleged that the two pieces are usually inclined outwards, which the specimens alluded to also dis- prove, there being no lateral deviation whatever in two, while in two others the projection was inward, leaving thus only six cases of outward displace- ment. The displacement forwards of the upper end is due to the joint action of the psoas and iliac muscles, assisted perhaps by the pectineal and the short head of the adductor, while it is dragged outwards mainly by the agency of the external rotators. The lower fragment,, on the contrary, is drawn up by the action of the flexor muscles of the thigh, and outwards by the tensor, vastus, and gluteal muscles. That the direction of the fracture materially influences the direction of the displacement is shown by the fact that in the only specimen out of the ten examined by me in which the line of fracture extended from before backwards, and from below upwards, the lower frag- ment overlapped the upper, and that to a great extent. Although the specimens here described are, I conceive, of great patholo- gical and practical value, yet it must not be forgotten that any inferences deducible from their examination are impaired, in *ome degree, by the fact that the displacement which characterizes them may have been* influenced more or less by the nature* of the treatment. Thus,*in consequence of the use of splints, the ends of the fragments, originally inclined inwards or out- wasds, may have been pushed and held in the opposite direction, thereby FRACTURES OF THE SHAFT OF THE FEMUR. 1027 completely reversing the primitive order of the deformity, as caused by the direction of the fracture, the weight of the limb, and the action of the muscles. The annexed drawings, two of which are from my own preparations, will serve to illustrate the nature o& the displacement so often met with in frac- tures of the superior portion of the shaft of the femur. • Fig. 425. Fig. 426. Fig. 427. Fracture of the shaft of the femur ; upper portion. • Fractures at the Middle of the Shaft.—A fracture at the centre of the shaft of the femur is, according to my observation, an uncommon occurrence; most generally the bone gives way some distance above or below this point. -The line of fracture Is, for the most part, very oblique, extending from behind for- wards and from above downwards, and the consequence is'that the superior fragment nearly always overlaps the inferior, the upper extremity of which is drawn backwards, aud usually, also, somewhat outwards, by the action of the flexor muscles, causing thus an amount of shortening of from two and a half to three and even four inches, with more or less angularity at the site of in- jury, and marked eversiou of the limb. Thejower end qf the superior frag- ment, on the contrary, forms a prominent projection on the fore part of the thigh, easily perceived by sight and touch. The symptoms are of course ens Pfiotpristic A perfectly horizontal fracture of the jshafj; ofj the femur is an extremely uncommon occurrence ; so much so that, although the phenomena might be such as to lead to the suspicion of its existence, the idea that it really is an injury of that kind should not be carried out in practice, lest, the requisite extension and counter-extension being omitted, permanent shortening should follow When there is no marked tendency to displacement, it will generally be found that the fracture, instead of being transverse, is slightly impacted, or that its extremities, being denticulated, are interlocked with 'each other, 1028 DISEASES OF.THE BONES AND THEIR APPENDAGES. and thus held in place. Corarainuted fracture of this portion of the shaft is not uncommon, especially in old subjects, laboring under fragility of the osseous tissue. The accident mayjae the result of'direct violence, as a kick or the passage of the wheel of a carriage, in which case it is often of a compound or com- plicated character; or it may be occasioned indirectly by a fall upon the foot or knee. Fractures of the Inferior Fourth of the Shaft.—Fracture of the«inferior portion of the shaft of this bone derives a special interest from the fact that, when occurring very low down, the inferior end of the upper fragment may, especially if it be very long and sharp, penetrate the joint, and thns*seriously complicate a case otherwise easy of management. The fracture, moreover, is liable to be compound, the upper piece piercing the muscles and integu- ments just above the knee. As in fracture of the other divisions of the shaft, already described, so in this the line of the solution of continuity generally ranges from behind forwards and from above downwards, a transverse fracture, properly so termed, being extremely uncomraon. The degree of obliquity is variable, but generally it is so considerable as to cause great * shortening of the lirab and angularity of the. part; which, together with the everted state of the knee and foot, are characteristic sfgns of the accident. The inferior fragment is always drawn ba'ckwards and upwards, its superior extremity forming a distinct prominence in the popliteal region, which can easily be effaced by restoring the pieces to their "natural position. When the fracture occupies the lower extremity of the shaft, nearly on a level with the joint, the upper fragment may descend so far'down as to push the patella away from the trochlea of the femur, over.upon the tibia, so as to create an appearance simulative of partial luxation of this little bone. If several hours have elapsed since the receipt of the injury, the diagnosis is soraetimes ob- scured by the tumefaction of the joint; but, in general, whatever may be the condition of the parts, any existing doubt may be cleared up by a thorough examination of the limb./ The relative position of the fragments in this fracture are well depicted in fig. 428, from a specimen in my cabinet. Fig. 428. Fracture of the thigh. The causes of fracture in this situation are commonly of a direct nature, a greater amount of force seeming to be necessary to produce it than when it is situated higher up. It may, however, be induced in an indirect manner, as when a person, f-alling from'a* considerable height, alights upon his foot or knee, the violence of the shock being concentrated upon the inferior portion of the femur. Treatment.—The treatraent of fractures of the shaft of the thigh-bone may FRACTURES OF THE, SHAFT OF THE FEMUR. 1029 be conducted according to several plans, of which that by extension .and count.er-extension, the limb being in the straight position, is, as a general- rule, the most eligible, fulfilling, as it does, more effectually than any other, the different indications presented by this class of injuries. Before any steps, however, are taken to adjust the broken pieces, it is the duty of the attend- ant to see that a suitable bed is procured for the comfortable accommodation of his patient, as well as for the secure management of the case. This sub- ject having already been discussed in a previous part of the work, it will, therefore, be sufficient for my present purpose, if I merely allude to it here, with the hope of enforcing its importance upon the mind of the reader. I am so thoroughly convinced of the utter impossibility of treating fractures of the femur successfully without a good bed, that I should consider any sur- geon justifiable in declining to undertake the management of any case unless his efforts were properly seconded in this respe.ct. There must be no com- promise upon the subject; for, if the cure turn out badly, no allowance will* be made by the patient and his friends for any deficiencies, short-coming, or want of co-operation on their part. The whole blame falls'upon the'profes- sional attendant, it being very properly assumed that he ought to know bet- ter than any one else what the emergency demands, and that he should, therefore, spare no pains to meet it. Every fracture-bed should have slats, a good, firm, but elastic mattress, and arrangements for the evacuation of the bowels, so that the patient may not be compelled to rise when he wishes to relieve Bimsdf. These essentials are all admirably combined in the ingeni- ous contrivances of Dr. B. H. Coates, Dr. Addinell Hewson, and others, which my limits, however, will not permit me to describe. When Jj|oth thighs are broken, or even when only one is affected, Jenks's fracture-bed, represented in fig. 429, will be found extremely convenient, both • ■ Fig. 429. Jenks's fracture-bed. for evacuating the bowels and for- making, up the bed.- It is thus described ^'It'is composed of two upright posts about six feet high, supported each by a pedestal;' of two horizontal bars, at the top, somewhat longer .than a 1030 DISEASES OF THE BONES AND THEIR'APPENDAGES. common bedstead; of a windlass of the same length placed six inches below the upper bar; of a cog-wheel and handle; of linen belts, frotn six to Uvdve inches wide; of straps secured at one end of the windlass, and at the other having hooks attached to corresponding eyes in the linen belts; of a head- piece made of netting; of a piece of sheet-iron twelve inches long, and hol- lowed out to fit and surround the thigh; pf a bed-pan, box, and cushion to support it, and of some other minor parts." For the purpose of securing quietude of the limb, and accuracy of appcfc sition of the ends of the fragments, numerous contrivances have been de- vised, all possessing, apparently, more or less merit, and yet not one of them so perfect as to be wholly unexceptionable. A bare description and delinea- tion of all the fracture apparatus now before the profession would form a stately volume. The surgical cabinets of some of our medical schools con- tain cart-loads of such material, most of it as effete as the contents of a ■curiosity-shop. Much of this apparatus has been patented, and extensively distributed by the inventors. The character of most of it is familiar to me, and Itlo not hesitate to declare that a large proportion of it is most villain- ous. The great and fundamental principles which every contrivance of the kind must necessarily possess is enjoyed by all, though in different degrees of perfection, and it cannot be doubted that the constant multiplication of such machinery, and the implicit confidence reposed iri it by the younger members of the profession, have been a prolific source of the many disastrous results, that have so frequently, especially of late years, attended tlte treat- ment of fractures of the thigh. I have long been satisfied that the more simple the apparatus is, the more easily is it managed, and the more likely to prove efficient. Writh a proper knowledge of what is needed, aiid a little ingenuity on the part ©f the surgeon, the requisite m^ans for the successful management of almost any case of fracture of the femur, however bad, may generally be provided upon the'spur of the occasion, or, at all events, within a reasonable time after the occurrence of the injury. In children, I have usually found the most convenient and suitable appa-. ratus to be a case made of stout, unoiled sole-leather, long enough to ex- tend from the groin to an inch and a half below the heel, and sufficiently wide to come well round the limb, especially the thigh. It is supplied with a foot-piece of the same material, and is well padded at its upper extremity, to prevent undue pressure upon the perineum. The outside portion of the trough is continued for some' distance over the hip, to which it is secured by. a spica, or common roller, carried round the thighs and pelvis. A splint, also of leather, or of binder's board, gutta-percha, or thin wood, is stretched along the forepart of the limb from the groin to the patella, wadding being suitably interposed to ward off pressure ; the apparatus is held in place by means of an ordinary bandage, adhesive strips having been previously secured to the leg and attached to the foot-piece. The dressing is completed by placing the limb, with its apparatus, in an easy position upon-a hair or cotton bolster, gradually tapering upwards, its thickness below not exceeding four inches. By this simple contrivance I have always found it easy to obtain the requisite extension and counter-extension, the perineum affording a point d'appui which effectually prevents the ascent of the apparatus, while the foot-piece serves to keep the foot in place, at the same time that it receives the extending bands. In fractures of the thigh-bone in adults, a more substantial apparatus is usually necessary, as there is generally a greater tendency to muscular con- traction and displacement of the fragments. The apparatus which is usually employed in this country is that .of. Desault, as modified and improved by Physick, consisting of one long splint, fig. 430, extending from below the sole of the foot to the axilla, and of a short one extending frora the same point to the perineum. They are connected below by a transverse bar, for FRACTURES OF THE S«HAFT'OF THE FEMUR. 1031 receiving the extending bands, and along the leg and thigh by strips of band- age. The counter-extension is effected by a suitable thigh belt, the ends of • • which are passed through-the mortise holes near the upper end Fig. 430. of the splint. The apparatus is, however, an awkward one, constantly subject to derangement, and the results obtained by its aid are by no means so .gratifying -as they should be. It has al- ways been found extremely unsatisfactory in my practice, and hence I have, for many years, never employed it in a single case, having given the preference to the fracture-box, represented in fig. 431. This box, which I used, for the first time, upwards of twenty • ' Fig. 431. The author's fracture apparatus. years ago, extends from the tuberosity of the ischium to a level with the Sole of the foot, which rests against the vertical piece, provided with two slit-like'holes for the passage of the extending bands. The posterior surface of the box is hollowed out for the more easy accommodation of the thigh and leg, while the side- pieces, fastened by hinges to the horizontal one, project so as to come to a level with the surface of the limb in front. To the out- side of the box is secured a movable splint, about two inches in width, crutch-shaped and well padded above, and-long enough to reach intothe axilla, while another, similarly arranged and con- structed, is attached to the inside, being intended to press against the perineum. The whole apparatus is made as light as possible, and any intervals that may exist between it and the limb, after it has been properly adjusted, may be filled with cotton, tow, or, what is preferable, especially in compound fractures, with wheat' bran, the latter answering an admirable purpose, under such circumstances, not only affording an agreeable protection to the broken bone, but absorbing the discharges and preventing the development of mag- gots, which are so liable to form in such cases in hot weather. Ip changing the dressings, all that is necessary is to let down the sides of the box, the extension being kept up, if necessary, in the meantime, by an assistant having hold of the foot. A broad leather splint, or one of binder's board, extending from the groin to the knee, should cover the thigh in front; it should be accurately moulded to the parts, and be firmly secured in its place by means of pieces of tape en- circling the box. "instead of the fracture-box now described, use may be made of two splints, one of binder's board and the other of wood, the former, which is intended for the inside of the thigh, reaching from the groin to the knee, while the other, placed along the outside of the limb, extends as high up, on the one. hand' as the crest of the ilium, and, on the other, as low down as four inches. below the level of the sole of the foot. These splints being well padded, are secured with an ordinary roller, the adhesive strips being attached to the inferior extremity of'the long one, in order to keep up the requisite degree of extension. Physick's long splint. 1032 DISEASES OF THE B*0NES4AND THEIR APPENDAGES. 432. Within the last few years adhesive plaster has been much employed in this city, both for maintaining extension and counter-extension in fractures of the thigh, chiefly through the influence and writings of Dr. Gilbert and Dr. Neill. The practice, which is rapidly coming into general vogue, is unquestionably, as stated elsewhere, a great improvement upon the ordinary means here- tofore in' use, as it not only tends to pre- serve better and closer union of the ends of the fragments, but, what is a matter of great moment to the patient, prevents the pain, chafing, and ulceration, which so fre- quently attend the old methods, The treat- ment is equally serviceable in simple and compound oblique fractures of the lower ex- tremity. • \ In a remarkable case of compound frac- ture of both thigh-bones, in. a boy eleven years of age, recently under the care of Dr. Gilbert, a most excellent cure was effected by means of adhesive plaster, aided by the apparatus, represented in fig. 432; the dressings being removed on the forty-fifth day. A long splint, it will be perceived, was stretched along the outside of each limb, from a few inches below the sole of the foot to within a short distance of the axilla ; the extending strips, tied under the sole of the foot,.and secured to a horizon- tal block, were controlled by a tourniquet; while the counter-extending strips were car- ried along the pelvis, both in front and be- hind, and firmly fastened by transverse barids passed round the hip-bones, the back, and abdomen. A valuable addition to the long splint, affording increased means for making coun- in 1860, by Dr. H. Lenox Hodge, of this seen by a reference to figs. 433 and 434, of a bar of wrought iron, secured to the outer and upper part of the splint by bolts with movable nuts, and bent to the right or left, id accordance with the side to which it is applied. The splint should be suffi- ciently wide above to per- mit the rod, which termi- nates in a horizontal hook, about 6ix inches in length, to pass clear of the patient's arm and shoulder. A long strip*of adhesive plaster, Dr. Hodge's method of counter-extension in fracture of the femur. at least tVV'O inches and a Dr. Gilbert's fracture apparatus. ter-extension, was suggested, city. It consists, as will be "FRACTURES OF THE SHAFT OF THE FEMUR. 