jt*;''.3if' BSpyt / A SYSTEM OF SURGERY; PATHOLOGICAL, DIAGNOSTIC, THERAPEUTIC, AND OPERATIVE. BY SAMUEL U. GrROSS, M.D., PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; SURGEON TO THE PHILADELPHIA HOSPITAL J 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. II. PHILADELPHIA: BLANCHARD AND LEA. 1862. _________________I % 6>3l,_________________ Entered according to the Act of Congress, in the year 1859, by BLANCHARD AND LEA, in 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. 3 7r~> tf ad» CONTENTS OF VOL. II PART SECOND. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. CHAPTER I. DISEASES AND INJURIES OF THE JOINTS. PAGE ect. I. Wounds ......... 19 II. Sprains ..... 23 III. Synovitis ..... 26 IV. Dropsy of the Joints 32 V. Movable Bodies within the Joints 35 VI. Tuberculosis of the Joints 41 1. General observations 41 2. Tuberculosis of particular joints . 53 1. Temporo-maxillary joint 53 2. Clavicular joints 54 3. Occipito-atloid and atlo-axoid joint s 54 4. Sacro-iliac joint 56 5. Wrist-joint . 56 6. Elbow-joint. 59 7. Shoulder-joint 60 8. Ankle-joint . 61 9. Knee-joint . 62 10. Hip-joint 63 VII. Chronic Rheumatic Arthritis 77 VIII. Anchylosis .... 80 IX. Neuralgia ..... 87 X. Dislocations .... 89 1. General considerations 89 2. Simple dislocations 93 3. Complicated dislocations . 107 4. Chronic, old, or neglected dislocations 111 5. Congenital dislocations 113 IV CONTENTS OF VOL. II. Sect. XI. PAGE Dislocations of Particular Joints . . 116 1. Head and trunk . 116 Dislocations of the hyoid bone . 116 of the jaw . . 116 of the clavicle . 119 of the spine . . 124 of the ribs . . . 126 of the pelvis . 127 2. Superior extremity . 129 Dislocations of the hand . . 129 of the fingers . 132 of the carpal bones . 134 of the wrist 135 of the radio-ulnar joints 136 of the elbow 139 of the shoulder 146 3. Inferior extremity . 159 Dislocations of the foot . 159 of the ankle . 163 of the tibio-fibular joints 167 of the patella 167 of the knee . 170 of the semilunar cartilages . 173 of the hip-joint 174 General remarks on reduction in hip-joint dislocations 184 Anomalous dislocations of the hip-joint 187 Chronic dislocations of the hip-joint . 189 Congenital dislocations < )f the hip-joint 191 CHAPTER II INJURIES AND DISEASES OF THE HEAD. Sect. I. Lesions of the Scalp 1. Wounds 2. Contusions . 3. Tumors II. Concussion of the Brain . III. Compression of the Brain Differential diagnosis of concussion and compression a. Compression from extravasation of blood . 6. Compression from depression of bone c. Compression from presence of foreign bodies d. Compression from effusion of pus . IV. Fractures of the Skull .... 1. Simple fracture without depression 2. Simple fracture with depression of bone . 3. Simple fracture with depression, and symptoms of compression 4. Compound fracture 193 193 195 196 197 204 205 206 210 211 211 213 214 215 216 216 CONTENTS OF VOL. II. V 5. Fracture of the base of the skull . 6. Punctured fracture 7. Fracture of the external table alone 8. Fracture of the internal table alone 9. Depression without fracture 10. Apparent depression Sect. V. Diseases of the Cranial Bones ■ . VI. OperationofTrephining VII. Contusions of the Brain VIII. Wounds of the Brain and its Membranes IX. Fungus of the Brain X. Gunshot Injuries of the Head . XI. Chronic Hydrocephalus and Tapping of the Skull XII. Bandaging of the Head .... PAGE 218 220 221 222 222 223 225 227 231 233 236 237 242 245 CH'APTER III. DISEASES AND INJURIES OF THE SPINAL CORD AND COLUMN. Concussion ..... . 247 Sprains ...... . .247 Wounds ...... . 248 Lateral curvature .... . 250 Tuberculosis of the spine . 256 Psoas abscess ..... . 262 Hydrorachitis ..... . 264 CHAPTER IV. INJURIES AND DISEASES OF THE FACE 269 CHAPTER V. DISEASES AND INJURIES OF THE EYE. Mode of examining the eye Foreign bodies in the eye Displacement of the ball of the eye Diseases of the conjunctiva Diseases and injuries of the cornea Diseases and injuries of the sclerotica Diseases and injuries of the iris . Artificial pupil .... Diseases of the chambers of the eye Diseases and injuries of the crystalline lens and Cataract .... Dislocation of the crystalline lens . its caps ule 275 280 282 283 297 305 308 313 316 317 317 333 VI CONTENTS OF VOL. II. Diseases of the retina Diseases of the choroid Strumous diseases Neuralgia of the eye Pyophthalmitis Malignant diseases of the eye Extirpation of the globe of the eye Diseases and injuries of the lachrymal apparatu Injuries and diseases of the lids Ptosis Epicanthus Strabismus Affections of the orbit CHAPTER VI. DISEASES AND INJURIES OF THE EAR. Examination of the ear . Sect. I. Affections of the External Ear . II. Affections of the Auditory Tube a. Malformations b. Foreign bodies c. Accumulations of wax d. Polypous and fungous growths e. Inflammation /. Herpetic affections g. Inflammation of the ceruminous glands k. Hemorrhage III. Diseases of the Membrane of the Tympanum a. Wounds b. Rupture c. Inflammation d. Abscess and gangrene e. Ulceration . IV. Inflammation of the Cavity of the Tympanum V. Diseases of the Internal Ear a. Nervous deafness . 6. Deafness from disease of the tympanum and other causes VI. Diseases of the Eustachian Tube VII. Affections of the Mastoid Cells VIII. Otalgia ... CHAPTER VII DISEASES AND INJURIES OF THE FRONTAL SINUS ■ • 409 CONTENTS OF VOL. II. Vll CHAPTER VIII. INJURIES AND DISEASES OF THE NOSE AND ITS CAVITIES. 1. Hemorrhage 2. Ulceration 3. Hypertrophy 4. Malformations 5. Calculi . 6. Foreign bodies 7. Polyps . 8. Encephaloid 9. Necrosis Lipoma of the nose Rhinoplasty PAGE 412 414 416 416 417 417 418 424 425 425 426 CHAPTER IX DISEASES AND INJURIES OF THE AIR-PASSAGES. Examination of the air-passages . 431 1. Laryngitis 433 2. G3dema 434 3. Scalds 436 4. Ulceration 436 5. Stricture 437 6. Polyps 438 7. Warty excrescences 439 8. Spasm 439 9. Paralysis 440 10. Fistule 440 11. Hernia of the trachea 441 12. Cauterization of the air-passages 441 13. Introduction of tubes 443 14. Foreign bodies 444 15. Bronchotomy 463 CHAPTER X. INJURIES AND DISEASES OF THE NECK, Sect. I. Wounds . II. Wryneck or Torticollis . III. Diseases of the Thyroid Gland IV. Encysted and other Tumors V. Bleeding at the Jugular Vein 466 469 472 478 480 viii CONTENTS OF VOL. II. CHAPTER XI. INJURIES AND DISEASES OF THE CHEST Sect. I. Wounds of the Chest and Lungs II. Hemothorax III. Pneumothorax . IV. Hydrothorax and Pyothorax V. Wounds of the Heart VI. Wounds of the Diaphragm CHAPTER XII. DISEASES AND INJURIES OP THE JAWS, TEETH, AND GUMS Sect. I. ^flections of the Superior Maxillary Bone Excision of the upper jaw II. Affections of the Inferior Maxillary Bone Excision of the lower jaw III. Affections of the Teeth . IV. Affections of the Gums . CHAPTER XIII. DISEASES AND INJURIES OF THE MOUTH AND THROAT Sect. I. Affections of the Lips II. Affections of the Tongue III. Affections of the Salivary Glands Parotid gland Submaxillary gland . Sublingual gland IV. Affections of the Palate . V. Affections of the Tonsils VI. Affections of the Uvula . VII. Affections of the Pharynx and Oesophagus CHAPTER XIV. HERNIA. Sect. I. General Observations 1. Reducible hernia . 589 592 CONTENTS OF VOL. II ix 2. Irreducible hernia 3. Strangulated hernia Treatment Sect. II. Hernias of Particular Regions Inguinal hernia Scrotal hernia Femoral hernia Umbilical hernia Ventral, pelvic, and diaphragmatic hernia III. Internal Strangulation of the Bowel IV. Artificial Anus .... CHAPTER XV. DISEASES, INJURIES, AND MALFORMATIONS OF THE ANUS AND RECTUM. Examination of the anus and rectum Injuries of the rectum Hemorrhage of the rectum Foreign bodies in the rectum Abscess of the anus Fistule of the anus Ulceration and fissure Sacs of the anus . Prolapse of the rectum Hemorrhoids Varicose hemorrhoidal vei Anal tumors Polyps of the rectum Stricture of the rectum and anus Cancer of the anus and rectum Neuralgia of the anus and rectum Pruritus of the anus and nates Malformations Formation of an artificial anus CHAPTER XVI WOUNDS OF THE ABDOMINAL ORGANS. Sect. I. Wounds of the Stomach II. Wounds of the Intestines III. Wounds of the Liver, Gall-Bladder, and Spleen IV. Foreign Bodies in the Stomach and Bowels V. Wounds of the Muscular Walls of the Abdomen VI. Gunshot Injuries of the Abdomen VII. Abscesses within the Walls and Cavity of the Abdomen 689 691 704 707 709 710 711 X CONTENTS OF VOL. II. Sect. VIII. Tumors in the Walls of the Abdomen IX. Ascites and Tapping of the Abdomen X. Affections of the Umbilicus . CHAPTER XVII. DISEASES AND INJURIES OF THE URINARY ORGANS Sect. I. Affections of the Bladder Malformations Wounds Laceration Inflammation . Suppuration and abscess Gangrene Ulceration Chronic inflammation, catarrh, or cystorrhcea Irritability or morbid sensibility Neuralgia Paralysis Retention of urine Catheterism . Puncture of the bladder Incontinence of urine Hemorrhage of the bladder . Polypous, fungous, erectile, and other morbid growths Heterologous formations Tuberculosis . Hernia of the bladder Urinary deposits Stone in the bladder . Treatment of stone 1. Medical means . 