1033 Bar of wrought iron for counter-extension. half in breadth, is extended Fig. 434. along the front of the body from the pelvis to the top r._- of the shoulder, and thence down the back to the but- tock, leaving, as it crosses the shoulder, a short loop, in which is placed a small block of wood, which is fastened by means of a tape to the hook of the bar. To prevent the long strip frora becoming detached, the body is completely facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch of medical science. The very extensive arrangements of the publishers are such as to aflord to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti- nent, thus enabling him to present in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part of the civilized world. To their old subscribers, many of whom have been on their list for twenty or thirty years, the publishers feel that no promises for the future are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in the high position which it has occupied for so long a period. By reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance, becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information of the day, while the "Library Department" is devoted to presenting stand- ard works on various branches of medicine. Within a few years, subxribers have thus received, without expense, many works of the highest character and practical value, such as " Watson's Practice," "Todd and Bowman's Physiology," " Malgaigne's Surgery," "West on Children," " West on Females, Part I.," "Habershon on the Alimentary Canal," &c. While the work at present appearing in its columns is CLINICAL LECTURES ON THE DISEASES OF WOMEN. By Professor J. Y. SIMPSON, of Edinburgh. WITH NUMEROUS HANDSOME ILLUSTRATIONS. These Lectures, published in England under the supervision of the Author, carry with them all the weight of his wide experience and distinguished reputation. Their eminently practical nature, and the importance of the subject treated, cannot fail to render them in the highest degree sutis- faciory to subscribers, who can thus secure them without cost. These Lectures are continued in the " News" for 1862. It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING NEARLY SIXTEEN HUNDRED LARGE OCTAVO PAGES, Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entitle them to the Journal only, without the News, and that they will be at the expense ol their own postage on the receipt of each number. The advantage of a remittance when order- ing the Journal will thus be apparent. Remittances of subscription can be mailed at our risk, when a certificate is taken from the Post- master thai the money is duly inclosed and forwarded. Address BLANCHARD & LEA, Philadelphia . AND SCIENTIFIC PUBLICATIONS. 3 ASHTON (T. J.), Surgeon to the Blenheim Dispensary, &c. ON THE DISEASES, INJURIES, AXD MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. From the third and enlarged London edition With handsome illustrations. In one very beautifully printed octavo volume, of about 300 pages. (Just Issued.) fri 00. The most complete one we possess on the subject. Medico-Chirurgical Review. We are satisfied, after a careful examination of the volume, and a comparison of its contents with those of its leading predecessors and contemporaries, that the best way for the reader to avail Himself of the excellent advice given in the concluding para- graph above, would be to provide himself with a c >py of the book from which it has been taken, and diligently to con its instructive pages Ttiej, may secure to him many a triumph and fervent blessing.— Am. Journal Med. Sciences. ALLEN (J. M.), M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. THE PRACTICAL ANATOMIST; or, The Student's Guide iu the Dissecting- ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, lea- ther. $2 25. We believe it to be one of the most useful works anon the subject ever written. It is handsomely illustrated, well printed, and will be found of con- venient size for use in the dissecting-room.—Med. Examiner. However valuable may be the "Dissector's 6uides" which we, of late, have had occasion to notice, we feel confident that the work of Dr. Allen is superior to any ol them. We believe with the author, that none is so fully illustrated as this, and Che arrangement of the work is such as to facilitate the labors of the student. We most cordiiily re- commend it to their attention.— Western Lancet. ANATOMICAL. ATLAS. By Professors H. H. Smith and W. E. Horner of the University of Pennsyl- vania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. E5F* See Smith, p. 331. ABEL (F. A.), F. C. S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 pages, with illustrations. $3 25. ASHWELL (SAMUEL), M.D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. The most useful practical work on the subject in I The most able, and certainly the most standard the English language. — Boston Med. and Surg, and practical, work on female diseases that we havo Journal. | yet seen.—Medico-Chirurgical Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50. _________________ BIRD (GOLDING), A. M., M. D., Sec. URINARY DEPOSITS : THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American, from the fifth and enlarged London edition. With eighty illustrations on wood. In one handsome octavo volume, of ajout 400 pages, extra cloth. $2 00. (Just Issued.) The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to other hands, and in his performance of the duty thus devolving on him, Dr. Birkett nas sedulously endeavored to carry out the author's plan by introducing such new matter and modifications of the text as the progress of science has called for. Notwithstanding the utmost care to keep the work within a reasonable compass, these additions have resulted in a considerable enlargement. It is therefore hoped that it will be found fully up to the present condition of the subject, and that the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- r iisn »nrl nn the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken mr or associated With, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts. pp. 130. $1 25. BARLOW (GEORGE H.), M. D. Physician to Guy's Hospital, London, See. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. A, ,A" rvi n author of "A Practical Treatise on Diseases of Children, "&c. In one hand- fomeTuvo^me11, leather, of over 600 pages. $2 75 -i r»r Barlow'sManualin the warm- I found it clear, eoncise, practical, and sound.-«2?M. WerecommendDr. »»ra[uab,e vade.mecum. We ton Med. and Surg. Journal. Sa'veTd'frequent occasion to consult it, and have | 4 BLANCHARD & LEA'S MEDICAL BUDD (GEORGE). M. D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 500. $3 00. Has fairly established for itself a place among the i is not perceptibly changed, the history of liver dis- classical medical literature of England.—British eases is made more complete, and is kept upon a level and Foreign Medieo-Chir. Review. with the progress of modern science. It is the best Dr. Budd's Treatise on Diseases of the Liver is work on Diseases of the Liver in any language.— now a standard work in Medical literature, and dur- London Med. Tunes and (razette. ing the intervals which have elapsed between the This work, now the standard book of reference on successive editions, the author has incorporated into the diseases of which it treats, has been carefully the text the most striking novelties which have cha- I revised, and many new illustrations of the views of racterized the recent progress of hepatic physiology the learned author added in the present edition.— and pathology; so thatalthough the Bize of the book I Dublin Quarterly Journal. BY THE SAME AUTHOR. ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $1 50. BUCKNILLU. C), M.D., and DAN I EL H . TU KE, M. D., Medical Superintendent of the Devon Lunatic Asylum. Visiting Medical Officer to tbe York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With a Plate. In one handsome octavo volume, of 536 pages. $3 00. The increase of mental disease in its various forms, and the difficult questions to which it is constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of the physician a constantly greater familiarity with this, the most perplexing branch of his profes- sion. At the same time there has been for some years no work accessible in this country, present- ing the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane. To fill this vacancy the publishers present this volume, assured that the distinguished reputation and experience of the authors will entitle it at once to the confidence of both student and practitioner. Its scope may be gathered from the declaration of the authors that "their aim has been to supply a text book which may serve as a guide in the acquisition ol such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently modern in its views and explicit in its teaching to suffice for the demands of the practitioner." BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which is added, a Review of the present state of Uterine Pathology. Fifth American, from the third English edition. In one octavo volume, of about 500 pages, extra cloth. $2 00. BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, Ac. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- WENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $160. Mr. Brown has earned for himself a high reputa-j and merit the careful attention of every surgeon" tion in the operative treatment of sundry diseases j accoucheur.—Association Journal. and injuries to which females are peculiarly subject. ,„ , ..,-,.». We can truly say of his work that it is an important | ** e have no hesitation in recommending this bo< k ~aa:^~, »« V>W»tri»>il lit.-.r»turn. The nnnrative I to t.ie careful attention of all surgeons who make addition to obstetrical literature. The operative subsections and contrivances which Mr. Brown de- I iemaie compwints a p; ,cnbe«, exhibit much practical sagacity and skill, | —Dubttn Quarterly J female comjilunts a partof their study and practice. 'ournal. BOWMAN (JOHN E.), M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY Second Ame- ncaa,froan the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp. 288. $125. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- L5f~SIS. Second American, from the second and revised London edition. Withnumerousillus- tratiotis. In oae neat vol., royal 12mo., extra cloth, pp.350. $125. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal limo., extra cloth, pp. 296. B0 cents. BUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp. 234. SO cents. BUCKLER ON THE ETIOLOGY, PATHOLOGY > AND TREATMENT OF FIBRO-BKONCHI- TIS AND RHEUMATIC PNEUMONIA. In one 8vo. volume, extra cloth, pp. ISO. $1 25. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp.460. $1 26. BRODIE'S CLINICAL LECTURES ON SUR- GERY. 1 vol. 8vo. cloth. 350pp. SI 25. AND SCIENTIFIC PUBLICATIONS. 5 BUMSTEAD (FREEMAN J.) M. D., Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. With illustrations on wood. In one very handsome octavo volume, of nearly 700 pages, extra cloth ; $3 75. (Now Ready.) By far the most valuable contribution to this par- ticular branch of practice that has seen the light within the lasc score of years. His clear and accu- rate descriptions of the various forms of venereal disease, and especially the methods of treatment he proposes, are worthy of the highest encomium. In these respects it is better adapted for the assistance of the every-day practitioner than any other with which we are acquainted. In variety of methods proposed, in minuteness of direction, guided by care- ful discrimination of varying forms and complica- tions, we write down the book as unsurpassed. It is a work which should be in the possession of every practitioner.—Chicago Med. Journal. Nov. 1861. Tne foregoing admirable volume comes to us, em- bracing the whole subject of syphilology, resolving many a doubt, correcting and confirming many an entertained opinion, and in our estimation the best, completest, fullest monograph on this subject in our language. As far as the author's labors themselves are concerned, we feel it u duty to say that he has not only exhausted his subject, but he has presented to as, without the slightest hyperbole, the best di- gested treatise on these diseases in our language He has carried its literature down to the prestnt moment, and has achieved his task in a manner which cannot but redound to his credit.—British American Journal, Oct. 1861. We believe this treatise will come to be regarded as high authority in this branch of medical practice, and we cordially commend it to the favorable notice of our brethren in the profession. For our own part, we candidly confess that we have received n.uny new ideas from its perusal, as well as modified many views which we have long, and, as we now thins. erroneously entertained on the subject of syphilis. To sum up all in a few words, this book is one which no practising physician or medical student can very well afford to do without.—American Med. Times, Nov. 2, 1861. The whole work presents a complete history of venereal diseases, comprising much interesting and valuable material that has been spread through med- ical journals within the last twenty years—the pe- riod of many experiments and investigations on the subject—the wh»le carefully digested by the aid of the author's extensive personal experience, and offered to the profession in an admirable form. Its completeness is secured by good plates, which are especially full in the anatomy of the genital organs. We have examined it with great satisfaction, and congratulate the medical profession in America on the nationality of a work that may fairly be called original.—Berkshire Med. Journal, Dec. 1861. One thing, however, we are impelled to say, that we have met with no other book on syphilis, in the English language, which gave so full, clear, and impartial views of the important subjects on which it treats. We cannot, however, refrain from ex- pressing our satisfaction with the full and perspicu- ous muuner in which the subject has been presented, and the careful attention to minute details, so use- ful—not tosay indispensable—in a practical treatise. In conclusion, if we may be pardoned the use of a phrase now become stereotyped, but which we here employ in all seriousness and sincerity, we do not hesitate to express the opinion that Dr. Bumstead's Treatise on Venereal Diseases is a " work without which no medical library will hereafter be consi- dered complete."—Boston Med. and Surg. Journal, Sept. 5, 1861. BARCLAY (A. W.), M. D., Assistant Physician to St. George's Hospital, &c. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Second American from the second and revised London edition. In one neat octavo volume, extra cloth, of 451 pages. $2 25. (Now ready.) The demand for a second edition of this work shows that the vacancy which it attempts to sup- ply has been recognized by the profession, and that the efforts of the author to meet the want have been successful. The revision which it has enjoyed will render it belter adapted than before to afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For this latter purpose its complete and extensive Index renders it especially valuable, offering facilities for immediately turning to any class of symptoms, or any variety of disease. The task of composing such a work is neither an easy nor a light one; but Dr. Barclay has performed it in a manner which meets our most unqualified approbation. He is no mere theorist; he knows hia work thoroughly, and in attempting to perform it, has not exceeded his powers.—British Med. Journal. We venture to predict that the work will be de- servedly popular, and soon become, like Watson's Practice, an indispensable necessity to the practi- tioner.— N. A. Med. Journal. An inestimable work of reference for the young practitioner and student.—Nashville Med. Journal. We hope the volume will have an extensive cir- culation, not among students of medreine only, but practitioners also. They will never regret a faith- ful study of its pages.—Cincinnati Lancet. An important acquisition to medical literiture. It is a work of high merit, both from the vast im- por since of the subject upon which it treats, and also from the real ability displayed in •** elabora- tion. In conclusion, let us bespeak for this volume that attention of every student of our art which it bo richly deserves - that place in every medical library which it can so well adorn.- -Peninsular medical Journal. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS nw THF UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof. «f Pat holo^v and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one oifavo^olume, of six huttdred pages, extra cloth. Price $3 00. It is a work of great practical value and interest. i^nT much fhat is new re alive to the severa containing rmich that =";"d the addition, diseases of which ttrea« , Thedistinct- of the edltor''8t;"dl1ttnt forms of fever are plainly ivefeaturei, of^the different« ^^ ^ dema^cation and f«rf lb|y P^umtely drawn, and to the Ameri- carefully and accurately ^leand ^ LVanywo?" on fever extant.-OAio Med. and ^This'Tce"^^ monograph on febrile disease, has stood deservedly high since its first publication. It will be seen that it has now reached its fourth edi- tion under the supervision of Prof. A. Clark, a gen- tleman who, from the nature of his studies and pur- suits, is well calculated to appreciate and discuss the many intricate and difficult questions in patho- logy. His annotations add much to the interest of the work, and have brought it well up to the condi- tion of the science as it exists at the present day in regard to this class of diseases.—Southern Med. and Surg. Journal. 6 BLANCHARD & LEA'S MEDICAL BARWELL (RICHARD,) F« R. C. S., Assistant Surgeon Charing Cross Hospital, A.c. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- ingrs on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $5 00. (Now Ready.) "A treatise on Diseases of the Joints equal to, or rather beyond the current knowledge of the day, has long been required—my professional brethren must judge whether the ensuing pages may supply the deficiency No author is fit to estimate his own work at the moment of its completion, but it may be permitted me to say that the study of joint diseases has very much occupied my atten- tion, even from my studentship, and that for the last six or eight years my devotion to that subject ha» been almost unremitting.....The real weight of my work has been at the bedside, and the greatest labor devoted to interpreting symptoms and remedying their cause."—Author's Preface. At the outset we may state that the work is ' to be of much use to the practising surgeon who worthy of much praise, und bears evidence of much may be in want of a treatise on diseases of the joints, thoughtful und careful inquiry, and here and there and at the same time one which contains the latest of no slight originality. We have already carried information on articular affections and the opera- tnis notice further than we intended to do, but not' tions for their cure.—Dublin Med. Press, Feb. 27, to the extent the work deserves. We can only add, 1861. that the perusal of it has afforded us great pleasure. Tnig voiume will be welcomed, both by the pa- The author has evidently worked very hard at his thoiogi8t and the 8urgeon, as being the record of subject, and his invest.gations into the Physiology „,„,.„ nonegt reBearch |nd c^reful investigation into and Pathology of Joints have been carried on in a | the nature and treatment of a most important class manner which entitles him to be listened to with , of di80rder,. We cannot conclude this notice of a attention and respect We must not omit to men- vaiuable and U3tful book without calling attention ion the very admirable plates with which the vo- . t0 the nraount of bonlfide work it contains. In the lume is enriched We se dom meet with such strik- resent d of uni„er8a, book-making, it is no slight i?//^ faithful delineat^ns of distase.-Lontfo* >tter fo/a volume to show labor?ou8 invelltjga. Med. Times and Gazette, Feb. 9, 1861. tioU) and at the same time original thougnt, on the We cannot take leave, however, of Mr. Barwell, | part of its author, whom we miiv congratulate on without congratulating him on the interesting tne successful completion of his arduous task.