2. Extraction of calculi through the urethra 3. Lithotripsy 4. Lithotomy General results of the different methods of lithotomy Stone in the bladder of the female Foreign bodies in the bladder II. Diseases and Injuries of the Urethra Malformations Laceration Hemorrhage Foreign bodies Morbid sensibility Neuralgia Polypoid tumors Stricture Infiltration of urine Urethral abscess CONTENTS OF VOL. II. Urethral fistule False passages Heterologous formations Sect. III. Diseases and Injuries of the Prostate Gland 1. Acute prostatitis 2. Abscess of the prostate 3. Ulceration of the prostate 4. Hypertrophy of the prostate 5. Atrophy 6. Prostatorrhoea 7. Heterologous formations 8. Cystic disease 9. Fibrous tumors 10. Hemorrhage 11. Calculi of the prostate CHAPTER XVIII. DISEASES AND INJURIES OF THE MALE GENITAL ORGANS. Sect. I. Affections of the Testicle II. Affections of the Vaginal Tunic Hydrocele Hematocele Fibrous tumors III. Affections of the Scrotum IV. Affections of the Spermatic Cord V. Affections of the Penis . VI. Affections of the Prepuce VII. Gonorrhoea VIII. Non-specific Urethritis . IX. Spermatorrhoea . CHAPTER XIX. DISEASES AND INJURIES OF THE FEMALE GENITAL ORGANS. Sect. I. Affections of the Uterus Examination of the uterus Malpositions . Inflammation . Hypertrophy . Atrophy Stricture and occlusion Dysmenorrhcea Neuralgia Collections of gas xii CONTENTS OF V Dropsy Hemorrhage . Retro-uterine hematocele Polyps Fibrous tumors Carcinoma Hysterotomy or Csesarean section Sect. II. Affections of the Ovary Inflammation . Tumors Treatment III. Affections of the Vagina IV. Affections of the Vulva V. Gonorrhoea in the Female VI. Vesico-vaginal Fistules Treatment of . VII. Vesico-rectal Fistules . VIII. Laceration of the Perineum Perineal bandage IX. Affections of the Mammary Gland Mammitis Abscess Gangrene Sore nipples . Neuralgia Hypertrophy . Atrophy Fistule Calcareous concretions Apoplexy Benign tumors 1. Sero-cystic tumors 2. Hydatic tumors . 3. Lacteal tumors . 4. Adenoid tumors . Malignant tumors 1. Scirrhus . 2. Encephaloid 3. Colloid and melanosis Treatment . Excision of the breast Bandages for the breast Diseases of the breast in the male Diseases of the breast in the infant Affections of the mammary region CONTENTS OF VOL. II. Xlll CHAPTER XX DISEASES AND INJURIES OF THE EXTREMITIES. Gunshot wounds ..... Onyxitis ...... Sect. I. Superior Extremity 1. Affections of the hand and fingers Congenital irregularities . Hypertrophy of the fingers Contraction of the hand and fingers Club-hand Removal of rings from the fingers Whitlow .... Varicose aneurism of the fingers Phlegmonous inflammation and abscess of the hand Tumors of the hand and fingers 2. Affections of the elbow 3. Affections of the shoulder 4. Affections of the axilla 5. Bandages for the superior extremity II. Inferior Extremity 1. Affections of the foot and toes Congenital and other deformities of the toes Corns Bunions . Inversion of the nail of the great toe Exostosis of great toe Club-foot . Flat-foot . Podelkoma Pododynia 2. Affections of the leg Varix Aneurismal varix Laceration of the tendo Achillis 3. Affections of the knee Anchylosis Knock-knee Housemaid's knee 4. Affections of the ham 5. Affections of the thigh 6. Affections of the nates 7. Affections of the groin 8. Bandages for the inferior extremity PAGE 983 989 990 990 990 991 992 994 995 995 997 998 998 1000 1000 1002 1004 1006 1006 1006 1007 1009 1009 1011 1011 1022 1023 1023 1024 1024 1026 1027 1027 1027 1028 1030 1031 1031 1032 1035 1038 XIV CONTENTS OF VOL. II. CHAPTER XXI. SPECIAL EXCISIONS OF THE BONES AND JOINTS. Trunk .... Excision of the clavicle Excision of the scapula Excision of the ribs . Excision of the sternum Excision of the pelvic bones . Superior Extremity Excision of the bones of the hand Excision of the wrist-joint . Excision of the bones of the forearm Excision of the olecranon Excision of the elbow-joint . Excision of the humerus Excision of the shoulder-joint Inferior Extremity Excision of the bones of the foot Excision of the ankle-joint . Excision of the knee-joint Excision of the patella Excision of the bones of the leg Excision of the hip-joint Excision of the great trochanter PAGE 1040 1040 1041 1042 1043 1044 1044 1044 1045 1046 1048 1048 1051 1051 1053 1053 1058 1059 1064 1064 1065 1068 CHAPTER XXII. SPECIAL AMPUTATIONS. Superior Extremity Amputation of the hand Amputation at the wrist Amputation of the forearm Amputation at the elbow Amputation of the arm Amputation at the shoulder Inferior Extremity Amputation of the foot Amputation at the ankle Amputation of the leg Amputation at the knee Amputation of the thigh Amputation at the hip 1069 1069 1072 1072 1073 1074 1075 1077 1077 1081 1083 1086 1087 1090 LIST OF ILLUSTRATIONS TO YOL. II. FIG. 1. Acute synovitis 2. Laced cap for dropsical joints 3. Loose articular concretions . 4. Attached articular concretions 5. Fimbriated synovial membrane 6. Fibroid bodies in the knee-joint 7. Section of strumous ulcer of a cartilage 8. Section of a strumous tibia 9. Tuberculosis of the wrist-joint 10. Tuberculosis of the elbow . 11. Tuberculosis of the ankle . 12. Tuberculosis of the knee 13. Appearances of parts in second stage of hip-joint disease 14. Appearances of parts in third stage of hip-joint disease 15. Changes in acetabulum and head of femur in coxalgia 16, 17. Davis's apparatus for extension in coxalgia 18. Sayre's apparatus for coxalgia 19. Changes of the acetabulum in chronic rheumatic arthritis 20. Head of the femur in chronic rheumatic arthritis . 21. Bony anchylosis of the knee .... 22. Kolbe's apparatus for straightening the knee 23. Mutter's and Stromeyer's apparatus for straightening the elbow 24. Barton's operation for anchylosis of the knee 25. Dislocation of knee backwards, from organic disease 26. Clove-hitch knot 27. French knot 28. Compound pulleys . 29. Pulleys applied 30. Staple for pulleys 31. Gilbert's substitute for the pulleys 32. Bloxam's dislocation tourniquet 33. Jarvis's adjuster applied 34. Old dislocation of the hip, a new acetabulum being formed 35. Double dislocation of the inferior maxilla . 36. External appearances of dislocation of the inferior maxilla 37- Dislocation of sternal end of clavicle 38. Dislocation of scapular end of clavicle 39. Dislocation of the spine between fourth and fifth cervical vertebrae 40. The same, seen laterally ..... 41. Ayres's case of bilateral dislocation of the fifth cervical vertebra 42. Dislocation of the first phalanx of the thumb, backwards . XVI LIST OF ILLUSTRATIONS TO VOL. II. thumb FIQ. 43. Reduction of the dislocated thumb by clove-hitch knot 44. Method of reducing a backward dislocation of the thumb 45. Dislocation of the phalanx of the thumb forwards 46. Dislocation of the phalanges backwards 47. Reduction of the same 48. Levis's apparatus for reducing dislocations of the 49. The same, applied .... 50. Dislocation of the carpus, backwards 51. Dislocation of the carpus, forwards 52. Dislocation of the head of the radius, forwards 53. Dislocation of the head of the radius, backwards 54, 55, 56. Dislocation of superior extremities of radius 57. Mode of reducing this dislocation . 58. Lateral dislocation of the elbow-joint, inwards 59. Lateral dislocation of elbow-joint, outwards 60. Dislocation of the ulna, backwards 61. Axillary dislocation of the humerus 62. Signs of axillary dislocation of the humerus 63, 64, 65, 6G. Reduction of dislocation of humerus into axilla 67. Thoracic dislocation of the humerus 68. Scapular dislocation of the humerus 69. Dislocation of the tendon of the biceps muscle 70. Dislocation of the ankle, inwards . 71. Dislocation of the ankle, outwards . 72. Compound dislocation of the ankle 73. Dislocation of the patella outwards 74. Dislocation of the patella inwards 75. Dislocation of the tibia forwards 76. Dislocation of the tibia backwards 77. Dislocation of the tibia inwards 78. Dislocation of the tibia outwards 79. Iliac dislocation of the femur 80. Signs of the same 81. Fracture of the neck of the femur within the capsule 82. Sciatic dislocation of the femur 83. Thyroid dislocation of the femur 84. Signs of the same 85. Pubic dislocation of the femur 86. Signs of the same 87. Reduction of iliac dislocation of the femur S8. Reduction of thyroid dislocation of the femur 89. Reduction of pubic dislocation of the femur 90. Fibrous tumor of the scalp . 91. Malignant ulcer of the scalp 92. Extravasation of blood from rupture of the 93. Simple fracture of the skull 94. Fracture with depression 95. Fracture at the base of the skull 96. Punctured fracture of the skull 97. Fracture of the inner table of the skull 98. Exostosis of the cranial bones 99, 100. Syphilitic exostosis of the cranial bones middle and fin and ulna backwards gers meningeal artery LIST OF ILLUSTRATIONS TO VOL. II. XVII FIG. 101. Syphilitic caries of the skull 102. Application of the trephine 103, 104, 105. Trephining instruments 106, 107, 108. Fungus of the brain after fracture 109. Chronic hydrocephalus 110. Skull of hydrocephalic child 111. Trocar for puncturing the cranium . 112, 113, 114, 115. Bandages for the head 116, 117. External characters of lateral curvature of the spine 118. Lateral curvature of the spine; appearance of the vertebrae 119. Caries of the vertebrae 120. Angular curvature of the spine from caries 121, 122. Posterior curvature of the spine 123. Abscesses of the spine from caries of the vertebrae 124. Angular curvature and anchylosis of the spine, with spontaneous 125. Bifid spine, as developed in the neck 126. Bifid spine, the sac being laid open 127. Bifid spine, showing the distribution of the 128, 129. Venous tumor of the lip and cheek 130. Corroding lupus 131. Mode of using the ophthalmoscope . 132. Healthy appearances of the eye 133. Hyperemia of the papilla 134. Inflammatory deposits on the retina 135. Extravasation of blood on the retina 136, 137, 138. Lid elevators 139. Bandage for the eyes after operations 140. Simple conjunctivitis 141. Chemosis .... 142. Granular lid . 143. Purulent ophthalmia of recent date 144. Purulent ophthalmia in newly-born infants 145. State of the lids in gonorrhoeal ophthalmia 146. Pterygium 147. Double pterygium 148. Encanthis 149. Corneitis 150. Ulceration of the cornea 151. Opacity of the cornea, an example of albug 152. Spherical staphyloma 153. Conical staphyloma 154. Staphyloma of the sclerotic coat 155. Sclerotitis 156. Sclerotitis extending to the internal tissues 157. Congenital fissure of the iris 158, 159. Acute iritis 160. Prolapse of the iris . 161. Iris scissors . 162, 163. Iris hooks 164. Knife for artificial pupil 165, 166, 167, 168. Operations for artificial pupil 169. Cellular hydatid in the anterior chamber of the eye VOL. II.