— amount of information which he hus compressed j London Lancet, March 9, 1861. into his book. The work appears to us calculated I CARPENTER (WILLIAM BJ, M. D., F. R. S., fcc, Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. In the preparation of this new edition, the author has spared no labor to render it, as heretofore, a complete and lucid exposition of the most advanced condition of its important subject. The amount of the additions required to effect this object thoroughly, joined to the former large size of the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate them in his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- siology of Man, the work in its present condition therefore presents even greater claims upon the student and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's) To eulogize thisgreat work would be superfluous. work has been considered by the profession gene- We should observe, however, that in this edition rally, both in this country and England, as the most the author has remodelled a large portion of the valuable compendium on the subject of physiology former, and the editor has added much matter of in- in our language. This distinction it owes to the high , terest, especially in the form of illustrations. We attainments and unwearied industry of its accom- I may confidently recommend it as the most complete plished author. The present edition (which,like the work on Human Physiology in our language — last American one, was prepared by the author him- Southern Med. and Surg. Journal. self), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Phy- siology. Nothing need be said in its praise, for its merits are universally known j we have nothing to say of iU defects, for they only appear where the science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. The greatest, the moat reliable, and the best book on the subject which we know of in the English language.—Stethoscope. The most complete work on the science in our language.—Am. Med. Journal. The most complete work now extant in our lan- guage.—JV. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —N. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of itsappearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Journ AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taining the Applications of the Microscope to Clinical Medicine, dec. By F. G. Smith, M. D. Illustrated by tour hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. Dr. Carpenter's position as a mtcroscopist and physiologist, and his great experience as a teacher, eminently qualify him to produce what has long been wanted—a good text-book on the practical use of the microscope. In the present volume his object has been, as stated in his Preface, " to combine, within a moderate compass, that information with regard to the use of his 'tools,' which is most essential to the working microscopist, with such an account of the objects best fitted for his study, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microsco- pists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is hoped, will adapt the volume more particularly to the use of the American student. Those who are acquainted with Dr. Carpenter's ' medical work, the additions by Prof. Smith give it frevious writings on Animal and Vegetable Physio- a positive claim upon the profession, for which we Dgy, willfully understand how vast a store of know- | doubt not he will receive their sincere thanks. In- ledge he is able to bring to bear upon so comprehen- | deed, we know not where the student of medicine sive a subject as the revelations of the microscope; will find such a complete and satisfactory collection and even those who have no previous acquaintance of microscopic facte bearing upon physiology and with the construction or uses of this instrument, ' practical medicine as is contained in Prof. Smith's will find abundance of information conveyed in clear appendix; and this of itself, it seems to us, is fully and simple language.—Med. Times and Gazette, worth the cost of the volume.—Louisville Medical Although originally not intended as a strictly [ R«""«' BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word "Elements" for that of " Manual," and with the author's sanction the title of "Elements" is still retained as being more expressive of the scope of the treatise. To say thai it is the best manual of Physiology | Those who have occasion for an elementary trea- now before the public, would not do sufficient justice i tise on Physiology, cannot do better than to possess to the author .—Buffalo Medical Journal. I themselves of the manual of Dr. Carpenter .—Medical In his former works it would seem that he had I Examiner. exhausted the subjectof Physiology. In the present,! The best and most complete expose of modern he gives theessence, as it were, ofthe whole.—N. Y.\ Physiology, m one volume, extant in the English Journal of Medicine. I language.—St. Louis Medical Journal. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80; leather, raised bands, $5 25. This book should not only be read but thoroughly i no man, we believe, could have brought to so suc- studied bv every member of the profession. None cessful an issue as Dr. Carpenter, ft required for are too wise o7old, to be benefited thereby. But its production a physiologist at once deeply read in Mnec^Uv to the younger class would we cordially I the labors of others capable of taking a general command it as best & of any work in the English critical, and unprejudiced view of those labors and commend it asDesi mira oi a.i> { d g of combining the varied, heterogeneoub materials at l^H?J?M£^mZMfh^m**i*t de- his disposal, so as to form an5harmoCious whole. prehension of ^f^"1™ X£?Co«»*eiilor. We feel that this abstractcan give the reader a very veloped in physiology —Medical Counsellor. imperfect idea of the fulness of this work, and no Without pretending to it, it is an encyc,op®°laa_ i Idea of its unity, of the admirable manner in which the subject, accurate and complete in all resP~V? . material has been brought, from the most various a truthful reflection of the advanced state ai wjuyi | gource8j t0 conduce to its completeness, of the lucid- the science has now arrived.—Dublin yuaneny i . of the reagoning jt contains, or of the clearness Journal of Medical Science. of language in which the whole is clothed. Not the a trnlvmairnificentwork—in itself a perfect phy- profession only, but the scientific world at large, f^OTSl W^^SJSla "* is one | nis high reputation.-M.rficaf Times. by the same author. (Preparing.) DBTwmpT FS OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC FKlJNL-lrJUi^' vx HISTOLOGy Wjtn a General Sketch of the Vegetable and Animal CHEMIST KY^a."^ and very han"dsome octavo volume, with several hundred illustrations. BY THE SAME ATTTHOR. a um7F ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH A mniaPASK New edition, with a Preface by D. F. Condie, M. D., and explanations of AND mSEASE. «w c* t ^ ^^ ^ ^ pp m ^ ^ 8 BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., ice. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large volume, 8vo., leather, of over 750 pages. $3 25. (Just Issued, 1859.) In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect "acomplete and faithful exposition ol the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of practitioners and observers have been tho- roughly incorporated, and that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. A few notices of previous editions are subjoined. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction.—Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. We feel assured from actual experience that nc physician's library can be complete without a copy of thiswork.—N. Y. Journal of Medicine. A veritable paediatric encyclopaedia, and an honoi to American medical literature.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, 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, notwithstanding all that has bien published, we still regard it in that light.—Medical Examiner. The value of works by native authors on the dis- eases which the physician is called upon to combat, will be appreciated by all; and the work of Dr. Con- die has gained for itself the character of a safe guide for students, and a useful work for consultation by those engaged in practice.—N. Y. Med. Time*. This is the fourth edition of this deservedly popu- lar treatise. During the interval since the last edi- tion, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said b< fore, we do not know of a better book on diseases of chil- dren, and to a large part of its recommendations we yield an unhesitating concurrence.—Buffalo Med. Journal. Perhaps the mostfull and complete work now be- In the department of infantile therapeutics, the fore the profession of the United States; indeed, we work of Dr. Condie is considered one of the best may say in the English language. It is vastly supe- which has been published in the English language, rior to mostof Its predecessors.—Transylvania Mid. — The Stethoscope. \Journal. CHRISTISON (ROBERT), M. D., V. P. R. S. E., Sec. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. COOPER (BRANSBY BJ, F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS —Edited by Bbansby B. Cooper, F. R. S., &c. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial 8vo., extra cloth, with 252 figures, on 36 plates. $2 50. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., ex- tra cloth, with 177 figures on 29 plates. 82 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 60 cents. CLYMER ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT In one octavo volume, leather, of 600 pages. SI 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. S3 50. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University ot Pennsylvania. Second and revised edi- tion. In one very neat octavo volume, extra cloth, of 208 pages. SI 50. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunterian Society, fce. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp.420. $2 00. AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 194 illustrations In one very handsome octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) This work has been so long an established favorite, both as a text-book for the learner and as a reliable aid in consultation for the practitioner, that in presenting a new edition it is only necessary to call attention to the very extended improvements which it has received. Having had the benefit of two revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- roughly brought up with the latest results of European investigation in all departments of the sci- ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty for the American editor to introduce, but he has endeavored to insert whatever has since appeared, together with such matters as his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. The result of all these additions is that the work now con- tains fully one-half more matter than the last American edition, with nearly one-half more illus- trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction ; the opinion of all writers of authority is given on questions of diffi- culty, as well as the directions and advice of the learned author himself, to which he adds the result of statistical inquiry, putting statistics in their pro per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It ap- pears to be written with the true design of a book on medicine, viz: to give all that is known on the sub- ject of which he treats, both theoretically and prac- tically, and to advance such opinions of his own as lie believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Cnur- cnill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the Btudent, and we hope it may be extensively pur- chased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press, June 20,1860. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in every thing* relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. The most popular work on midwifery ever issued rrom the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but me work on midwifery, and permitted to choose, ffe would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof. R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rankfof works in this department of re medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not th very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. —TV. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all Others.—Southern Medical and Surgical Journal. by the same author. (Lately Published.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author Edited, with Notes, by W. V. Keating, M D In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In nrenarine this work a second time for the American profession, the author has spared no l«hnr in c-ivinl it a very thorough revision, introducing several new chapters, and rewriting others, whilV^wrv portion of the volume has been subjected to a severe scrutiny. The efforts of the Am«riP»n editor have been directed to supplying such information relative to matters peculiar t thisAountrv as might have escaped the attention of the author, and the whole may, there- r K* ««felv pronounced one of the most complete works on the subject accessible to the Ame- ' p nfrgsion By an alteration in the size of tbe page, these very extensive additions have tee? accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. IT^SAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- r^TTT TAR TO WOMEN. Selected from the writingsof British Authors previous to the close of the Eigbteettth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. CHURCHILL (FLEETWOOD), M. D., M. R. I. A., Sec. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of " A Practical Treatise on the Diseases of Children." 'vVith nume- rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the mo«t recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most ex- j extent that Dr. Churchill does. His, indeed, is the act and comprehensive expositions of the present only thorough treatise we know it t>n the subject; state of medical knowledge in respect to the diseases ; and it may be commended to practitioners and stu- of women that has yet been published.—Am.Journ. dents as a masterpiece in its particular department. Med. Sciences. i —Tht Western Journal of Medicine and Surgery. This work is the most reliable which we possess | As a comprehensive manual for students, or a on this subject; and is deservedly popular with the work of reference for practitioners, it surpasses any profession— Charleston Med. Journal, July, 1857. other that has ever issued on the same subject from We know of no author who deserves that appro- the British press.—Dublin Quart. Journal. bation, on "the diseases of females," to the same DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia ELEMENTS OF MEDICINE; a Compendious View of Pathology and Therv peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume of 750 pages, leather. $3 75. (Just Issued.) The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with tbe practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., Sic. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) A work which like Druitt's Surgery has for so many years maintained the position of a lead- ing favorite with all clas>es of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artistical execution of the work, which, printed in the best style, on new t>pe, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive ' nothing of real practical importance has been omit- work on surgery, has undergone many corrections, ' ted; it presents a faithful epitome of everything re- improvements, and additions, and the principles and luting t > surgery up to the present hour. It is de- the practice of the art have been brought down to j servedly a popular manual, both with the student the latest recoru and observation. Of the operations and practitioner.—London Lancet, Nov. IB, 1859. in surgery it is impossible to speak too highly. The I .,.,...,.. j descriptions are so clear and concise, and the illus- I In closing this brief notice, we recommend as cor- trations so accurate and numerous, that the student j jjially as ever this most useful and comprehensive can have no difficulty, with instrument in hand, and hand-book. It must prove a vast assistance, not book by his side, over the dead bodv. in obtaining on'y *°.the ■tudent of surgery, but also to the busy book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much neglected department of medical education.—British and Foreign Medico-Chirurg. Review, Jan. I960. In the present edition the author has entirely re- practitioner who may not have the leisure to devote himself to the study of more lengthy volumes.— London Med. Times and Gazette, Oct. 23,1859. In a word, this eighth edition of Dr Druitt's written many of the chapters, and has incorporated Manual of Surgery is all that the surgical student the various improvements and additions in modern or practitioner could desire. — Dublin Quarterly surgery. On carefully going over it, we find that \ Journal of Med. Sciences, .Nov. 1859. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C>, M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $4 00; leather, raised bands, $4 50. (Just Issued, 1861.) The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Im- bibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and the Work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is in- tended. It will be seen, therefore, that Dr. Dalton's best own original views and experiments, together with efforts have been directed towards perfecting his a desire to supply what he considered some deficien- work. The additions are marked by the same fea- cies in the first edition, have already made the pre- tures which characterize the remainder of the vol- , sent one a necessity, and it will no doubt be even ume, and render it by far the most desirable text- more eagerly sought for than the first. That it is book on physiology to place in the hands of the not merely a reprint, will be seen from the author's Btudent which, so far as we are aware, exists in statement of the following principal additions and the English language, or perhaps in any other. We alterations which he has made. The present, like therefore have no hesitation in recommending Dr. , the first edition, is printed in the highest style of the Dalton's book for the classes for which it is intend- printer's art, and the illustrations are truly admira- ed, satisfied as we are that it is better acapted to ble tor their clearness in expressing exactly what their uee than any other work of the kind to which their author intended.—Boston Medical and Surgi- they have access.—American Journal of the Med. cal Journal, March 28, 1861. Sciences, April, 1861. I T . j ..,,,,,. . j It is unnecessary to give a detail of the additions; It is, therefore, no disparagement to the many suffice it to say, that they are numerous and import- books upon physiology, most excellent in their day, ant, and such as will render the work still more to say that Dalton's is the only one that gives us the valuable and acceptable to the profession as a learn- science as it was known to the best philosophers i ed and original treatise on this all-important branch throughout the world, at the beginning of the cur- ! of medicine. All that was said in commendation rent year. It states in comprehensive but concise of the getting up of the first edition, and the superior diction, the facts established by experiment, or style of the illustrations, apply with equal foTce to other method of demonstration, and details, in an this. No better work on physiology can be placed understandable manner, how it is done, but abstains , in the hand of the student.