—1 .Will LIST OF ILLUSTRATIONS TO VOL. II. FIG. 170. Cataract 171. Operation of solution of cataract 172. Scarpa's needle 173. Hays's knife-needle . 174. Keratonyxis . 175, 176. Depression of cataract 177. Conjunctiva forceps . 178. Beer's knife . 179. Superior section of the cornea 180. Inferior section of the cornea 181. Exterior and inferior section of the cornea 182. Curette with silver scoop 183. Lens passing through incision of the cornea 184. Curved cornea knife 185. Probe-pointed scissors 186. Dislocation of the lens into the anterior chamber 187. Scrofulous ophthalmia 188. Ulcerated encephaloid of the eye 189. Encephaloid of the eye 190, 191. Melanosis of the eyeball 192. Anel's probe .... 193. Anel's syringe .... 194. Operation for relieving the nasal duct 195. Style for the nasal duct 196. Lachrymal fistule in its chronic stage 197. Entropion of both lids 198. Entropion forceps .... 199. Ectropion of the lower eyelid 200. Operation for the same 201. Plastic operation for ectropion 202. Trichiasis ..... 203. Operation for epicanthus 204. Lid-holder ..... 205. Hook for steadying the eye . 206. Forceps for pinching up the conjunctiva 207. Plan of the eye, showing the line of incision in the conjunctiva 208. Curved eye probe 209,210,211. Ear specula 212, 213. Application of Miller's lamp to the inspection of the external 214. Dr. Grant's aural reflector . 215. Ear syringe ..... 216. Hullihen's basin and syringe 217. Toynbee's ear-spout 218. Forceps for extracting foreign bodies from the ear 219. Toynbee's rectangular forceps 220. Gross's instruments for the removal of foreign bodies from the ear 221. Curette 222. Gelatinoid polyp of the ear . 223. Lobulated aural polyp 224. Microscopical characters of a recurring fibroid aural polyp 225. Aural forceps 226. Wilde's aural canula / LIST OF ILLUSTRATIONS TO VOL II. XIX FIG. PASE 227, 228, 229. Rupture of the membrana tympani from different causes . 390 230. Toynbee's artificial tympanic membrane .... . 400 231. Catheter for the Eustachian tube . . 402 232. Toynbee's otoscope . . 403 233. Application of the otoscope . . 403 234. Ear explorer . 404 235. Mode of examining the ear . . 404 236. Dr. Simrock's rhinoscope . 412 237. Bellocq's canula . 414 238. Plugging of the nose . 414 239. Nasal polyps . 418 240. Fibrous nasal polyp . 419 241. Frog-face from nasal polyps . 420 242. Gross's polypus forceps . 421 243. Mode of applying the forceps to a polyp 422 244. Double canula and silver wire for the removal of polyps 423 245. Application of the same . . . . 423 246. Encephaloid of the nose .... 425 247. Lipoma of the nose ..... 426 248, 249. Pancoast's tongue and groove suture . 428 250. Depressed nose ..... 429 251. Result of rhinoplastic operation for the same 429 252. Taliacotian operation for the formation of a new nose . 430 253. Laryngoscope ..... 431 254. Glass mirror for the same .... 432 255. Church's laryngoscope and tongue depressor 433 256. False membrane of croup .... 433 257. OZdema of the larynx .... 434 258. Buck's knife for oedema of the larynx 435 259. Double stricture of the windpipe . 437 260. Polyp of the larynx .... 438 261. Warts in the larynx .... 439 262. Sponge probang for the larynx .... 442 263. Erichsen's laryngeal syringe . 443 264. Trachea tube ..... 443 265. Cockle-bur from the air-passages 444 266. Ear of grass from the air-passages .... 444 267. Artificial teeth from the air-passages 445 268. Puffdart from the air-passages 445 269. Gross's forceps for extracting foreign bodies from the air-passages 458 270. Trousseau's forceps for holding apart the edges of the wound in the trachea 459 271. Hook for extracting foreign bodies from the air-passages . 459 272. Probe for exploring the air-passages 459 273. Mop for removing extraneous matters from the larynx 459 274. Plexus of veins embracing the trachea 460 275. Position of the middle thyroid artery 460 276. Perforation of the larynx .... 462 277. Tracheotomy ...... 464 278. Torticollis .... 469 279. Tenotome .... 471 280. Jorg's apparatus for torticollis 472 281. Goitre .... 474 XX LIST OF ILLUSTRATIONS TO VOL. FIG. 282. Cystic degeneration of the thyroid gland 283. Ossified thyroid gland 284. Fibrous tumor of the neck . 285. Encephaloid tumor of the neck 286. Bleeding from the jugular vein 287. General emphysema of the whole surface 288. Instrument for tapping the chest 289. Tapping of the chest 290. Shot wound of the heart 291. Perforation of the antrum . 292. Dropsy of the antrum 293, 294. Encephaloid of the antrum 295. Excision of the upper jaw . 296, 297, 298. Bone-forceps 299. Clawed forceps 300. Epulis, in its earlier stages . 301. Epulis, in its advanced stages 302, 303. Cystic tumor of the lower jaw 304. Scultetus's lever for separating the jaw 305. Lever for anchylosis of the lower jaw 306, 307, 308. Plastic operation on the cheek 309. Saws for dividing the jaw bone 310, 311. Gross's elevators for removal of lower j 312. Vicious position of the wisdom tooth 313. Fusion of teeth 314. Malformation of the fangs of a tooth 315, 316, 317. Caries of the teeth 318. Fungous vegetation of a tooth 319. Fungous tumor of a tooth . 320, 321. Sac of alveolar abscess 322. Gum-lancet . 323, 324, 325. Tooth forceps 326. Application of the same to a tooth 327. Application of the key 328. Tooth elevator 329. Tooth hook . 330. Hypertrophy of the gums . 331. Encysted tumor of the lower lip 332. Epithelioma of the lower lip in its earliest stages 333. Epithelial cancer of the lower lip, in an advanced stage 334. Papilla taken from an epithelial cancer 335. Elliptical incision 336. Excision of epithelioma of lip by a V-shaped incision 337. Eversion of the mucous membrane of the lip 338. Hare-lip 339. Double hare-lip 340, 341. Deformity of the nasal septum in hare-lip 342. Malgaigne's operation for hare-lip . 343. Elliptical hare-lip suture 344. Dewar's compressor . 345. Fissure of the cheek 346. Cheiloplasty, showing lines of the incision LIST OF ILLUSTRATIONS TO VOL. II. XXI FIG. 347. Cheiloplasty ..... 348. Glossitis ...... 349. Hypertrophy of the tongue .... 350. Expansion of the jaw from pressure by the tongue 351. Minute appearance of epithelial tumor of the tongue 352. Curved needle for ablation of the tongue . 353. Ligation of the tongue 354. Excision of the tongue 355. Removal of the tongue with the ecraseur . 356. Salivary calculus .... 357. Minute appearance of scirrhus of the sublingual gland 358. Cleft palate ..... 359. Obturator for the palate 360. Gross's needle-forceps 361. Schwerdt's needle-forceps 362, 363. Arrangement of ligatures in staphylorraphy 364. Gap left after staphylorraphy 365, 366. Fissure of the hard palate, and operation for its cure 367. Tongue depressors .... 368. Inhaler ..... 369, 370. Hypertrophy of the tonsils 371. Volsella ..... 372. Probe-pointed bistoury 373. Fahnestock's tonsillotome . 374. Stricture of the oesophagus . 375. Carcinoma of the oesophagus 376. Ulcerated scirrhus of the oesophagus 377, 378. Bond's oesophagus forceps 379. Burge's oesophagus forceps . 380, 381. Instruments for extracting foreign bodies from the oesophagus 382. Hernial sac ..... 383. Hernial truss .... 384. The same applied .... 385. Wutzer's instrument for the radical cure of hernia 386. Agnew's instrument for the radical cure of hernia 387. Curved needle forming part of it . 388. Wood's instrument for radical cure of hernia 389. Strangulated hernia ..... 390. Operation for strangulated hernia . 391. Grooved hernia director .... 392. Searching for the seat of stricture . 393. Mode of holding the knife in its division . 394. Hernia knife of Sir A. Cooper 395. Probe-pointed bistoury .... 396. Plan of inguinal hernia .... 397. Hernial sac, showing its position in front of the spermatic cord 398. Double truss .... 399. Direct inguinal hernia . . . 400. Scrotal hernia .... 401. Scrotal hernia, showing the relation of the sac to the vaginal tunic 402. Infantile hernia .... 403. Ordinary site and appearance of femoral hernia 1* XX11 LIST OF ILLUSTRATIONS TO VOL. II. 416. 417. 418. 419. 420. 421. 422. 423. 424. 425. 428. 429. 430. 433, 434 435 436 437 438 439 440 4i >4. Plan of femoral hernia . 405. Intussusception of the bowel 406, 407. Dupuytren's enterotome and its application . 408. Gross's enterotome . 409. Fenestrated speculum . 410. Valvular speculum . 411. Fistule of the anus . 412. Mode of exposing and dividing the parts in anal fistule 413. Mode of operating in anal fistule . 414. Pouches of the rectum . 415. Partial prolapse of the rectum Complete prolapse of the rectum . External hemorrhoids .... Minute structure of an internal hemorrhoidal tumor Internal hemorrhoids Protruding hemorrhoid Ulcerated hemorrhoids Forceps for seizing piles Bushe's needle carrier Application of the ecraseur Polyp of the rectum—external appearance 426. Polyp of the rectum—internal appearance , 427. Stricture of the rectum Imperforate rectum and anus Amussat's operation for artificial anus Wound of the bowel—eversion of the mucous membrane 431. Attachment of the omentum to the bowel, external to the wound 432. Continued suture of the bowel Ligature of bowel partially detached Lembert's suture Gely's suture Trocar Tapping of the abdomen Extrophy of the urinary bladder Columniform bladder Sacculated bladder . 441, 442, 443. Catheters . 444. Contrivance for retention of the catheter in the bladder 445. Rectal puncture of the bladder 446. Supra-pubic puncture of the bladder 447. Male urinal for incontinence of urine 448. Female urinal for incontinence of urine 449. Erectile tumor of the bladder 450. Microscopical structure of stricture of the bladder 451. Group of urinary deposits . 452. Crystallized uric acid ■453. Crystallized oxalate of lime 454. Triple phosphate 455. Calculus with a cork for a nucleus 456. Thorny calculus 457. Peculiar form of urinary calculus 458 459. Uric calculus—external and internal appearance LIST OF ILLUSTRATIONS TO VOL. II. xxiii FIG. PAGE 460, 461. Mulberry calculus, showing its external and internal structure . 766 462. Hemp-seed calculus ....... . 766 463. Phosphatic calculus ...... . 766 464. Ammoniaco-magnesian calculus ..... . 767 465, 466. Fusible calculus, showing its external and internal structure 767 467, 468. Cystic calculus, showing its external and internal structure . 767 469. Encysted calculi of the bladder ..... . 768 470, 471. Sounds ........ . 770 472. Encysted calculi ....... . 771 473. Sounding for stone in enlarged prostate .... . 772 474. Sir Astley Cooper's lithotomy forceps .... 776 475. Heurteloup's lithotriptor ...... 777 476, 477. Screw of the same, and mode of using it 777 478. Calculus in the grasp of the same ..... 778 479. Calculus grasped in the bladder ..... 778 480, 481, 482. Different forms of lithotriptic instruments . . 7 78, 779 483. Jacobson's stone-crusher, as modified by Velpeau . 779 484. Band for securing patients in lithotomy .... 784 485. Grooved staff ....... 785 486. Gross's lithotomy knife ...... 785 487. Probe-pointed bistoury ...... 785 488. Method of incision in the lateral operation of lithotomy . 786 489. Finger and knife in the groove of the staff 786 490. Lithotomy forceps . . . . . ' . 787 491. Mode of seizing the stone with the forceps 787 492. Scoop for extracting fragments of calculus .... 788 493. Scoop and finger grasping the calculus .... 788 494. Left lobe of the prostate as it is divided in the lateral operation of lithotom. Y 789 495. Crushing forceps ....... 790 496. Physick's artery forceps ...... 791 497. Gross's artery compressor ....... 791 498. Canula for plugging the wound in lithotomy 792 499. Gorget ........ 797 500. Single lithotome ....... 797 501. Double lithotome ........ 797 502. Bilateral operation for lithotomy ...... 798 503. Lithotomy with the rectangular staff . 799 504. Instrument for dilatation of female urethra . 802 505. Female staff ......... 803 506, 507. Forceps for extracting foreign bodies from the bladder 804 508. Epispadias ......... 805 509. Bonnet's articulated scoop ....... 808 510. Hunter's forceps ........ 808 511. Urethral forceps ........ 808 512. Polyp of the urethra ....... 811 513. Indurated stricture of the urethra ...... 812 514. Bridle stricture of the urethra ...... 812 515. Graduated bougie ........ 813 516. Dilatation of the urethra behind the seat of stricture 814 517. Effects of stricture of the urethra upon the rest of the urinary organs 814 518, 519, 520, 521. Bougies ....... 816 522. Buchanan's compound circular catheter . . . . . 817 XXIV LIST OF ILLUSTRATIONS TO VOL. I FIG. 523 Sheppard's instrument for dilating the urethra 524, 525, 526, 527. Wakley's stricture instruments 528. Porte-caustique 529. Urethrotome 530. Syme's staff . 531. Urethral abscess, with stricture and false passages 532. Urinary fistules 533, 534. Urethroplasty . 535. Stricture of the urethra, with false passage 536. Abscess of the prostate 537. Hypertrophy of both lobes of the prostate 538. Lobulated hypertrophy of the prostate 539. Hypertrophy of the middle lobe of the prostate 540, 541. Prostatic calculi 542. Acute orchitis 543. Strapping of the testicle 544. Abscess of the testicle 545. Fungus of the testicle 546. Fibrous degeneration of the testicle 547. Calcareous matter in the testicle 548. Cystic testicle 549. Fatty tumor of the testicle 550. Tuberculosis of the testicle 551. Excision of the testicle 552. Gum-elastic suspensory 553. Mayor's suspensory apparatus 554. Spermatozoa in the fluid of hydrocele 555. Hydrocele of the vaginal tunic 556. Trocar 557. Operation of tapping a hydrocele 558. Encysted hydrocele . 559. Hydrocele associated with hernia 560. Hematocele of the scrotum . 561. Fibrous tumor of the vaginal tunic 562, 563. Cystic tumor of the scrotum 564, 565. Elephantiasis of the scrotum 566. Varix of the scrotum 567. Chimney-sweeper's cancer . 568. Encysted hydrocele of the spermatic cord 569. Diffused hydrocele of the spermatic cord 570. Encysted hematocele of the cord 571. Varicocele 572. Operation for varicocele 573. Fatty tumor of the spermatic cord 574. Warts on the penis . 575. Phymosis 576. Operation for phymosis 577. Paraphymosis 578. Aggravated form of paraphymosis 579. Operation for paraphymosis 580. Discharge from gonorrhoea, seen under the microscope 581. Discharge in non-venereal gleet, seen under the microscope LIST OF ILLUSTRATIONS TO VOL. II. XXV FIG. 582. 583. 584. 585. 586. 587. 588. 589. 590. 591. 592. 593. 594. 595. 596. 597. 598. 599. 600. 601. 602. 603. 604. 605. 606. 607. 608. 609. 610. 611. 612. 613. 614. 615. 616. 617, 619. 620. 621, 626. 627. 628. 629. 630. 631. 632. 633. 634. 635. 636. organ -vesico- Syringe catheter Cylindrical vaginal speculum Valvular vaginal speculum Simpson's sound Apparatus for applying carbonic acid to the uterus Retroversion of the uterus . Anteversion of the uterus . . . Inversion of the uterus Follicular disease of the uterus Stricture of the uterus Dysmenorrhceal membrane . Retro-uterine hematocele Fibrous polyp of the uterus Uterine polyp attached to the base of the organ Uterine polyp hanging from the vulva Carroll's knot-tier .... Fibrous tumors of the uterus—both internal and external Section of fibrous tumor of the uterus Incipient cancer, beginning in the body of the uterus Carcinoma of the uterus, beginning at the mouth and neck of the Cauliflower excrescence of the uterus Epithelial cells from the same Carcinoma, beginning in the neck of the uterus, ending in recti vaginal fistule ..... Amputation of the neck of the uterus with the ecraseur Ovarian cyst ..... Section of a multilocular ovarian tumor Section of a colloid tumor of the ovary Microscopical characters of the fluid of an ovarian tumor Prolapse of the vagina .... Hypertrophy of the mucous crypts of the vulva . Varicose veins of the vulva Encephaloid of the nymphae and clitoris . Hypertrophy of the clitoris and nymphae . Vascular excrescence of the female urethra One of the modes of holding a female catheter 618. Bozeman's button .... Bozeman's speculum .... Position of the patient in the operation for vesico-vaginal fistule 622, 623, 624, 625. Instruments for paring the edges of a vesico-vaginal fistule ..... Needle-holder used in vesico-vaginal fistule Hook for assisting the easy passage of the needle in vesico-vaginal fistule Fork for the same ..... Introduction of the sutures in vesico-vaginal fistule Suture adjuster ..... Appearance of parts after adjustment of the sutures Application of the button .... Instrument for securing the button . Crotchets applied to the wires The button as finally applied Simpson's iron wire splint .... XXVI LIST OF ILLUSTRATIONS TO VOL. II. FIG. 637. 638. 639. 640. 641. 642. 643. 644. 645. 646. 647. 648. 649. 650. 651. 652. 653. 654. 655. 656. 657. 658. 659. 660. 661. 662. 663. 664. 665. 666. 667, 669. 670. 671. 672. 673. 674. 675. 676. 677, 679. 680. 681. 682. 683. 684. 685. 686, 688. 689, 691. Druitt's suture needle Startin's suture needle Coghill's wire twister Extremity of wire twister Sims's catheter Needle for introduction of sutures in laceration of the perineum Application of ligatures in laceration of the perineum Perineal bandage .... Hypertrophy of the mammary gland Cystic disease of the breast Adenoid tumor of breast Microscopic characters of fibrous mammary tumor Scirrhus of the mamma, showing the retraction of the nipple Scirrhus of the breast, showing section of a retracted nipple Scirrhous mamma laid open to show its lobulated surface . Section of a scirrhous nodule .... Ulcerated scirrhus of the breast .... Secondary scirrhous nodules .... Fungus hematodes of the mamma, in its open bleeding state Encephaloid of the mamma of the hematoid variety Incisions for removal of the breast . Excision of the breast Mode of supporting the breast by strapping Sling for the breast .... Malignant onyxitis of the big toe . Malignant onyxitis of the index finger Supernumerary thumb Webbed fingers .... Contraction of the thumb . Contraction of the ring finger 668. Contraction of the palmar aponeurosis, causing deformity of Deformity of the fingers from the vicious cicatrices of a burn Club-hand . Paronychia of the thumb . Necrosis of the bones in whitlow Varicose aneurism of the fingers Enchondroma of the index finger . Gouty deposits in the joints of the fingers and bursa of the elbow Scirrhus of the axilla 678. Bandages for the hand and fingers Roller for the superior extremity Bandage for the axilla Spica for the shoulder and upper part of the arm Deformity of the second toe Deformity of the great toe from inflammation of the metatarso geal joint .... Bunion .... Exostosis of the distal phalanx of the great toe 687. Varus..... Valgus .... 690. Equinus .... Calcaneus the fingers phalan- LIST OF ILLUSTRATIONS TO VOL. II. xxv n FIG. 692, 694. 695. 696. 697. 698. 699. 700. 701. 702. 703. 704. 705. 706. 707. 708. 709. 710. 711, 713. 714. 715. 716. 717. 718, 720. 721. 722. 723. 724. 725. 726. 727. 728. 729. 730. 731. 732. 733. 734. 735. 736. 737. 738. 739. 740. 741. 742. 743. 744. 743. 