—St. Louis Medical and from the discussion of unsettled or theoretical points. Surgical Journal, May, 1861. Herein it is unique; and these characteristics ren Tnese additions, while testifying to the learning uer it a text-book without a rival, for those who I and industry of the author, render the book exceed- desire to study physiological science as it is known ingly usefuf as the most complete expose of a sci- to its most successful cultivators. And it isphysi- ene6) of which Dr. Dalton is doubtless the ablest ology thus presented that lies at the foundation of representative on this side of the Atlantic—New correct pathological knowledge; and this in turn is Orleans Med. Times, May, J861. the basis of rational therapeutics: so that path Mo- i . . .... e ... , ,. , , ry, in fact, becomes of prime importance in the ' A second edition of this deservedly popular work proper discharge of our everyday practical duties. : having been called for in the short space of two -Cincinnati tancet, May, 1861. years, the author has supplied deficiencies, which ' •" existed in the former volume, and has thus more Dr. Dalton needs no word of praise from us. He completely fulfilled his design of presenting to the is universally recognized as among the first, if not profession a reliable and precise text-book, and one the very first, of American physiologists now living, which we consider the best outline on the subject The first edition of his admirable work appeared but of which it treats, in any language.—N. American two years since, and the advance of science, his Medico-Chirurg. Review, May, 1861. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *** This work contains no less than four hundred and eighteen distinct treatises, contributed by lixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine extant; or, at feast, in our language.—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. The editors are practitioners of established repu- tation, and the list of contributors embraces many of the most eminent professors and teachers of Lon- don. Edinburgh, Dublin, and Glasgow. It is, in- deed, the great merit ol this work that the principal articles have been furnished by practitioners who .. , .,. .. n( have not only devoted especial attention to the dis- One of the most valuable medical publications ot ; eageg about/whieh the) have written, but have the day—as a work of reference it is invuiuaDie.— |aIgo enjoyed opportunitie» for an extensive practi- Western Journal of Medicine and Surgery. \ cal aCqUajntance with them and whose reputation r*k u „„ ►„„« both as learner and teacher, a carries the assurance of their competency justly to It has been ^'l.^^'^^"^^^^^ appreciate the opinions of others, while it stamps mo0dekrnEng^ha meSe" U eSife'dTn tnemost j thrown doctrines witr. high and just authority.! advantageous light.-ilfedicaJ Examiner. I American Medical Journal. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the onth^r's last improvements and corrections In nneoctavovolume, extra cloth, of 600pages. S3 20. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD REN. The last edition. In one volume, octavo, extra cloth, 518 pages. $2 80 DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. 83 00 n BLANCHARD & LEA'S MEDICAL DUNQLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, Src. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, in small type; strongly bound in leather, with raised bands. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish thK large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the pasre. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care hns been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition I tells us in his preface that he has added about six of which, it has become our duty and pleasure to thousand terms and subjects to this edition, which, announce, is perhaps the most stupendous monument . before, was considered universally as the best work of labor and erudition in medical literature. One I of the kind in any language.—Silliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete nnd thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and most com- plete Medical Lexicon in the English language. perpetuate the name of the author more effectually j The amount of labor which the distinguished author than any possible device of stone or metal. Dr. ; has bestowed upon it is truly wonderful, and the Dunglison deserves the thanks not only of the Ame- ' rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of every medical term, that in this edition " about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research. skilful judgment, and vast physical labor, that will A Medical Dictionary better adapted for the wants learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary of the profession than any other with which we are j '{j"" this.—St. Louts Med. and Surg. Journ., Jan acquainted, and of a character which places it far 1858> above comparison and competition.—Am. Journ. It is the foundation stone of a good medical libra- Med. Sciences, Jan. 1858. ry, and should always be included in the first list of We need only say, that the addition of 6,000 new ! books purchased by the medical student.—Am. Med. terms, with their accompanying definitions, may be I ■Mont*«yi Jan. 1858. said to constitute a new work, by itself. We have I A very perfect work of the kind, undoubtedly the examined the Dictionary attentively, and are most I most perfect in the English language.—Merf. and happy to pronounce it unrivalled of itB kind. The j Surg. Reporter, Jan. 1868. erudition displayed, and the extraordinary industry It is now emphatically the Medical Dictionary of which must have been demanded, in its preparation tne English language, and for it there is no substi- and perfection, redound to the lasting credit of its ! tute._2V. H. tfed.'jnn., Jan. 1858. author, and have furnished us with a volume mdis- I , . , pensable at the present day, to all who would find I J1,18 scarcely necessary to remark that any medi- themselves au niveau with the highest standards or cal »brary wanting a copy of Dunylison's Lexicon medical \n{orm&t.\on.—Boston Medical and Surgical \ must De imperfect— Cm. Lancet, Jan. 1858. Journal, Dec. 31, 1857. We have ever considered it the bestauthority pub- Good lexicons and encyclopedic works generally, lished, and the present edition we may safely say has are the most labor-Baving contrivances which lite- , »° ^al ,n the world— Peninsular Med. Journal, rary men enjoy; and the labor which is required to *'an- 1858. produce them in the perfect manner of this example The most complete authority on the subject to be is something appalling to contemplate. The author | found in any language.— 7a. Med. Journal, Feb. '58. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 35. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. [n revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that itcan trulybe said, no more com- plete repertory of facts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.—Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.—Amer.Med. Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a pcifcct mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by thebody, thestudent will find it all he wishes.—Nashville Journ. of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the great encyclopaedia on the subject, and worthy of a place in every phy- sician's library.— Western Lancet. BY the same author. (A new edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. In announcing a new edition of Dr. Dnnglison's General Therapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he nas made to the work, and the careful re- vision to which he has subjected the whole.—N. A. Medico-Chir. Review, Jan. 1658. The work will, we have little doubt, be bought and read by the majority of medical students: its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful as a work of refer- ence. The young practitioner, more especially, will find the copious indexes appendtd to this edition of great assistance in the selection and preparation of suitable formulae.—Charleston Med. Journ. and Re- view, Jan. 1858. BY THE SAME AUTHOR. (A new Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the " New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection ; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.—Preface. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire te examine the original papers.—The American Journal of Pharmacy. One of the most useful of the author's works— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physiHans, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. ELLIS (BENJAMIN), M.D. THF MEDICAL FORMULARY: being a Collection of Prescriptions, derived r tho writings and practice of many of the most eminent physicians of America and Europe. trom tne wr a u,uai Dietetic Preparations and Antidotes for Poisons. To which is added Together wiijiw the'Endermic HSe of Medicines, and on the use of Ether and Chloroform. Tbe an APP®1™ ' n:e(i with a few brief Pharmaceutic and Medical Observations. Eleventh editioi , whole aocomp«h ex(ended by RoBKRT p. Thomas, M. D., Professor of Materia Medica m the Philadelphia College of Pharmacy. (Preparing.) 14 BLANCHARD ft LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, Ac. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries. Diseases, and Operations. New and improved American, from the second enlarged and carefullv revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, leather, raised bands. $4 50. (Just Issued.) The very distinguished favor with which this work has been received on both sides of the Atlan- tic has stimulated the author to render it even more worthy of the position which it has so rapidly attained a- a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is. in our humble judgment, decidedly the best step of the operation, and not deserting him until the final issue of the case is decided —Sethoscopt Embracing, as will be perceived, the wiiole surgi- cal domain, and each division of itself almost com- plete and perfect,each chapterfull and explicit, each subject faithfully exhibited, we can only express nu» estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the bes' <=ingle volume now extant on the subject, and proximaiesto the fulfilment of the peculiar wants of i wjtn great pleasure we add it to our text-books— young men just entering upon the study of this branch tfashville Journal of Medicine and Surgery. oook of the kind in the English language Strange that jusl such books are notoftener produced by puh lie teachers of surgery in this country and Great Britain Indeed, it is a matterof great astonishment, j but no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for mediosAtudents, this is the only one lhal even ap- of the profession.— Western Jour.of Med. anil Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we jegard ii the mosi serviceable guide which he can consult. He will find a fulness of detail leading him throLgh every }f Medicine and Surgery Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.—N. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, *c. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We regard it, in point both of arrangement and of the marked ability of its treatment of the subjects, as destined to take the first rank in works of this class. So far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the A work of original observation of the highest merit. We recommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon cases numerically examined, it carries the evidence of careful study and discrimina- tion upon every pa?e. It does credit to the author, diagnosis of doubtful cases, and in shedding light and, through him, to the profession in this country. upon difficult phenomena.—Buffalo Med. Journal. It is, what we cannot call every book upon auseul- I tation, a readable book.—Am. Jour. Med. Sciences. by the samb author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $2 75. We do no* know that Dr. Flint has written any- thing which is nor. first rate; but this, his latest con- tribution to medical literature, in our opinion, sur- passes all the others. The woik is most comprehen- sive in its scope, and most sound in the views it enun- ciates. The descriptions are clear and methodical; the statements are substantiated by facts, ai.d are made with such simplicity and sincerity, that with great forceand beauty, and, with his previous work, places him nt the head of American writers upon diseases of the chest. We nave adopted his work upon the heart as a text-book, believing it to be more valuable for that purpose than any work of the kind that has yet appeared.—Nashville Med. Journ. With more than pleasure do ed bands. Price 812. The exhaustion in little more than two years of a large edition of so elaborate and comprehen- sive a work as this is the best evidence that the author was not mistaken in his estimate of the want which existed of a complete American System of Surgery, presenting the science in all its necessary deiails and in all its branches. That he has succeeded in the attempt to supply this want is shown not only by the rapid sale of the work, but also by the very favorable manner in which it has been received by the organs of the profesj-ion in this country and in Europe, und by the fuel that a translation is now preparing iii Holland—a mark of appreciation not often bestowed on any scien- tific work so extended in size. The author has not been insensible to the kindness thus bestowed upon his labors, and in revising ihe work for a new edition he has spared no pains to render it worthy of the favor with which it ha> been received. Every portion has been subjected to close examination and revision ; any defi- ciencies apparent have been supplied, and the results of recent progress in the science and art ol surgery have been everywhere introduced ; while the series of illustrations has been enlarged bv the addition of nearly three hundred wood-cuts, rendering it one of the most thoroughly illustrated works ever laid before the profession. To accommodate these very extensive additions, the work has been printed upon a smaller type, so that notwithstanding the very large increase in the matter and value of the book, its size is more convenient and less cumbrous lhan before. Every care has been taken in the printing to render the typographical execution unexceptionable, and it is confi- dently presented as a work in every way worthy of a place in even the most limited library of the piactitioner or student. A few testimonials of the value of the former edition are appended. Has Dr. Gross satisfactorily fulfilled this object? A careful perusal of his volumes enables us to give an answer in the affirmative. Not only has he given to the reader an elaborate and well-wriiten account of his own vast experience, but he has not failed to embody in his pages the opinions and practice of surgeons in this and other countries of Europe. The result has been a work of such completeness, that it has no superior in the systematic treatises on sur- gery which have emanated from English or Contii rental authors. It has been justly objected that these have been far from complete in many essential particulars, many of them having been deficient in some of the most important points which should characterize such works Some of them have been elaborate—too elaborate—with respect to certain diseases, while they have merely glanced at, or given an unsatisfactory account of, others equally important to the surgeon. Dr. Gross has avoided this error, and has produced the most complete work that has yet issued from the press on the science and practice of surgery. It is not, strictly speaking, u Dictionary of Surgery, buc it gives to the reader all the information that he may requirt forhis treatment of surgical diseases. Having said so much, it might apnear superfluous to add another wjrdj but it is only due to Dr. Gross to state that be has embraced the opportunity of transferring to his pages a vast number of engravings from English and other au- tuors, illustrative ot the pathology and treatment of Enr?ical diseases. To these are added several hun fired original wood-cuts. The work altogether com- mends itself to the attention of Britisii surgeons, from whom it cannot fail to meet with extensive patronage.—London Lancet, Sept. 1, I860. Of Dr. Gross's treatise on Surgery we can say no more than that it is the most elaborate and com- plete work on this branch of the healing art which has ever been published in any country. A sys- tematic work, it admits of no analytical review; but, did our space permit, we should gladly give some extracts from it, to enable our readers to judge of the classical style of the author, and the exhaust- ing way in which each subject is treated.—Dublin Quarterly Journal of Med. Science. The work is so superior to its predecessors in matter and extent, as well as in illustrations and style of publication, that we can honestly recom- mend it as the best work of the kind to be taken home by the young practitioner__Am. Med. Journ. With pleasure we record the completion of this long-anticipated work. The reputation which the author has for manv years sustained, both as a puf- geon and as a writer, had prepared us to expect a treatise of great excellence and originality ; but we confess we were by no means prepared tor the work which is before us—the most complete treatise upon surgery ever published either in this or any otm r country, and we might, perhaps, safelv Bay, the most original. There is no subject belonging pro- perly to surgery which has not received from the author a due share of attention. Dr. Grots ha* sup- plied a want in surgical literature which has long been felt by practitioners; he has furnisheu us with a complete practical treatise upon surgery in all its departments As Amencins, we are proud of the achievement; as surgeons, we are most sineerely thankful to him for his extraord nary labors in our behalf —N. Y. Monthly Review and Buffalo Med. Journal. BY THE SAME AUTHOR. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings. Price in extra cloth, $4 75; leather, raised bands, S") 25. (Lately Publislied.) The very rapid advances in the Science of Pathological Anatomy during the last few years\ave rendered essential a thorough modification of this work, with a view of making it a correct expo- nent of the present state of the subject. The very careful manner in which this task has been executed, and the amount of alteration which it has undergone, have enabled the author to say that " with the many changes and improvements now introduced, the work may be regarded almost as a new treatise," while the efforts of the author have been seconded as regards the mechanical execution of the volume, rendering it one of the handsomest productions of the American press. We most sincerely congratulate the author on the We have been favorably impressed with the gene- successful manner in which he has accomplished his proposed object. His book is most admirably cal- culated to fill up a blank which has long been felt to exist in this department of medical literature, and as such must become very widely circulated amongst all classes of the profession. — Dublin Quarterly Journ. of Med. Science, Nov. 1857. ral manner in which Dr. Gross has executed his task of affording a comprehensive digest of the present state of the literature of Pathological Anatomy, and have much pleasure in recommending his work to our readers, as we believe one well deserving of diligent perusal and careful study.—Montreal Mid. CArnn, Sept. 1857. BY THE SAMS AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. 92 75. AND SCIENTIFIC PUBLICATIONS. 17 GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, tec. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. In leather, raised bands, $5 25; extra cloth, $4 75. Philosophical in its design, methodical in its ar- i agree with us, that there is no work in the English rangement, ample and sound in its practical details, language which can make any just pretensions to it may in truth be said to leave scarcely anything to . be its equal.—N. Y. Journal of Medicine be desired on so important a subject—Boston Med. | Avolume replete with truths and principles of the utmost value in the investigation of these diseases.__ and Surg Journal. Whoever will peruse the vast amount of valuable practical information it contains, will, we think, American Medical Journal. GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, tec. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D.,late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 larjre and elaborate engravings on wood. Price in extra cloth, $6 25; leather, raised bands, $7 00. (Now Ready, 1862.) The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- cution have been found to present superior practical advantages in facilitating the study of Anato- my. In presenting it to tbe profession a second tune, the author has availed himself of the oppor- tunity to supply any deficiencies which experience in its use had shown to exist, and to correct any errors of detail, to which the first edition of a scientific work on so extensive and complicated a science is liable. The-e improvements have resulted in some increase in the size of the volume, while twenty-six new wood-cuts have been added to the beautiful series of illustrations which form so distinctive a feature of the work. The American edition has been passed through the press under the supervision of a competent professional man, who has taken every care to render it in all respects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired. With little trouble, the busy practitioner whose , to exist in this country. Mr. Gray writes through- knowledge of anatomy may have become obscured by want of practice, may now resuscitate his former anatomical lore, and be ready for any emergency. It is to this class of individuals, and not to the stu- dent alone, that this work will ultimately tend to be of most incalculable advantage, and we feel sat- isfied that the library of the medical man will soon be considered incomplete in which a copy of this work does not exist.— Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and enlarged, and contains several new illustrations by Dr. Westma- eott. The volume is a complete companion to the dissectine-room, and saves the necessity of the stu dent possessing a variety of" Manuals."—The Lon- don Lancet, Feb. 9, 1861. out with both branches of his subject in view. His description of each particular part is followed by a notice of its relations to the parts with which it is connected, and this, too, sufficiently ample for all the purposes of the operative surgeon. After de- scribing the bones and muscles, he gives a concise statement of the fractures to which the bones of the extremities are most liable, together with the amount and direction of the displacement to which the fragments are subjected by muscular action. The section on arteries is remarkably full and ac- curate. Not only is the surgical anatomy given to every important vessel, with directions for its liga- tion, but at the end of the description of each arte- rial trunk we have a useful summary of the irregu- larities which may occur in its origin, course, and termination.—iV. A. Med. Chir. Review, Mar. 1859. The work before us is one entitled to the highest praise, and we accordingly welcome it as a valu- Mr. Gray's book, in excellency of arrangement able addition to medical literature. Intermediate ! and completeness of execution, exceeds any work in fulness of detail between the treatises of Siar j on anatomy hitherto published in the English lan- pey and of Wilson, its characteristic merit lies in I guage, affording a complete view of the structure of tne number and excellence of the engravings it i the human body, with especial reference to practical contains. Most of these are original, of much I surgery. Thusthe volume constitutes a perfect book larger than ordinary size, and admirably executed, of reference for the practitioner, demanding a place The various parts are also lettered after the plan adopted in Holden's Osteology. It would be diffi- cult to over-estimate the advantages offered by this mode of pictorial illustration. Bones, ligaments, muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names; thus enabling thestudent to c< mprehend, at a glance, What would otherwise often be if^d oral any yMU^, to the gtadent of anatomv. To rate, acquired only by prolonged and irksome ap , djgc«*e of y tly degi in even the most limited library of the physician or surgeon, and a work of necessity for the student to fix in his mind what he has learned by the dissecting knife from the book of nature.—The Dublin Quar- terly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present, volume cannot but present many ad- the zealous of real im- QB Vllir *»i bit^. ..»"»------- v __ , , p I VVI1I UC HU uuuiruuicu SOuSenQ. .. uc |rti,uiiai ,aiuc to educational literature.—N. X. mommy neview. <)f Mf Gray,8 mo(le of illustration is nowhere more Dec. 1859. markedly evident than in the chapter on osteology, In this view, we regard the work of Mr. Gray as and especially in those portions which treat of the far better adapted to the wants of the profession, I bones of the head and of their development. The ,.j -oneeiallv of the student, than any treatise on study of these parts is thus made one of comparative »n»tomv vet published in thi.country. It is destined we beHev^tbsupeede ,11 others, both as a manual of^s ecttons, and a standard of reference to the iuident of general or relative anatomy.-iV. Y. Journal of Medicine, Nov. 1859. c^rthi* truly admirable work the profession is hOrlUlK ""/,...___:mt,-A onthnr nf <> Rnv on ease, if not of positive pleasure; and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work of reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.—Am. jKr„Htn the distinguished author of "Gray on which we have already suffi SoTeen'' The vacancy it fills hag been long felt I Journ. Med. Sci., July, 1859. the Splee 18 BLANCHARD & LEA'S MEDICAL GIBSONS INSTITUTES AND PRACTICE OF SURGERY. Eighth edition, improved and al- tered. With thirty-four plates. In twohandsome octavo volumes, containing about 1,000 pages, leather, raised bandi. $6 50. GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal l*2mo. vol., cloth, pp. 396, with wood cuts. SI. GI.UUE'S ATLAS OF PATHOLOGICAL HIS- TOLOGY Translated, with Notes and Addi- tions by Joseph Lkidy, M D. In one volume, very large imneria" quarto, extra c,"th>,w.l!.n copper plate figures, plain and colored, So 00. HUGHES' INTRODUCTION TO THE PRAC- TICE OF AUSCULTATION AND ?THER MODES OF PHYSICAL DIAGNOSIS IN DIS- EASES OF THELUNtiSAND HEART. Se- cond edition 1 vol. royal 12mo., sx. cloth, pp. 304. SI 00. HAMILTON (FRANK H.), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. In one large and handsome octavo volume, of over 750 pages, with 289 illustrations. $4 25. (Now Ready, January, 1860.) Among the many good workers at surgery of whom America may now boast not the least is Frank Hast- ings Hamilton; and the volume before us is (we say it with a pang of wounded patriotism) the best and handiest book on the subject in the Er.glish lan- gunge. It is in vain to attempt a review of it; nearly as vain to Beek for any sins, either of com- mission or omission. We have seen no work on practical surgery which we would sooner recom- mend to our brother surgeons, especially those of '• the services," cr those whose practice lies in dis- tricts where a man has necessarily to rely on his own unaided resources. The practitioner will find in t directions for nearly every possible accident, easily found and comprehended ; and much pleasant reading for him to muse over in the after considera- tion of niscases.—Edinburgh Med. Journ Feb 1661. This is a valuable contribution to the surgery of most important affections, and is the more welcome, inasmuch as at the present time we do not possess a single complete treatise on Fractures and Dislo- cations in the English language. It has remained for our American brother toproduce a complete treatise upon the subject, and bring together in a convenient form those alterations and improvements that have been made from time to time in the treatment of these affections. One great and valuable feature in the work before us is the fact that it comprises all the improvements introduced into the practice of both English and American surgery, and though far from omitting mention of our continental neighbors, the author by no means tncourages the notion—but too prevalent in some quarters— that nothing is good unless imported from France or Germany The latter half of the work is devoted to the considera- tion of the various dislocations and their appropri- | sincerely congratulate theprof'eYsionof the'United opinion may be gathered as to its value.—Boston Medical and Surgical Journal, March 1, 1860. The work is concise, judicious, and accurate, and adapted to the wants of the student, practiticner, and investigator, honorable to the author and to the profession.—Chicago Med. Journal, March, 1860. We regard this work as an honor not only to its author, but to the profession of our country. Were we to review it. thoroughly, we could not convey to the mind of the reader more forcibly our honest opinion expressed in the few words—we think it the best book ol its kind extant. Every man interested in surgery will soon have this work on his desk. He who does not, will be the loser.—New Orleans Medical News, March, 1860. Now that it is before us, we feel bound to say that much as was expected from it, and onerous as was the undertaking, it has surpassed expectation, and achieved more than was pledged in its behalf; for its title does not express in full the richness of its contents. On the whole, we are prouder of this work than of any which has for years emanated from the American medical press; its sale will cer- tainly be very large in this country, and we antici- pate its eliciting much attention in Europe.—Nash- ville Medical Record, Mar. 1860. Every surgeon, young and old, should possess himself of it, and give it a careful perusal, in doing which he will be richly repaid.—St. Louis Med. and Surg. Journal, March, 1860. Dr. Hamilton is fortunate in having succeeded in filling the void, so long felt, with what cannot fail to be at once accepted as a model monograph in some respects, and a work of classical authority. We ate treatment, and its merit is fully equal to that of I states on the appearance of such a publication from the preceding portion.—The London Lance*,May 5,1 one of tneir number. We have reason to be proud 188"• | of it as an original work, both in a literary and sci- It is emphatically the book upon the subjects of entific point of view, and to esteem it as n valuable which it treats, and we cannot doubt that it will i guide in a most difficult and important branch of continue so to be for an indefinite period of time, study and practice. On every account, therefore. When we say, however, that we believe it will at | we hope that it may soon be widely known abroad once take its place as the best book for consultation as an evidence of genuine progress on this side of by the practitioner; and that it will form the most complete, available, and reliable guide in emergen- cies of every nature connected with its subjects; and also that the student of surgery may make it his text- book with entire confidence, and with pleasure also, from its agreeable and easy style—we think our own the Atlantic, and further, that it may be still more widely known at home as an authoritative teacher from which every one may profitably learn, and as affording an example of honest, well-directed, and untiring industry in authorship which every surgeon may emulate.- Am. Med. Journal, April, 1860. HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the" American Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double columned pages. $1 50. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation.—Charleston Med. Journ. We know of no dictionary better arranged and adapted. It is not encumbered with the obsoleteterms of a bygone age, but it contains all that are now in use; embracing every department of medical science down to the very latest date.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. HOLLAND'S MEDICAL NOTES AND RE- l FLECTIONS. From the third London edition. in one handsome octavo volume, extra cioth. S3. HORNER'S SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition. Extensivly revised and modified. In two large octavo volumes, ex- tra cloth, of more than 1000 pages, with over 300 illustrations. 86 00. AND SCIENTIFIC PUBLICATIONS. 19 Professor of Midwifery and the Diseases of Women and Children in theUniversity of Pennsylvania, &c. °m DIS^?ES. PECULIAR TO WOMEN, including Displacements of the ^IUS* „ i Arigl2S,n1iluBt,!S?ion?; In one beautifuHy printed octavo volume, of nearly 500 pages, extra cloth. $3 25. (Now Ready.) " VVewill say at once that the work fulfils its object capitally well j and we will moreover venture the assertion that it will inaugurate an imnroved prac- tice throughout this whole country. The secrets of the author's success are so clearly revealed that the attentive student cannot fail to insure a goodly por- tion of similar success in his own practice. It is a credit to all medical literature; and we add, that the physician who does not place it in his library, and who does not faithfully con its pages, will lose a vast deal of knowledge that would be most useful to himself and beneficial to his patients. It is a practical work of the highest order of merit; and it will take rank as such immediately.—Maryland and Virginia Medical Journal, Feb. 1861. This contribution towards the elucidation of the pathology and treatment of some of the diseases peculiar to women, cannot fail to meet with a favor- able reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obscurity; the amount of malaise and even of actual suffering by which they are invariably attended; their obstinacy, the difficulty with which they are overcome, and their disposition again and again to leeur—these, taken in connection with the entire competency of the author to render a correct ac- count of their nature, their causes, and their appro- priate management—his ample experience, his ma- tured judgment, and his perfect conscientiousness— invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim.— Am. Journ. Med. Sciences, Jan. 1861. Indeed, although no part of the volume is not emi- nently deserving of perusal and study, we think that the nine chapters devoted to this subject, are espe- cially so, and we know of no more valuable mono- graph upon the symptoms, prognosis, and manage- ment of these annoying maladies than is constituted by this part of the work. We cannot but regard it as one of the most original and mjst practical wotks of the day ; one which every accoucheur and physi- ciai should most carefully re id; for we are per- suaded that he will arise from its perusal with new ideas, which will induct him into a more rational practice in regard to many a suffering femile, who may have placed her health in his hands.—British American Journal, Feb. 1661. Of the many excellences of the work we will not speak at length. We advise all who would acquire a knowledge of the proper management of the mala- dies of which it treats, to study it with care. The second part is of itself a most valuable contribution to the practice of our arc.—Am. Med. Monthly and New York Review. Feb. 1861. The illustrations, which are all original, are drawu to a uniform scale of one-half the natural size. HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, CESOPHAGUS, STOMACH, CAECUM, AND INTES- TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra cloth $1 75. (Now Ready.) JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, tec. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. JONES (C. HANDHELD), F. R. S., 8e EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. $3 75. obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work of reference, therefore, it is of great value to the As a concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum m our lite- rature. Heretofore the student of pathology was student of pathological anatomy, and should be in every physician's library.— Western Lancet. KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A new American, from the third and im»m™,i T ondon edition. With two hundred illustrations. In one large and handsome royal IK. volume, leather, pp.586. $2 00. (Lately Published.) Th.« i« a new and very much improved edition of DrKirke8'wTu-kn..wn Handbook of Physiology. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busypractitioner .-Dublin Quarterly Journal. n' „f the very best handbooks of Physiology wi no^sess-presen^ng just such an outline of the sc InaeZ the student requires during his attendance ence as ™* f lectures, or for reference whilst "Pepnaraing fo^examination!- Am. Medical Journal Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs. Kirkesand Paget, have the gift of telling us what we want to know, without thinking it necessary to tell us all they know__Boston Med and Surg. Journal. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know.—Charleston Med. Journal. 20 BLANCHARD & LEA'S MEDICAL KNAPP'S TECHNOLOGY; or,Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richardson, and Prof. W. R. Johnson. In two handsome 8vo. vols., with about 500 wood-engravings. $6 00. LAYCOt'K S LECTURES ON THE PRINCI- PLES AND METHODS OF MEDICAL OB- SKRVATION AND RESEARCH. For the Use of Advaneed Students and Junior Practitioners. In one royal 12mo. volume, extra cloth. PriceSl. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHEA. By M. Lallkmand. Translated and edited by Henry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESiCULiE SEMINALES; and their associated organs. With special refer- ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) LA ROCHE (R.), M. D., 8ec. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from lr>y9to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. From Professor S. H. Dickson, Charleston, S. C, September 18, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in our city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, tftat this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth., of 500 pages. $3 00. LAWRENCE (W.), F. R. S., Sec. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. LUDLOW (J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, leather, of 61 •) large pages. $2 50. We know of no better companion for the student I crammed into his head by the various professors to daring the hours spent in the lecture room, or to re- whom he is compelled to listen.—Western Lancet, fresh, at a glance, his memory of the various topics | May, 1857. LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. $6 00. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which it treats.—Edinburgh Journal of Medical Science. The most important contribution as yet made to Physiological Chemistry.—Am. Journal Med. Sci- tnces, Jan. 1856. BY the same author. (Lately Published.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsylvania, with illus- trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. Frowi Prof. Jackson's Introductory Essay. In adopting the handbook of Dr Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weignt of his autho- rity in that important department of medical science are fully recognized. AND SCIENTIFIC PUBLICATIONS 21 LYONS (ROBERT D.), K. C. C, Late Pathologist in-chief to the British Army in the Crimea, tec. A TREATISE ON FEVER; or. selections frora a course of Lectures on Fever Being part of a course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth; $2 00. (Now Ready.) ' From the Author's Preface. "I 8m i"d.uce.d to Publish this work on Fever with a view to bring within the reach of the student and junior practitioner, m a convenient form, the more recent results of inquiries into the Pathology and Therapeutics of this formidable class of diseases. " The works of the great writers on Fever are so numerous, and in the present day are scattered in so many languages, that they are difficult of access, not only to students but also to practitioners. I shall deem myself fortunate if I can in any measure supply the want which is felt in this resDect . We have great pleasure in recommending Dr. Lyons' work on Fever to the attention of the pro- fession. It is a work which cannot fail to enhance the author's previous well-earned reputation, as a diligent, careful, and accurate observer.—British Med. Journal, March 2, 1861. Taken as a whole we can recommend it in the highest terms as well worthy the careful perusal and study of every student and practitioner of medi- which is felt in this respect. cine. We consider the work a most valuable addi- tion to medical literature, and one destined to wield no little influence over the mind of the profession.— Med and Swe. Reporter, May 4, 1861. This is an admirable work upon the most, remark- able and most important class of diseases to which mankind are liable.—Med. Journ. of N. Carolina, May, 1861. MEIGS(CHARLES D.), M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. Though the work has received only five pages of enlargement, its chapters throughout wear the im- press of careful revision. Expunging and rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions —Western Lancet, Jan. 1857. The best American work on Midwifery that is accessible to the student and practitioner—N. W. Med. and Surg. Journal, Jan. 1857. This is a standard work by a great American Ob- stetrician. It is the third and last edition, and, in the language of the preface, the author has "brought the subject up to the latest dates of real improve- ment in our art and Science."—Nashville Journ. of Med. and Surg., May, 1857. BY THE same author. (Just Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lee tures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume, leather, of over 700 pages. $3 60. In other respects, in our estimation, too much can- not be said in praise of this work. It abounds with beautiful passages, and for conciseness, for origin- ality, and for all that is commendable in a work on the diseases of females, it is not excelled, and pro- biblynot equalled in the English language. On the whole, we know of no work on the diseases of wo- men which we can so cordially commend to the student and practitioner as the one before us.—Ohio Med. and Surg. Journal. The body of the book is worthy of attentive con- sideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external or- gans, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality.—The British and Foreign Medico-Chi- rurgical Review. Every chapter is replete with practical instruc- tion, and bears the impress of being the composition of an acute and experienced mind. There is a terse- ness, and at the same time an accuracy in his de- scription of symptoms, and in the rules for diagnosis, which cannot fail to recommend the volume to the attention of the reader.—Ranking's Abstract. It contains a vast amount of practical knowledge. by one 'who has accurately observed and retained the experience of many years.—Dublin Quarterly Journal. Full of important matter, conveyed in a ready and agreeable manner.—St.Louis Med. and Surg. Jour. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under 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 Med. Journal. BY THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of bis Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. The instructive and interesting author of this work, whose previous labors have placed his coun- trymen under deep and abiding obligations, again challenges their admiration in the fresh and vigor- ous, attractive and racy pages before us. It is a de- lectable book. * # * This treatise upon child- bed fevers will have an extensive sale, being des- tined, as it deserves, to find a place in the library of every practitioner who scorns tolag in the rear__ Nashville Journal of Medicine and Surgery. BY THE SAME AUTHOR ', WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. $4 50. 22 BLANCHARD « LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet l.-sued in thi* country. $11 00. %* The size of this work prevents its transmi^-ion through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. One of the greatest artistic triumphs of the age ' A work which has no parallel in point of accu- in Surgical Anatomy.—British American Medical racy and cheapness in the English language.—N. Y Journal. | Journal of Medicine. No practitioner whose means will admit should I _„ , ... . . „__,,„„„. ,„ ,„. fail to possess it—Ranking', Abstract. We are extremely gratified to announce o the profession the completion of this tmly magnificent Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal. 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. work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. Wa It is very rare that so elegantly printed, so well j know of no other work that would justify a stu- illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. dent, in any degree, for neglect of actual dissec- tion. 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.—The Western Journal of Medi- cine and Surgery. MILLER (HENRY), M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c; including the Treat- ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- tavo volume, of over 600 pages. (Lately Published.) $3 75. We congratulate the author that the task is done. | tion to which its merits justly entitle it. The style We congratulate him that he has given to the medi- is such that the descriptions are clear, and each sub- cal public a work which will secure for him a high ject is discussed and elucidated with due regard to and permanent position among the standard autho- rities on the principles and practice of obstetrics. Congratulations are not less due to the medical pro- fession of this country, on the acquisition of a trea- tise embodying the results of the studies, reflections, and experience of Prof. Miller. Few men, if any, in this country, are more competent than he to write on thisdepartmentof medicine. Engaged for thirty- five years in an extended practice of obstetrics, for many years a teacher of this branch of instruction in one of the largest of our institutions, a diligent Btudentas well us a careful observer, an original and independent thinker, wedded to no hobbies, ever ready to consider without prejudice new views, and to adopt innovations if they are really improvements. and withal a clear, agreeable writer, a practical treatise from his pen could not fail to possess great value.—Buffalo Med Journal. In fact, this volume must take its place among the standard systematic treatises on obstetrics; a posi- its practical bearings, which cannot fail to make it acceptable and valuable to both students and prac- titioners. We cannot, however, close this brief notice without congratulating the author and the profession on the production of such an excellent treatiee. The author is a western man of whom we feel proud, and we cannot but think that his book will find many readers and warm admirers wherevei obstetrics is taught and studied as a science and an art—The Cincinnati Lancet and Observer. A most respectable and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country prac- titioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the science; and we hope to see this American produc- tion generally consulted by the profession.—Va. Med. Journal. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, tec. tec. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section ol the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, MiUer ls t0? we" and to° favor- ! The wnrk ta^s rank with Watson's Practice of ably known among us, as one of our best text-books, Physic; it certainly does not fall behind that great to render any further notice of it necessary than the work in soundness of principle or depth of reason- announcement of a new edition, the fourth in our I ing and research Vo physician who values hiB re- country, a proof of its extensive circulation among | putation, or seeks the interests of his clients, can us. As a concise and reliable exposition of the sci- i acquit himself before his God and the world without ence of modern surgery, it stands deservedly high— ! making himself familiar with the sound and philo- we know not its superior—Boston Med. and Surg. | sophical views developed in the foregoing book.— Journal. \ jfew Orleans Med. and Surg.Journall BY the same author. (Just Issued.) THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. No encomium of ours could add to the popularity | his works, both on the principles and practice of of Miller's Surgery. Its reputation in this country | surgery have been assigned the highest rank. If we is unsurpassed by that of any other work, and, when : were limited to but one work on surgery, that one taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art.— Southern Med. and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. MiUer—or so richly merited the reputation they have acquired. The author is an eminently sensi should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding theattention. Whether ble, practical, and well-informed man, who knows as a text-book for students or a book of reference exactly what he is talking about and exactly how to . for practitioners, it cannot be too strongly recom- talk it.— Kentucky Medical Recorder. I mended.—Southern Journal of Med. and Physical By the almost unanimous voice of the profession, j Sciences. MORLAND (W. W.l, M. D., Fellow of the Massachusetts Medical Society, &c. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, of about 600 pages, extra cloth. (Just Issued.) $3 50. Taken as a whole, we can recommend Dr. Mor- l refer. This desideratum has been supplied by Dr. lard's compendium as a very desirable addition to ' Morland, and it has been ably done. He has placed the library of every medical or surgical practi- | before us a full, judicious, and reliable digest. tioner — Brit, and For. Med.-Chir. Rev., April, 1859. [ Each subject is treated with sufficient minuteness, r. j- i ..•»• i ..„„*;„„ i,„„ i vet in a succinct, narrational style, such as to render Every medical practitioner whose attention 1has 'v l 0 ' interest"and one which will been to any extent attracted towards the class of ^ ^ f , he a, diseases to which this treatise relates, must have » *HHm..r _*? Y Tourn of Medicine often and sorely experienced the want of some full, practitioner.—N. Y. Journ. oj Mcaicine, yet concise recent compendium to which he could I by the same author —(Now Ready.) THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the Fi^ke Fund Prize was awarded, July 11, 1861. In one small octavo volume, 83 pages, extra cloth. 75 cents. MONTGOMERY (W. F.), M. D., M. R. I. A., Sec, Professor of Midwifery in the King and Queen's College of Physicians iu Ireland, tec. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous^ wood-cuts. In, one very handsome octavo volume, extra cloth, of nearly 600 pages. (Lately Published.) $J 70. A hook nnusuallv rich in practical suggestions.— i fresh, and vigorous, and classical is our author's Am bj7ur:TmdySciences:j,n. 1357. | style ; and oneforgets, in.rte renewed ^charm of T sel> ironing'oftenThV honor and domestic peace of a I pointVconneVted wit"h "pregnancy,~to"be everywhere family, the legitimacy of offspring, or tne »itt ot its ' j d as a manuai 0f special jurisprudence, at parent are all treated with an e egance of diet on ; onceJTmnonncingfact>affordpilljrBrgume^>e.tabl.'!l». fulness of illustrations, acutenessand justice ot rea- preCedent, and governing alike the juryman, ad- ST T^ SSS"t c^^Kf^o vo^te, and judge.*-*. A. Med.-Chir. Review. MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). o-pArTICAL PHARMACY. Comprising the Arrangements, Apparatus, and «• lotion* of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, Mampuiauoiu pR0CTER o( the Philadelphia College of Pharmacy. In one handsomely bV ted octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75. 21 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania H ospital, tec.; and FRANCIS QURNEY SMITH, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 00. The very flattering reception which has been accorded to this work, and the high estimate placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with the advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by a slight enlargement of the page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge of the changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are acquainted.—Med. Examiner. Having made free use of this volume in our ex- aminations of pupils, we can speak frora experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them ; and this is unquestionably the best of its class.—Transylvania Med. Journal. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though eoncisely, laid before the student. There is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the gradu- ates in medicine of more than ten years' standing. who have not studied medicine since. They will perhaps find ou t from it that the science is not exactly now what it was when they left it off.—The Stetho- scope. NELIGAN (J. MOORE), M. D., M. R. I.A., Sec. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations ol disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the profession some years since. The publishers feel juslified in saying that few more beautifully exe- cuted plates have ever been presented to the profession of this country. Neligan's Atlas of Cutaneons Diseases supplies a long existent desideratum much felt by the largest class of our profession. It presents, in quarto size, give, at a coup d'ctil, the remarkable peculiarities of each individual variety. And while thus the dis- ease is rendered more definable, there is yet no loss ».».» ... v». K.w.^.aB.vu. .. |/i^avu.a, an uua.ii.w e»4*^. oaoc IB 1CI1UCICU II1UIC UCllUUUlC, lllCTC IB yCL UU 1UVB 16 plates, each containing from 3 to 6 figures, and of proportion incurred by the necessary concentra- forming in all a total of 90 distinct representations tion. Each figure is highly colored, and so truthful of the different species of skin affections, grouped has the artist been that the most fastidious observer together in genera or families. The illustrations could not justly take exception to the correctness of have been taken from nature, and have been copied the execution of the pictures under his scrutiny.— with such fidelity that they present a striking picture Montreal Med. Chronicle. of life; in which the reduced scale aptly serves to BT THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Third American edition. In one neat royal 12mo. volume, extra cloth, ol 334 pages. $1 00. t*aF* The two volumes will be sent by mail on receipt of Five Dollars. °*£S i«« Journal of Medicine and Surgery. AND SCIENTIFIC PUBLICATIONS. 25 PARRISH (EDWARD), Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, tec. AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- mulae and Prescriptions. Second edition, greatly enlarged and improved. In one handsome octavo volume of 720 pages, with several hundred Illustrations, extra cloth. $3 50. (Just Issued.) During the short time in which this work has been before the profession, it has been received with very great favor, and in assuming the position of a standard authority, it has filled a vacancy which had been severely felt. Stimulated by this encouragement, the author, in availing himself of the opportunity of revision, has spared no pains to render it more worthy of the confidence be- stowed upon it, and his assiduous labors have made it rather a new book than a new edition, many portions having been rewritten, and much new and important matter added. These alterations and improvements have been rendered necessary by the rapid progress made by pharmaceutical science during the last few years, and by the additional experience obtained in the practical use of the volnme as a text-book and work of reference. To accommodate these improvements, the size of the page has been materially enlarged, and the number of pages considerably increased, presenting in all nearly onf-half more matter than the last edition. The work is therefore now presented as a complete exponent of the subject in its most advanced condition. From the most ordinary matters in the dispensing office, to the most complicated details of the vegetable alkaloids, it is hoped that everything requisite to the practising physician, and to the apothecary, will be found fully and clearly set forth, and that the new matter alone will be worth more than the very moderate cost of the work to those who have been consulting the previous edition. will find all that they desire to know, and should That Edward Parrish, in writing a book upon practical Pharmacy some few years ago—one emi- nently original and unique—did the medical and pharmaceutical professions a great and valuable ser- vice, no one, we think, who has had access to its know, but very little of which they do really Know in reference to this important collateral branch of their profession; for it is a well established fact, that, in the education of physicians, while the sci- VIIC, 111* I'MO, Wl* irlllun, wilt' IIUO 1IAU aLb^lM K\J 11< O llicb, ... 