746, 693. Kolbe's apparatus for club-foot Tenotome . Effect of the operation for club-foot. Flat-foot .... Podelkoma . Laced stocking Obliteration of varicose veins by ligation . Twisted suture for the same Subcutaneous ligation of the same by silver wire Apparatus for ruptured tendo Achillis Gemrig's apparatus for deformity of the thigh and Knock-knee .... Housemaid's knee .... Congenital cyst of the nates Fibro-cystic tumor of the nates Microscopic examination of the same Roller bandage applied to the foot and leg . Bandage for the knee 712. Bandages for the groin . Osteo-sarcoma of the scapula, necessitating removal Caries of the elbow-joint Excision of the elbow-joint . Heath's splint, in the excision of the elbow Appearance of the wound after excision of the head of the humerus 719. Flap operations in excision of the head of the humerus Caries of the head of the humerus .... Excision of the calcaneum ..... Scrofulous caries of the ankle-joint Caries of the inferior extremity of the tibia and fibula Excision of the knee-joint ..... Excised lower end of the femur .... Excised upper end of the tibia .... Butcher's box for after-treatment of excision of the knee . Price's apparatus for after-treatment of excision of the knee An excised knee swung in Salter's apparatus Shortening after excision of the knee Appearance of excised knee two years after operation Ravages of hip-joint disease .... Excision of the hip-joint ..... Portion of femur removed for hip-joint disease Fergusson's apparatus for after-treatment of excision of the hip-joint Appearance of limb twelve years after excision of the hip Amputation of the finger, at the distal articulation Amputation of finger at metacarpal phalangeal joint Removal of the bone with the pliers Amputation of the thumb and metacarpal bone Amputation at the wrist Wrist, carpal and metacarpal joints Amputation of the forearm . Short stump of the forearm . Amputation of the arm 747. Amputation at the shoulder 1075 PAGE 1018 1019 1021 1022 1023 1024 1025 1025 1025 1027 1028 1029 1030 1033 1034 1034 1038 1039 1039 1042 1047 1049 1050 1052 1052 1053 1053 1058 1058 1060 1060 1060 1061 1061 1062 1063 1064 1066 1066 1066 1067 1068 1069 1070 1070 1070 1072 1072 1073 1073 1074 1076 XXviii LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 74S. Amputation of the toe ...... . 1077 749. Amputation of the metatarsal bone of the great toe . 1078 750. Amputation of the great toe at its junction with the cuneiform bone 1078 751. Hey's amputation .... 1079 752. Articulation of the foot . 1079 753. Appearance of stump after Hey's operation . 1079 754. Chopart's operation . 1080 755. Stump after the same 1080 756. Amputation at the ankle 1081 757. Mode of removing calcaneum 1081 758. Stump after Syme's operation 1082 759. Pirogoff's amputation 1082 760. Amputation of the leg at its inferior third 1084 761. Stump after the same 1084 702. Amputation of the leg above its middle 1085 763. Stump after the same 1085 764. Amputation of the thigh 1088 765. Stump after the same 1089 766. Amputation at the hip-joint 1091 767. Stump after the same 1092 PART SECOND. SPECIAL SURGERY; OR, DISEASES AND INJURIES OP PARTICULAR ORGANS, TEXTURES, AND REGIONS. vol. n__2 A SYSTEM OF SURGERY. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. CHAPTER I. DISEASES AND INJTJ-RIES OF THE JOINTS. SECT. I.—WOUNDS. The joints are liable to be laid open in various ways—by cuts, stabs, punctures, balls, machinery, and other means—and hence such lesions are said to be incised, punctured, gunshot, or contused and lacerated, according to the nature of the vulnerating body. In extent they may be small or large ; in character, simple or complicated ; in effect, trivial or severe. The symptoms are generally sufficiently distinct. When any of the large joints have been opened, in whatever manner, whether by a cut, laceration, or bullet, the nature of the accident is generally denoted by an immediate escape 'of synovial fluid, rapidly followed by great pain, tension, and swelling of the part, with severe constitutional disturbance. ' "When the wound is very large, especially if it be of a gunshot nature, there will generally be, along with-the symptoms just mentioned, violent shock, the patient being deadly pale, faint, and sick at the stomach ; and some hours may elapse before reac- tion comes on. In from twelve to twenty-four hours after the accident,'fever commonly sets in, often preceded by rigors, and soon followed by delirium, great gastric distress, intense thirst, and excessive restlessness, with a strong, full, and bounding pulse. The local phenomena assume a more aggravated character. The heat, pain, redness, and swelling increase in intensity, and the surface of the limb, at the seat of the injury, often assumes an erysipela- tous aspect, sometimes as early as the first thirty-six hours after the accident, and seldom later than the third or fourth day. Meanwhile, the discharge of synovial fluid augments in quantity, as well as in consistence, exhibiting a thick, ropy,.turbid appearance; or, if the wound be closed, and the fluid is retained, the joint becomes distended in every direction, but particularly in its more dilatable parts, the integuments pit on pressure, and distinct fluctu- ation is perceived. The secretion now takes on a puriform character; the patient has frequent rigors, alternating with flushes of heat, and succeeded by copious sweats ; the*joint is exceedingly tense; the synovial membrane is universally involved ; perforative ulcers form at different points; matter is freely discharged, often of a highly fetid nature; the bones are rendered carious ; and the ligaments, softened and thickened, yield at various points 20 DISEASES AND INJURIES OF THE JOINTS. of their 'extent. Tn some cases matter forms exterior to the joint, and is extensively diffused among the muscles and through the subcutaneous cellular tissue. ,. , . But it is not always that matters progress in this wise. The case which 1 have described is an extreme one. In many instances, depending mainly upon the nature and extent.of the lesion, and the character of the treatment, the inflammation, after having persisted for a few days, gradually disappears, and the patient recovers with hardly an untoward symptom, the joint, it is true, remaining temporarily stiff, but ultimately completely regaining its functions. It cannot, however, be disguised that all wounds of the joints, however trivial or insignificant they may apparently be, are in" reality fraught with danger, if not soon after their occurrence, at a period more or less remote. Gunshot and lacerated wounds in particular are hazardous, and are not un- • frequently followed by fatal consequences. I have seen, however, what, in- deed, all men of experience must occasionally witness, some very extraordinary, cases of recovery after injuries of this description. Thus, I attended, many years ago, a lad of fourteen, who, while bathing, struck his knee against the sharp point of a rock, causing a severe penetrating wound, which.got well without any serious local or constitutional symptoms, although it was in all respects, at first, most unpromising. In another case the knee-joint was opened by a pistol ball, entering by the side of the patella, and apparently lodging in one of'the. condyles of the femur, with no other effect than that of a moderate synovitis, aud slight lameness. ' Simple incised wound? are to be less dreaded, as a general rule, than lacerated and gunshot, although undoubtedly many cases occur where the symptoms are extremely severe, and where the-risk to limb and life is very great. . It may also be assumed that a wound of a small joint is less danger- ous than a similar injury of a large joint, an incised than a lacerated one, a small wound than a large one, and a simple than a complicated one; the lesions, in these respects, being governed by the same laws as wounds in other parts of the body. There are several circumstances, however, which render wounds of the joints, especially of the more important ones, as those of the knee, ankle, and elbow, peculiarly perilous, and which are the more to be dreaded, because they ate of frequent occurrence. These are erysipelas, pyemia, and tetanus. Erysipelas, as a consequence of articular wounds, usually sets in tfithin the first thirty-six hours, beginning at the site of injury, and spreading thence gradually over the neighboring surface. Its precise type will depend mate- rially upon the state of the system at the time of the accident; its symptoms exhibit nothing peculiar, but its progress is often very rapid, and its presence is always denotive of a bad state of the constitution, which it is frequently difficult to counteract by remedies. Pyemia is a frequent result of wounds of the larger joints, especially when of a lacerated, contused, or gunshot nature. Abscess of the internal organs, as a consequence of such lesions, was occasionally noticed by some of the older surgeons. The viscera which are most liable to suffer are the lungs liver,spleen, and kidneys, the disease usually appearing within the first five or six days, and speedily undermining the constitution.# As a concomitant of this occurrence important changes take place in the local symptoms The pain becomes extremely intense, the swelling rapidly increases, and the wound discharges an abundant fluid, of a thin, sanious, and highly fetid character denotive of the bad nature of the inflammation. The general phenomena are typhoid, the patient is delirious, and death soon closes the scene Tetanus is an occasional occurrence after injuries of this kind but t frequently, perhaps, as is generally supposed. I have seen only a few cases WOUNDS. 21 of it. The last which I had under my charge was a young man, of twenty- four, who received a large wound in his knee, involving the patella, from a fall of his horse, the animal rolling upon his.leg. For some days he was progressing favorably, when delirium tremens and tetanus set in, and he djed shortly afterwards. Such an occurrence must be much more common in military than in civil practice. The hemorrhage which follows wounds of the joints, although generally trivial, is occasionally quite profuse, not always "so much from'lesion of the articular vessels themselves as from injury of those in the immediate vicinity. When the blood accumulates in the cavity of the articulation, whether from internal effusion, or in consequence of outward introduction, it may act as an extraneous substance, undergoing decomposition,, and thus greatly aggrava- ting the case. Treatment.—The treatment of these wounds is sufficiently simple, inasmuch as it involves no principles different from those" which guide us in the manage- ment of similar lesions in cither regions of the body. It consists, mainly, in approximating the edges of the incision, removing extraneous matter, ex- cluding the admission of air, forbidding all motion of the joint, and e'mploying antiphlogistics to their fullest extent. When the wound is simply an incised one, a few strips of adhesive plaster will generally suffice to effect approximation, and the risk of admitting air ■will be greatly diminished, if the part be covered with a compress wet with blood, and bound down by a roller, extending from the distal porti&n of the limb upwards. The practice, however, which I generally follow in such a case, is to bring the lips of the wound together with collodion, applied with great care, so that there shall not be the least possible risk of the admission of the atmosphere, which, although in itself perfectly innocuous, is extremely liable to prove prejudicial by causing rapid decomposition of the inflammatory products. Hence, too much caution cannot be observed in the application of our dressings. If the wound be large, a few sutures may be necessary; but in general they may be dispensed with altogether. Should their aid be required, care must be taken to carry them .merely through the common in- teguments, and when so used, they will, I am satisfied, notwithstanding what has been said to the contrary, be just as innocent here as in" any other parts of the body. .In lacerated wounds, it will generally be advantageous to pare the edges before approximating them, as this will place them in a better condition for immediate reunion. When the wound is large, the synovial membrane may be covered with extraneous matter, as dirt, sand, or other substance, which may not only prove difficult of removal, but will be sure to enhance the danger of erysipelas, pyemia, and tetanus. Clearance must be thorough, and the finger and for- ceps will be the best instruments'for effecting it. Any clotted blood that may exist must be dealt with in a similar manner. If the foreign matter be deeply imbedded in the joint, and the wound is disproportionately small, rendering a search for it difficult and uncertain, the safest plan will be to let it alone. Balls ought certainly always to be treated in this manner. If, on the con- trary, the projectile lie loose in the articulation, it should unquestionably be extracted-at once, and so with every other movable or floating body, provided it is readily accessible, or that it can be taken away without the risk of inflict- ing serious additional injury. All officious interference, by finger, probe, or other instruments, must be scrupulously avoided, as the synovial membrane is exceedingly intolerant and resentful of manipulation, however gently con- ducted, bearing, in this* respect, the greatest possible^ resemblance to the peritoneum, which, as is well known, can hardly be touch'ed without becoming inflamed. When there is no prospect of union by the first intention, or when the 22 DISEASES AND INJURIES OF THE JOINTS condition of the wounded joint is such as to render suppuration incvlt^.e' the proper course to be pursued is to draw the edges of the wound ii„ iy together with adhesive strips, and to resort, without delay, to medicateu ap- plications, either in the form of water-dressing, or of emollient cataplasms. To do otherwise would only enhance the danger of inflammation ana 01 otner bad consequences,without any compensating advantages. Whatever dressings be employed, it is of paramount importance to keep the joint in an elevated and quiet position, all motion being guarded against by the use of splints and other suitable means. If the inflammation run high, liberal use must be made of leeches, scattered over the affected surface, and applied in such numbers and with such frequency as the particular exigencies of the case may seem to require. If the patient be young and plethoric, blood is promptly taken from the arm, the bowels are thoroughly moved, and the saline and antimonial mixture is freely employed, a few drops of tincture of aconite being conjoined with each dose, in orde.r to lessen more effectually the heart's action. Opium, or its salts, in large doses, will be required to relieve pain and spasm; and there is hardly a case, certainly none of severe articular wound, where it will not be proper to combine calomel with the anodyne, with a view to its speedy effects upon the system. The acknow- ledged efficacy of mercury in all inflammations of the serous textures clearly points to its administration as a matter of paramount importance here. ' It not only exerts a most happy influence upon the-capillary vessels of the dis- eased membrane, modifying and changing their action, but it is a powerful sorbefacient, and thus proves beneficial in the removal of effused fluids. Its effects, however, must be carefully watched, lest they exceed our intention, which is only to cause tenderness of the gums, and not positive ptyalism. During the progress of the case, matter may form within the joint, and become pent up for the want of an adequate outlet. Under such circum- stances, relief must be afforded by a valve-like aperture, the puncture being immediately closed by collodion, and afterwards reopened as occasion may seem to demand. When the quantity of pus is very great, pressing upon the joint in every direction, a free, direct incision should be made, to admit of full drainage. It has always appeared to me that surgeons are too timid in these cases, and that they do not sufficiently co-operate with nature in her efforts to effect a cure. It can assuredly not be necessary here to describe the per- nicious consequences which purulent accumulations, especially if long retained, must inevitably exert upon the component elements of the articulation. They can be nothing short of utter, ruin of the synovial membrane, cartilage, ;and bone. Early evacuation must also be effected, if matter form immediately around the joint, beneath the integuments and among the muscles. When the discharge is profuse and offensive, injections of linseed tea, slightly medicated with the chlorides, will be of service; they should be thrown in tepid, several times in the twenty*four hours, and may sometimes be advantageously followed by the introduction of very wreak solutions of iodine, or nitrate of silver, with a view of modifying the action of the syno- vial membrane.. Too much caution, however, cannot be used in the appli- cation of these remedies, as the inflamed membrane is often exquisitely sensitive, and intolerant of such contact. Whenever there is extensive suppuration, the parts will either recover by union of their contiguous surfaces, or the cartilage and bone will perish, or, at all events, become so involved in disease as to require removal. In the former case, the joint should be placed in the best position for future conve- nience and usefulness^; while in the latter the affected structures should either be excised, or the limb be amputated. The choice of the proceeding must be regulated by circumstances. If the inflammation has measurably subsided and the patient's strength is not too much exhausted, the joint may possibly SPRAINS. 23 bear excision; but in all cases of an opposite character the removal of the limb will be the safer operation. In the milder forms of wounds, where there is no risk either of limb or life, the gregt point of interest is to guard against anchylosis, which is so liable to occur even in the most trivial affections of the articulations. Passive mo- tion, sorbefacient embrocations, and the gradual use of the limb, will be the surest means of preventing this. Primary amputation will be required when the joint is severely shattered, whether by gunshot or otherwise, and the external opening is unusually large, or complicated with lesion of the principal vessels and nerves of the limb. • As a general rule, it may be assumed that gunshot wounds of the large arti- culations of the extremities are nearly always followed by fatal consequences, if amputation be not speedily employed. The same may be said, though in a more limited sense, of gunshot injuries of the jojnts of the toes and fingers,* in which tetanus and other bad effects are prone to ensue. In the subjoined case, where an attempt was made to save the limb, life was lost by locked- jaw. Amputation ought to have been performed on the spot. John E. Wilsop, aged tweqty-four, of stout, muscular frame, but intempe- rate habits, was thrown, while intoxicated, from his horse, the animal falling upon him, and inflicting a frightful wound upon the right knee, penetrating the joint. The patella was broken into several pieces, and a considerable quantity of dirt and gravel lay in the gap, a good deal being also imbedded in the muscles and cellular tissue. Amputation being strenuously objected to, the wound was cleared,of foreign matter, and united by suture and adhesive strips, supported by a roller extended from the toes upwards. The limb was placed in an easy, elevated position upon an inclined plane, and the joint was kept constantly wet with cold water-dressing. A grain of morphia was immediately given to allay pain, which was very severe. The case, under the judicious management of Dr. Metcalf, went on kindly until the third day, when the man was seized with erysipelas and delirium tremens, which were treated in the usual manner. He remained in this con- dition for nearly a week, alternately better and worse, so far as his general symptoms were concerned, but doing well as it respected the limb. At the end of this period a decided improvement became manifest, lasting, however, only for about twenty-four hours, when tetanus supervened, causing death a few days afterwards. SECT. IT.