1.111* v u u > a.iuu \f l pj|, .tl/ldUD. miUC LUG DU1- pages will deny; doubly welcome, then, is this new ' ence of medicine is generally well taught, very edition, containing the added results of his recent and rich experience as an observer, teacher, and practict) operator in the pharmaceutical laboratory. The excellent plan of the first is more thoroughly, and in detail, carried out in this edition.—Peninsular Med. Journal, Jan. 1860. Of course, all apothecaries who have not already a copy of the first edition will procure one of this; it is, therefore, to physicians residing in the country and in small towns, who cannot avail themselves of the skill of an educated pharmaceutist, that we would especially commend this work. In it they little attention is paid to the art of preparing them for use, and we know not how this defect can be so well remedied as by procuring and consulting Dr. Parrish's excellent work.—St. Louis Med. Journal. Jan. 1860. We know of no work on the subject which would be more indispensable to the physician or student desiring information on the subject of which it treats. With Griffith's " Medical Formulary" and this, the practising physician would be supplied with nearly or quite all the most useful information on the sub- ject.—Charleston Med. Jour, and Review, Jan. 1860. PEASLEE (E. R.), M. D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- some octavo volume, of over 600 pages. (Lately Published.) $3 75. It embraces a library upon the topics discussed within itself, and is just what the teacher and learner need. Another advantage, by no means to be over- looked, everything of real value in the wide range which it embraces, is with great skill compressed into an octavo volume of but little more than six hundred pages. We have not only the whole sub- ject of Histology, interesting in itself, ably and fully discussed, but what is of infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pa- thology, which are here fully and satisfactorily set forth.—Nashville Journ. of Med. and Surgery. We would recommend it to the medical student and practitioner, as containing a summary of all that is known of the important subjects which it treats; of all that is contained in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, we would say to the medical student and practitioner—master this book and you know all that is known of the great fundamental principles of medicine, and we have no hesitation in saying that it is an honor to the American medi- cal profession that one of its members should have produced it.—St. Louis Med. and Surg. Journal. PEREIRA (JONATHAN), M. D., F. R. S., AND L. 3. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the M^HMiml Substances in use in the civilized world, and forming an Encyclopaedia of Materia Mlta EdheT^th Additions, by Joseph Carson, M. D Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages ot small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. Vd 00. -** Vol. II. will no longer be sold separate. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. TWF MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- 1^.7Itj v AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- ^^alafe and successful methoS. With numerous Cases, Formula*, and Clinical Observa- lis, by »"* the Third and entirely rewritten London edition. In one neat octavo volume, eSa cloth, of 316 pages. $175.__________________ onVTF'S MATERIA MEDICA AND THERAPEUTICS; including the KUx-UJA Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. FjTmanv new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. WloneTa"g, strongly bound in leather, with raised bands; with sixty-four beautiful Flutes, and numerous Wood-cuts in the text, containing in all nearly 200 large and beuutilul figures. *'> 00. From Prof. Hodge, of the University of Pa. To the American public, it is raost valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, beextensive throughout our country. It is unnecessary to say anything in regard to the | truly elegant style in which they have brought it utility of this work. It is already appreciated in our ; out, excelling themselves in its production, espe- country for the value of the matter, the clearness of i cially in its plates It is dedicated to Prof. Meigs, its style, and the fulness of its illustrations. To the and has the emphatic endorsement of Prof. Hodge, physician's library it is indispensable, while to the as the best exponent of British Midwifery. We student as a text-book, from which to extract the i knt.w of no text-book which deserves in all respects material for laying the foundation of an education on to be more highly recommended to students, and we obstetrical science, it has no superior.—Ohio Med could wish to see it in the handsof every practitioner, and Surg. Journal. I for they will find it invaluable for reference— Med. The publishers have secured its success by the ! Gazette. RICORD (P.), M. D. A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph Ricord, M.D. Translated and Edited, with Notes, by Freeman J. Bumstead, M.D., Lecturer on Venereal at the College of Physicians and Surgeons, New York. Second edition, revised, containing a resume of Ricord's Recent Lectures on Chancre. In one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. (Just Issued.) In revising this work, the editor has endeavored to introduce whatever matter of interest the re- cent investigations of syphilographers have added to our knowledge of the subject. The principal source from which this has been derived is the volume of "Lectures on Chancre," published a few months since by M. Ricord, which affords a large amount of new and instructive material on many controverted points. In the previous edition, M. Ricord's additions amounted to nearly one-third of the whole, and with the matter now introduced, the work may be considered to present his views and experience more thoroughly and completely than any other. Every one will recognize the attractiveness and secretaries, sometimes accredited and sometimes not. value which this work derives from thus presenting the opinions of these two masters side by side. But, it must be admitted, what has made the fortune of the book, is the fact thai it contains the '' most com- plete embodiment of the veritable doctrines of the Hdpital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted.are incontestabiy dominant, have heretofore only been interpreted by more or lessskilfu) In the notes to Hunter, the master substitutes him- self forhis interpreters, and gives hisoriginal thoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we. can say that this is incon- testabiy the best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope thai it may find a place in the library of every phy- sician.— Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D. In one neat octavo volume, of 270 pages, extra cloth. $2 00. ROKITANSKY (CARL), M.D., CuratOT of the Imperial Pathological Museum, and Professor at the University of Vienna, tec. A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, bound in two, extra cloth, of about 1200 pages. Translated by W. E. Swaine, Edward Sieve- king, C. H. Moore, and G. E. Day. $5 50. The profession is too well acquainted with the re- i so charged his text with valuable truths, that any putution of Rokitansky's work to need our assur- attempt of a reviewer to epitomize is at once para- ance that this is one of the most profound, thorough. | lyzed, and must end in a failure.— Western Lancet. and valuable books ever issued from the medical As thig u the hi?he8t Bource 0f knowledge upon press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has the important subject of which it treats, no real student can ufford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. Asa book of reference,therefore, this work must prove of inestimable value,and we cannot toohighly recommend it to the profession.—Charleston Med. Journal and Review. This book is a necessity to every practitioner.— Am. Med. Monthly. RIGBY (EDWARD), M.D., Senior Physician to the General Lying-in Hospital, tec. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. BY the same author. (Lately Published.) ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. AND SCIENTIFIC PUBLICATIONS. 27 mTT™,.™-, STILLE (ALFRED), M. D. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. In two large and handsome octavo volumes, of 1789 pages. (Just Issued.) $8 00. This work is designed especially for the student and practitioner of medicine, and treats the various articles of the Materia Medica from tbe point of view of the bedside, and not of the shop or of the lecture-room. While thus endeavoring to give all practical information likely to be useful with respect to the employment of special remedies in special affections, and the results to be anticipated from their administration, a copious Index of Diseases and their Remedies renders the work emi- nently fitted for reference by showing at a glance ihe different means which have been employed, and enabling the practitioner to extend his resources in difficult cases with all that tne experience of the profession has suggested. Rarely, iudeed, have we had submitted to us a . fied us that we were not mistaken in our anticipa- work on medicine so ponderous in its dimensions tions —New Orleans Mediral News, March, 1960. as that now before us, and yet so fascinating in its contents. It is, therefore, with a peculiar gratifi- cation that we recognize in Dr. Stille the posses- sion of many of those more distinguished qualifica- tions which entitle him to approbation, and which justify him in coming before his medical brethren as an instructor. A comprehensive knowledge, tested by a sound and penetrating judgment, joined to a love of progress —which a discriminating spirit of inquiry has tempered so as to accept nothing new because it is new, and abandon nothing old because it is old, but which estimates either accorc ing to its relations to a just logic and experience—manifests itself everywhere, and gives to the guidance of the author all rhe assurance of safety which the diffi- culties of his subject can allow. In conclusion, we earnestly advise our readers to ascertain for them- selves, by a study of Dr. Suite's volumes, the great value and interest of the stores of knowledge they present. We have pleasure in referring rather to the ample treasury of undoubted truths, the real and assured conquest of medicine, accumulated by Dr. Stille in his pages ; and commend the sum of his la- bors to the attention of our readers, as alike honor- able to our science, and creditable to the zeal, the candor, and the judgment of him who has garnered the whole so carefully.—Edinburgh Med. Journal. Our expectations of the value of this work were based on the well-known reputation and character of the author as a man of scholarly attainments, an elegant writer, a candid inquirer after truth, and a philosophical thinker; we knew that the task would be conscientiously performed, and that few, if any, among the distinguished medical teachers in this country are better qualified than lie to prepare a systematic treatise on therapeutics in accordance with the present requirements of medical science. Our preliminary examination of the work has satis- The most recent authority is the one last men- tioned, Still6. His great work on " Materia Medi- ca and Therapeutics,'' published last year, in two octavo volumes, of some sixteen hundred pages, while it embodies the results of the labor of others up to the time of publication, is enriched with a great amount of original observation and research. We would draw attention, by the way, to the very convenient mode in which the Index is arranged in this work. There is firstan " Index of Remedies;" next an " Index of Diseases and their Remedies." Such an arrangement of the Indices, in our opinion, greatly enhances the practical value of books of this kind. In tedious, obstinate cases of disease, where we have to try one remedy after another until our stock is pretcy nearly exhausted, and we are almost driven to our wit's end, such an index as the second of the two just mentioned, is precisely what we want.—London Med. Tim', sand Gazette, April, 1861. We think this work will do much to obviate the reluctance to a thorough investigation of this branch of scientific study, for in the wide range of medical literature treasured in the English tongue, we shall hardly find a work written in a style more clear and simple, conveying forcibly the facts taught, and yet free from curgidity and redundancy. There is a fas- cination in its pages that will insure to it a wide popularity and attentive perusal, and a degree of usefulnebs not often attained through the influence of a single work. The author has much enhanced the practical utility of his book by passing briefly over the physical, botanical, and commercial history of medicines, and directing attention chiefly to their physiological action, and their application for the amelioration or cure of disease. He ignores hypothe- sis and theory which are so alluring to many medical writers, and so liable to lead them astray, and con- fines hinuelf to such facts as have been tried in the crucible of experience.—Chicago Medical Journal. SMITH (HENRY H.), M. D. AND HORNER (WILLIAM E.), M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. These figures are well selected, and present a-late the student upon the completion of this Atlas complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is " got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SHARPEY (WILLIAM), M. D., JONES QUAIN, M.D., AND RICHARD QUAIN, F. R. S., See. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M D Professor of Anatomy in the University of Pennsylvania Complete in two large octavo wiumes,TeIt her, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00._________________ SIMPSON (J. Y. , M. D., With nume- Professor of Midwifery, tec, in the University of Edinburgh, &c. CLINICAL LECTURES ON THE DISEASES OF FEMALES. rous illustrations. • ...„■»» XT \^Z- oinnhle series of practical Lectures is now appearing in the « Medical News and This v»l»»blJ8^rIf8"B1°traSd 1862, and can thus be had without cost by subscribers to the « American Journal of the MedicalSciences." Seep. 2. its Structure „mlYON THE HUMAN BRAIN ; its Struct S<£i -Lloev, and Diseases. From the Second PhllAnfar "d London edition. In one octavo rdume « « cloth, of 500 pages, with 120 wood- a tavo SrVa oo. SKEY'S OPERATIVE SURGERY In one very handsome octavo volume, extra cloth, of over 65(1 pages, with about one hundred wood-cuts. S3 35. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention ano Cure of Disease. In one octavo volume, extra cloth, of '212 pages SI 25. 23 BLANCHARD & LEA'S MEDICAL SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. vol., of nearly 400 pages, with 184 wood cuts. Leather, $1 50. (Now Ready ) The value of this work as a handy and convenient manual for surgeons engaged in active duty in the field and hospital, has induced the publishers to render it more complete for those purposes by the addition of a chapter on gun-shot wounds and other matters peculiar to military surgery. In its present form, therefore, with no increase in price, it will be found a very cheap and convenient vade-mecum for consultation and reference in the daily exigencies of military as well as civil practice. We have read Bourgerie's Minor Surgery with pleasure and profit, but in many respects the volume now betore us immeasurably transcends it. We consider that no better book could be placed in the hanus of an hospital dresser, or the young surgeon, whose education in this respect has not been per- fected. Wt most cordially commenJ this volume as one which the medical student should must close ly study, to perfect himself in these minor surgical operations in which neatness and dexterity are so much required, and on which a great portion of his rtputation as a future surgeon must evidently rest. And to the surgeon in practice it must prove itself a valuable volume, as instructive on many points which he may have forgotten.—British American Journal. May, 1S02. The instruction given upon the subject of Ban- daging, is alone of great value, and while the author modestly proposes to instruct the students of medi- cine, and the younger physicians, we will s.iy that experienced ph)sicians will obtain many exceed- ingly valuable suggestions by its perusal. With- out attempting to particularize further, we will conclude our brief notice by saying, that it will be found one of the most satisfactory manuals for refer- ence ia the field, or hospital yet published; thor- oughly adapted to the wants of Military surgeons, and at the same time equally useful for ready and convenient reference by surgeons everywhere.— Buffalo Med. and Surg. Journal, June, 1662. SMITH (W. TYLER), M. D., Physician Accoucheur to St. Mary's Hospital, &c. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRH02A. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $1 50. TANNER (T. H.), M. D., Physician to the Hospital for Women, tec. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. Second American Edition. In one neat volume, small 12mo., extra cloth, 87j cents. TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Fifth American, from the seventh improved and enlarged London edition. With Notes and References to American Decisions, by Edward Haktshoune,M.D. In one large 8vo. volume, leather, of over 700 pages. (NowReady.) $3 25. This standard work having had the advantage of two revisions at the hands of the author since the appearance of the last American edition, will be found thoroughly revised and brought up com- pletely to the present state of the science. As a work of authority, it must therefore maintain its position, both as a text-book for the student, and a compendious treatise to which the practitioner can at all limes refer in cases of doubt or difficulty. No work upon the subject can be put into the | American and British legal medicine. It should be in the possession of every physician, as the subject is one of great and increasing importance to the public as well as to the profession.—St. Louts Med. and Surg. Journal. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence, it is certainly one of the most attractive Dojks that we have met with ; sup- plying so much both to interest and instruct, that we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In the last London edition, all the newly observed and accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Pa- thological research, besides papers on numerous subjects never before published.—Charleston Med. Journal and Review. hands of students either of law or medicine which will engage them more closely or profitably; and none could be offered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would be more likely to afford the aid desired. We therefore recommend itas the best and safest manual for daily use.—American Journal oj Medical Sciences. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In sa>ing this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it.—N. W. Medical and Surg. Journal It is at once comprehensive and eminently prac- tical, and by universal consent Hanus at the head of BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition. In one large octavo volume, ol 755 pages, leather. $3 50. Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi- nary advantages in acquiring experience on these subjects, nearly all cases of moment being leferred to him for examination, as an expert whose testimony is generally accepted as finaf. The results of his labors, therefore, as gathered together in this volume, carefully weighed and sifted, and presented in the clear and intelligible style for which he is noted, may be received as an acknowledged authority, and as a guide to be followed with implicit confidence. AND SCIENTIFIC PUBLICATIONS. 29 TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price $4 50. El** Gentlemen who have received portions of this work, as published in the « Medical News and Library, can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts I., II., III. (pp. 25 to 552), $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00 Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. A magnificent contribution to British medicine, and the American physician who shall fail to peruse it, will have failed to read one of the most instruc- tive books of the nineteenth century.—N. O. Med and Surg. Journal. It is more concise than Carpenter's Principles, and more modern than the accessible edition of Muller's Elements; its details are brief, but sufficient; its descriptions vivid; its illustrations exact and copi- ous; and its language terse and perspicuous.— Charleston Med. Journal. We know of no work on the subject of physiology so well adapted to the wants of the medical student. Its completion has been thus long delayed, that the authors might secure accuracy by personal observa- tion.—St. Louis Med. and Surg. Journal. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, already tran- scends our limits ; and, with the indulgence of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands. — The Northwestern Med. and Surg. Journal. TODD (R. B.) M. D., F. R. S., Sec. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume, 284 pages. $1 50. BY THE SAME AUTHOR. (N»W Ready.) CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra cloth. $1 75. TOYNBEE (JOSEPH), F. R. S., Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one very handsome octavo volume, extra cloth, $3 00. (Just Issued.) The work, as was stated at the outset of our no- tice, is a model of its kind, and t very page and para- graph ol it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated, and happily il- lustrated with cases and drawings—it is by far the ablest monograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable contributions to the art and science of sur- gery in the nineteenth century.—N. Amer. Medico- Chirurg Review, Sept. 1860. To recommend such a work, even after the mere hint we have given of its original excellence and value, would be a work of supererogation. We are speaking within the limits of modest acknowledg- ment, and with a sincere and unbiassed judgment, when we affirm thai a8 a treatise on Aural Surgery, it is without a rivtl in our language or any other.— Charleston Med. Journ. and Review, Sept. i860. The work of Mr. Toynbee is undoubtedly, upon the whole, the most valuable produciion of tne kind in any language. The author has long Deen known by his numerous monographs upon subjects con- nected with diseases of the ear, and is now regarded as the highest authority on most points in his de- partment of science. Mr. Toynbee's work, as we have already said, is undoubtedly the most reliable guide for the Btudy of the diseases of the tar in any language, and should be in the library of every phy- sician.— Chicago Med. Journal, July, 1860. WILLIAMS (C. J. B.), M.D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE. An Eleiuentaiy View of the Causes, Nature3 Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- servation of health. A new American, from theihird and revised London edition. In one octavo volume, leather, of about 500 pages. $2 50. (Just Issued.) We find that the deeply-interesting matter and style of this book have so far fascinated us, that we have unconsciously hung upon its pages, not too lone, indeed, for our own profit, but longer than re- viewers can be permitted to indulge. We leave the further analysis to the studentand practitioner. Our judgment of the work has already been sufficiently expressed. It is a judgment of almost unqualified praise.—London Lancet. A text-book to which no other in our language is comparable.—Charleston Medical Journal. No work has ever achieved or maintained a more deserved reputation.— Va. Med. and Surg. Journal, WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. $1 00. t i-he observer who prefers accuracy to blunders I One of the finest aids to a young practitioner we Z°lVision to carelessness, this little book is :u- have ever seen —Peninsul ar Journal of Medici**. &u.b1o." *• B. Journal of Medicine. I 30 BLANCHARD & LEA'S MEDICAL New and much enlarged edition—(Just Issued.) WATSON (THOMAS), M.D., Sec, Late Physician to the Middlesex Hospital, tec. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." &c. With one hundred and eighty.five illustrations on wood. 1° one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small tvpe; the whole strongly bound in leather, with raised bands. Price $4 25. That the high reputation of this work might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful >crutiny of the editor has likewise introduced whatever posses^:s immediate importance to the American physician in relation to diseases incident to our climate which are little known in England, as well as those points in which experience here has led to different modes of practice ; and He has also added largely to the series of illustrations, believing that in this manner valuable assistance may be conveyed to the student in elucidating the text. The work will, therefore, be found thoroughly on a level with the most advanced state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at a price within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best systematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with ihe advancing know- ledge of the day, and to bring the results of the labors, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. One scarcely knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical m- foi ination condensed into the Lectures—or the man- ly, kind-hearted, unassuming character of the lec- turer shining through his work.— Lond. Med. Times. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with The lecturer's skill, his wisdom, his learning, are equalled by the ease of his graceful diction, his elo- quence, and the far higher qualities of candor, of courtesy; of modesty, and of generous appreciation of merit in others.—N. A. Med -Chir Review. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth edition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of anew—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank hiin for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been severely felt for the last three years. For Dr. Watson has not merely which they were from the first invested, but yet j caused the lectures to be reprinted, but scattered richer than before in the results of more prolonged through the whole work we find additions or altera- observation, and in the able appreciation of the | tions which prove that the author has in every way- latest advances in pathology and medicine by one | sought to bring up his teaching to the level of he of the most profound medical thinkers of the day.— j most recent acquisitions in science.—Brit, and For. London Lancet. J Medico-Chir. Review. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London, tec. A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; including the Principles of Physical Diagnosis. A new American, from the third revised and much en- larged Lonfon edition. In one vol. octavo, of 468 pages. $2 25. The present edition hns been carefully revised and much enlarged, and may be said in the main to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; the causes and mode of production of the more important affections, so far as they possess direct prac- tical significance, are succinctly inquired into; an effort has been made to bring the description ol anatomical characters to the level of the wants of the practical physician; and the diagnosis and prognosis of each complaint are more completely considered. The sections on Treatment and the Appendix (concerning the influence of climate on pulmonary disorders), have, especially, been largely extended.—Author's Preface. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS, including the Principles of Physical Diagnosis. Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 420 pages, extra cloth. $225. (Just Ready.) From the Author's Prefacs. The present edition has been carefully revised ; much new matter has been added, and the entire work in a measure remodelled. Numerous facts and discussions, more or less completely novel, will be found in the description of the principles of physical diagnosis; but the chief additions have been made in the practical portions of the book. Several affections, of which little or no account had been given in the previous editions, are now treated of in detail. Functional disorders of the heart, the frequency ot which is almost rivalled by the misery they inflict, have been closely recon- sidered ; more especially an attempt has been made to render their essential nature clearer, and consequently their treatment more successful, by an analysis of their dynamic elements. AND SCIENTIFIC PUBLICATIONS 31 New and much enlarged edition—(Just Issued.) WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged English Edition. Edited by W. H. Gobrecht, M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, of over 600 large pages; leather. $3 25. The publishers trust that the well earned reputation so long enjoyed by this work will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustra- tions, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. It may be recommended to the student as no less distinguished by its accuracy and clearness of de- scription than by its typographical elegance. The wood-cuts are exquisite.—Brit, and For. Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take up this volume without being struck with the great beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally evident. Let students, by all means examine tue claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. We regard it as the best system now extant for students.—Western Lancet. It therefore receives ourhighestcommendation.__ Southern Med. and Surg. Journal. BY THE SAME AUTHOR. (Just Issued.) ON DISEASES OF THE SKIN. Fourth -and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. The writings of Wilson, upondiseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The presentedition isagreat improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us. seriatim, would indeed be an agreeable service; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount of space in this Journal. We will, howtver, look at some of the more salient points with which it abounds, and which makeilincompuiaoiy superior in uxcellence to all other treatises on the subject of der- matology. No mere speculative views are allowed a place in this volume, which, without a doubt, will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion.—Am. Jour. Med. Science, Oct. 1857. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. The plates by which this edition is accompanied We have already expressed our high appreciation leave nothing to be desired, so far as excellence of of Mr. Wilson's treatise on Diseases of the Skin. delineation and perfect accuracy of illustration are The plates are comprised in a separate volume, concerned —Medico-Chirurgical Review. which we counsel all those who possess the text to ... -., .. .„„„„!,,nnhiirtilir purchase. It is a beautiful specimen of color print- Of these plates it is impossible to sneak: too highly ^ ientatioM & th . f A f The representations of the various forms of cutane- ^ diseage are ag fahhful ag .g posslble in ,ateg ous disease are singularly accurate, ancI tne coior of th Medical Review. BY THE SAME AUTHOR. ON INSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON cvrrnn ITTr ERUPTIONS In one small octavo volume, extra cloth, beautifully printed, with foM exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. »2 25. BY THE SAME AUTHOR. HWATTHY SKIN- A Popular Treatise on the Skin and Hair, their Preserva- Hnn and Management.' Second American, from the fourth London edition One neat volume, royaU2mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 75 cents. BY THE SAME AUTHOR. mxrw DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third A ,ir«an from the last revised and enlarged English edition. Modified and rearranged, by Af16 am Hunt M D., Demonstrator of Anatomy in the University ol Peni^ylvania. In one Iwl handsome royal 12ino. volume, leather, of 582 pages, with 154 illustrations. $2 00. 32 BLANCHARD & LEAS MEDICAL PUBLICATIONS. WINSLOW (FORBES), M. D., D. C. L., Sec. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one handsome octavo volume, of nearly 600 pages. (Just Issued.) $3 00. We close this brief and necessarily very imperfect ] yourselves; and we extend the invitation to^0^ notice of Dr. Winslow's great and classical work, by expressing our conviction that it is long since so important and beautifully written a volume has is- sued from the British medical press.—Dublin Med. J-ress, July 25, 1860. We honestly believe this to be the best book of the season.— Kanking's Abstract, July, 1860. It en* cu us back to our old days of novel reading, it kept us from our dinner, from our business, and fn n. our slumbers; in short, we laid it down only wnen we had got to the end of the last paragraph. and even then turned back to the reperusal ofsever.il passages which we had marked as requiring further Btudy We have failed entirely in the above notice to give an adequate acknowledgment of the profit and pleasure with which we have perused the above worn. We can only say to our readers, study it fessional as well as professional m»-n, believing that it contains matter deeply interesting not to physi- cians alone, but to all who appreciate the truth that: " The proper study of mankind is man."—Nashville Medical Record, July, 1860. The 'atter portion of Dr. Winslow's work is ex- clusively devoted to the consideration of Cerebral Pathology. It completely exhausts the subject, in the same manner as the previous seventeen chapters relating to morbid psychicalvhenomena left nothing unnoticed in reference to the mental symptoms pre- monitory of cerebral disease. It is impossible to overrate the benefits likely to result from a general perusal of Dr. Winslow's valuajle and deeply in- teresting work— London Lancet, June 23, 1660. It contains an immense mass of information.— Brit, and For. Med.-Chir. Review, Oct. 1-60. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, tec. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one handsome octavo volume, extra cloth, of about 500 page>; price $2 50. (Now Ready, July, 1861.) **.* Gentlemen who received the first portion, as issued in the " Medical News and Library," can now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter, &c, 8vo., cloth, price $ 1. We mustnow conclude this hastily written sketch | tion in easy garments; combining pleasure with with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician isapparent on every page.—N. Y. Journal of Medicine, March, 1858. We know of no treatise of the kind so complete and yet so compact.—Chicago Med. Jour. Jan. 1858. A fairer, more honest, more earnest, and more re- liable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal, January 1858. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. We have to say of it. briefly and decidedly, that it is the best work on the subject m any language ; and that it stamps Dr. West as the facile printtpt of British obstetric authors.—Edinb. Med. Journ. As a writer. Dr. West stands, in our opinion, see- ond only to Watson, the " Macaulay of Medicine ;" he possesses that happy faculty of clothing instruc- BY THE SAME AUTHOR. (Just Issued.) LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Third American, from the fourth enlarged and improved London edition. In one handsome octavo volume, extra cloth, of about six hundred and fifty pages. Si 75. profit, he leads his pupils, in spite of the ancieut proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that, wilt please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a can- did, safe, and valuable guide.—N. A. Med.-Chirurg. Review, July, 1858. Happy in his simplicity of manner, and moderate in his expression of opinion, the author is a sound reasoner and a good practitioner, and his book is worthy of the handsome garb in which it has ap- peared.— Virginia Med. Journal. We must take leave of Dr. West's very useful work, with our commendation ol the clearness of its style, and the intustry and sobriety of judgment of Wkicn It gives evidence.—London Med Times. Sound judgment and good sense pervade every chapter of the book. From its perusal we nave de- rived unmixed satisfaction.—Dublin Quart. Journ. The three former editions of the work now before us have placed the author in the foremost rank of those physicians who have devoted special attention to the diseases of early life. We attempt no ana- lysis of this edition, but may refer the reader to some of the chapters to which the largest additions have heen made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a prooi that the work is really a new edition; not a mere reprint. In its pretent shape it will be found of the greatest possible service in the every-day practice of nine- tenths of the profession.—Med. Times and Gazette, London, Dec. 10, 1859. All things considered, this book of Dr. West is by far the best treatise in our language upon such modifications of morbid action and disease as are witntssed when we have to deal with infancy and c'nluhood. It is true that it confines itself to such disorders as come within the province of the phy- sician, and even with respect to these it is unequal as regards minutentss of consideration, and some diseases it omits to notice altogether. But those who know anything of the present condition of paediatrics will readily admit chat it would be next to impossible to effect more, or effect it better, than the accoucheur of St. Bartholomew's has done in u single volume. The lecture (XVI.) upon Disorders of the Mind in children is an admirable specimen of the value of the later information conveyed in tne Lectures of Dr. Charles West.—London Lancet, Oct. 22, 1859. Since the appearance of the first edition, about eleven years ago, the experience of the author has doubled; so that, whereas the lectures at first were founded on six hundred observations, and one hun- dred and eighty dissections made among nearly four- teen thousand children, they now embody the results of nine hundred observations, and two hundred and eighty-eight post-mortem examinations mude among nearly thirty thousand children, who, during the past twenty years, have been under his cure.— British Med. Journal, Oct. 1, 1859. BY THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. SI 00. WHITEHEAD ON THE CAUSES AND TREAT- MENT OF ABORTION AND STERILITY. Second American Edition. In one volume, octa- vo extra cloth, pp. 308. 81 79. NLM032899532