—SPRAINS. A sprain is the wrenching of a joint in which its ligaments are severely stretched, if not partially torn, and more or less injury is done to the parts around. Falls, blows, and twists, attended with rotation of the articulating surfaces, or a movement of these surfaces in opposite directions, are the most common causes of the accident. The joints which are most obnoxious to sprains are the ginglymoid, or those which admit of motion principally in two directions, as the knee, ankle, and elbow. The articulations of the toes, thumb, and fingers frequently suffer for the same reason, their functions and exposed situation rendering them especially prone to such accidents. The reason why the orbieular joints are so seldom affected in this way is their greater latitude and freedom of motion, their surfaces being thus enabled to undergo extensive rotation with- out putting their ligaments or the surrounding parts materially upon the stretch, whereas in the hinge-like joints the most trivial twist, by opposing a sudden check to their extremities, must necessarily cause a severe wrench. Moreover, it must not be forgotten that there is an essential difference in the 24 DISEASES AND INJURIES OF THE JOINTS. structure of the ligaments themselves in the two classes of joints, which can- not fail to exert a powerful influence upon the production of the accident in question. In the orbicular joints the connecting media are of a fibrous tex- ture, comparatively thin, yielding, and extensible, and therefore able, to a considerable extent, to get out of the way of injury; in the ginglymoid on the contrary, the ligaments are exceedingly firm, short, and indisposed to stretch, or, when stretched, incapable"of withstanding rupture, either partial or complete, of their fibres. The orbicular joints are, however, notwith- standing their greater latitude of motion and the more yielding nature of ■their ligaments, occasionally severely sprained in consequence of the extreme abduction of the limbs. Thus the ileo-femoral articulation is sometimes violently sprained by the sudden slipping of the foot outwards, far beyond the line of the body, so as to put both the capsular and round ligaments «trongly upon the stretch, inducing symptoms extremely simulative of disloca- tion of the head of the bone into the thyroid notch. It is probable that there is, in every case of severe sprain, more or less in- jury inflicted upon the parts in immediate relation with the affected joint. The muscles and tendons must necessarily participate in the wrench, suffering partial displacement, and sometimes even slight laceration ; the nerves and vessels are stretched, and the integuments are often bruised and discolored, especially when the accident has been the result of external violence. In the latter case, the articulating surfaces, being violently brought together, not only experience a severe shock, but sustain a considerable degree of contusion, thus greatly aggravating the case. Symptoms.—The symptoms denotive of sprain are the instantaneous oc- currence of pain, referred to the affected joint, impairment or total loss of motion, and a sense of faintness or sickness, caused by the shock of the sys- tem, which is sometimes extremely severe, even when no external injury has been sustained, the accident having been induced merely by a wrench or twist of the limb. If some time has elapsed since the accident, there will be swell- ing and tenderness of the integuments, as well as of the deeper structures, and probably also an indistinct perception of crepitation, depending upon the deposit of plastic matter. Discoloration of the surface, from extravasa- tion of blood, is also a not uncommon phenomenon. The pain is often at first excessive, and quite overpowering in its effects upon the system. The only accident with which a sprain is liable to be confounded is dislo- cation ; but from this it may generally be readily distinguished by a careful manual examination, by the form of the joint, by a comparison of the length of the affected limb with that of the sound one, by the history of the cause of the lesion, and, lastly, by the fact that the patient is usually able to use the parts, at least to some extent, immediately after the receipt of the injury. The examination should always be most thorough, lest a luxation be ulti- mately found, and that, perhaps, when too late to effect reduction, where originally only a sprain was sflspected. When the sprain is slight, the pain gradually subsides, the swelling is re- solved, and the joint soon regains its accustomed functions. It is far other- wise, however, when the injury is of an opposite character or Attended with severe wrenching of the ligaments, violent contusion of the articular surfaces and considerable lesion of the surrounding parts. The suffering will then be ■ proportionately great, inflammation will be apt to run high, convalescence will be tedious, and the joint may remain weak and tender for many months if noffior several years. A severe sprain, in fact, is often a much more seri- ous accident, as it respects its secondary effects, than a dislocation or a frac- ture near a joint. In neglected or ill-treated cases, and sometimes even when every possible precaution has been adopted, it will be found that the articu lation not only continues to be weak and uncomfortable for a long time b t SPRAINS. 25 that the corresponding limb becomes cold, wasted, flabby, and exquisitely sensitive; perhaps also the seat of neuralgic pain, subject to severe exacer- bation whenever exercise is attempted, or there is a change in the weather. Occasionally, indeed, the movements of the joint are never regained. Con- joined with this local trouble there is generally grave disorder of the general health, the patient being extremely nervous, irritable, and dyspeptic, fancying himself helpless and disqualified for all useful exertion, both of mind and body. The probable cause of all this suffering is the shock or concussion sustained by the nerves of the affected joint at the moment of* the accident, the effect thus produced exercising a pernicious influence upon the nutritive functions of the whole limb, and indirectly upon the well-being of the general system, especially the great nervous and ganglionic centres. .Treatment.—Two leading indications present themselves in eveYy case of sprajn, whether slight or severe ; the first is to limit and combat inflamma- tio'n, and the second to restore the joint, if possible, to its wonted functions. The first is fulfilled by the judicious use of antiphlogistics ; the second, by sorbefacients, passive motion, and exercise in the open air. As soon as the joint has been subjected to the requisite examination for determining the diagnosis, the limb connected with it is to be carefully band- aged, and placed perfectly at rest in an easy, elevated position, splints, a tin case, or a wooden box being used* if necessary, to insure more certain quietude. Sometimes the object is readily attained by laying the limb simply upon a pillow, though in warm weather this will be objectionable, as tending to keep up too much heat. Fomentations will usually be found to be more agree- able and soothing than cold applications, especially during the first few days, in nervous, irritable subjects ; and the one which I generally prefer to any other is a strong solution of acetate of lead and opium in hot water, applied by means of a piece of flannel, arranged in four, six, or eight thicknesses, and covered with a piece of oiled silk, to confine the heat and moisture. Instead of removing the cloth whenever it becomes dry, the best plan is to squeeze the lttion upon it, as occasion may require, from a sponge, as this will ob- viate injurious motion and exposure to the atmosphere. Solutions of hy- drochlorate of anfmonia and opium, a mixture of warm water, laudanum, and alcohol, and thin bags of hops will also be found extremely soothing. In sprains of the ankle-joint, I have frequently seen the happiest effects pro: duced by protracted immersion "of the limb in hot salt water. When the pain and swelling are unusually severe, leeches will be necessary, and should be employed in numbers suited to the age and strength of the patient, and other exigencies of the case. Anodynes wilr usually be required to allay muscular spasm, and should be given in liberal doses, either alone or in union with diaphoretics. Purgatives must not be neglected, and if there be any constitutional excitement, the saline and antimonial mixture will come in play. In short, the whole antiphlogistic system must be carried out in its full extent. When warm applications prove disagreeable, or are unproductive of relief, they should be replaced by cold, consisting either simpby of water or of some refrigerating mixture. The proper rule is, in all cases, to continue no re- medy longer than it is found to be soothing and beneficial. The bandage must be carefully watched; judiciously employed, its effects are usually highly advantageous, affording support to the injured joint and lynb, preventing swelling and.spasm, and promoting the absorption of effused fluids. In the milder forms of sprains, more simple means will of course answer, such, for instance, as'applications of the tincture of arnica, laudanum, or lauda- num and spirits of camphor, aided by perfect quietude of the affected parts; The urgent inflammatory symptoms having thus been dissipated, embro- cations, liniments, or lotions will be of use, the object now being the removal 26 DISEASES AND INJURIES OF THE JOINTS. of effused fluids and the gradual restoration of the functions of the joint. These should be applied at first once, and afterwards twice a day with the bare hand, the friction being gradually increased as the pain and tenderness diminish, and it will be well generally to keep the parts constantly wet with the medicine by means of a piece of flannel. Whatever local remedies be used, the bandage must on no account be neglected ; for, beneficial as it may have been in the first instance, its effects will now be incomparably more so. The limb, weakened by the previous suffering, requires tone and support, and there is Nothing so well calculated to afford these as the careful and judicious employment of the roller. It should be renewed at least once a day. At a still later stage of the treatment, great benefit will accrue from the cold douche, the water being pupped upon the part, or poured upon it from a considerable height, and the surface well rubbed afterwards with the bare hand, or a piece of coarse flannel. In some cases, where a more powerful impres- sion is necessary, it will be fqund highly advantageous to use the hot and cold douche, in immediate succession. Along with these means the use of the bandage is still steadily continued, and it may even be necessary to per- sist in the employment of stimulating embrocations. In some of these ob- stinate cases I have derived marked benefit from the daily application of fish- brine, which seems to possess other properties than those simply dependent upon the presence of saline matter,* though it is impossible to define their character. Occasionally a blister affords more relief than any other remedy, and now and then electricity is advantageous. Finally, as soon as the disease has reached the chronic stage, the joint must be gently exercised, and the patient made to walk about upon crutches in the open air. As great care should always be taken, in the acute stage, not to move the parts too soon, so in this we must not too long postpone its employment. Motion is the proper stimulus of a joint, as air is of the lungs, or food of the stomach,-and when, after any injury, it is long neglected, se- rious consequences will be sure to arise. By and by the crutch must be laid aside for the cane, and this in turn for the limb, the joint and muscles being gradually compelled into action. In nervous hysterical persons this will often be a sore trial, requiring no ordinary effort of tllfe will; neverthe- less, it must be done ; there is no alternative ; the parts must be used, or they will inevitably remain stiff and tender, and ultimately become worthless. When there is much constitutional suffering, as there often is in the more severe forms of sprains, alteratives and tonics will "be needful, and the best of these will be found to be blue mass, quinine, iron, iodide of potassium, and bichloride of mercury. Exercise in the open air must not be neglected. ■ SECT. III.—SYNOVITIS. Inflammation of the joints, technically called synovitis, is liable to occur in all articulations, but more especially in such as are of large size and of great importance as it respects their functional activity ; it may be induced by various causes, both local and constitutional, as exposure to cold the presence of interarticular bodies, and mechanical violence, as sprains blows falls, and contusions. In the great majority of cases, however, it arises from the effects of rheumatism, gout, eruptive fevers, syphilis, scrofula, and the inordinate use of mercury. Symptoms#—The symptoms characterizing inflammation of a synovial mem- brane may be stated, in general terms, to be stiffness of the corresponding joint, which is usually greatest in the morning immediately after rising but gradually diminishes upon exercise; pain and tenderness on moving and percussing the limb ; swelling and fluctuation of the affected part; a&pale SYNOVITIS. 27 glossy appearance of the skin ; inability to maintain the extended position ; and a sense of heat within the articulation. t As the malady progresses the symptoms increase in severity, and the system, sympathizing with the local disorder, is thrown into violent commotion, there being high fever, a full, bounding pulse, and an arid skin, with excessive thirst and all the other phenomena of inflammatory excitement. Under such circumstances the pain is generally very excruciating, especially at some particular spot, depriving the patient completely of appetite and sleep, and requiring large doses of opiates for its subjugation. The disease, however induced, frequently comes on in a slow, gradual, and insidious manner, even when caused by external injury, being characterized, perhaps, merely by a trifling • • enlargement of the joint, arising Fig. 1. from an increase of synovial fluid within its cavity, or partly from this and partly from in- flammatory deposits in the sur- rounding structures, attended with some degree of tenderness on pressure, and more or less suffering on motion of the af- fected parts. Eventually, how- ever, yet it may be not under several weeks, or even months, the joint assumes a soft and really swollen appearance, as in fig. 1, the limb becomes wasted, the functions of the articulation are materially impaired, and all the symptoms are aggravated. In rheumatic synovitis the symptoms are usually bold and well-marked from the start. The attack often comes on in this Way : The patient, having been exposed to cold, or been guilty of some excess in eating or drinking, retires at night, with some degree of soreness in his joints, commonly attended with a general feeling of malaise, and wakes up in the morning with excessive pain, great tenderness on pressure of the affected parts, with considerable discolor- ation of the integuments, and probably utter inability to use his limb. He is feverish and uncomfortable; his pulse is strong and full ; the skin is hot and dry ; the bowels are costive ; and the urine is scanty, high-colored, and loaded with urates. The joints-become gradually more deeply involved ; all the local symptoms increase in violence; an abundance of synovial fluid is effused ; and if the inflammation be not speedily arrested, suppuration will probably take place, the event being preceded and accompanied by rigors and high constitutional excitement. The joints most liable to suffer from rheumatic synovitis are the knee, ankle, wrist, and elbow, those of the hip and shoulder being seldom involved. The articulations of the fingers also frequently suffer, and, that of the great toe rarely escapes when the disease in the other joints is at all severe. The inflammation often begins simultaneously in several joints; or, if it commences in one only, it is extremely prone to involve others in its progress, especially its fellow on the opposite side. Thus, articular gout, or rheumatism of one knee, nearly always attacks the other knee before it finally ceases. In chronic articular rheumatism, calculous concretions are liable to form, Acute synovitis of the right knee, the other being healthy. 28 DISEASES AND INJURIES OF THE JOINTS. especially in the joints of the fingers, where they always prove a source of great inconvenience and suffering. Their character will be specially consi- dered under the head of interarticular bodies. % . Syphilitic synovitis belongs to the tertiary form of syphilitic diseases, and seldom makes its appearance until several years after the primary affection. It is most frequently met with in persons whose health has become exhausted by profuse courses of mercury and habitual intemperance. The larger arti- culations, especially the tibio-fepioral and humero-ulnar, are its most common seat; but the smaller ones, particularly those of the fingers, are by no means exempt from it. A good deal of effusion of synovial fluid usually attends; the joint, in consequence, is swollen and fluctuating, motion is impeded, the ■ parts are tender cm pressure, and the patient is harassed by excessive pain, which is always worst at night, after he has become warm in bed. This latter circumstance, together with the history of the case, and the co-existence of syphilis in other structures, will always suffice to determine the diagnosis. Of strumous synovitis particular mention will be made under a separate head; meanwhile, it is only necessary to state that the disease is almost peculiar to childhood, that it most commonly attacks the hip, knee, arid elbow, and that it occurs only in persons of a strumous predisposition. Morbid Anatomy.—The pathological changes which characterize this affec- tion must necessarily vary a good deal, according to the nature of the exciting caase, and the duration of the morbid action. Under ordinary circumstances, and in the earlier stages of the malady, there is merely some degree of vascu- larity, along with slight opacity of the affected membrane, and some increase of the natural secretion. Here apd there a little plastic matter is perceptible, either adherent to the inflamed surface, or floating about in the midst of the synovial fluid, which is usually, at the same time, more or less turbid, and abnormally thick and viscid. At a subsequent period, and especially in the more severe forms of the disease, the morbid appearances here enumerated exist in a still higher degree. There is a greater amount of lymph, the vas- cularity is more intense, as well as more diffused, and the synovial secretion is of a dirty, glutinous nature. In some instances the inflammation produces results still more disastrous; pus is freely poured out, and lining membrane, cartilage, and bone, are all involved in the ruinous consequences. In the worst cases the purulent fluid excites perforative ulceration, and escapes from the joint, the passages afterwards remaining fistulous. The surrounding structures are thickened by plastic deposits, softened, and unnaturally red and congested. Suppuration, as a consequence of ordinary synovitis, is unusual. Arthritic inflammation of the joints also rarely terminates in the formation of pus; in articular syphilis it is occasionally witnessed, but still it is infrequent; in scrofulous affections of the joints, on the contrary, it is extremely common, and constitutes one of the great dangers of the disease. The phenomena which announce the occurrence of suppuration are such as denote its presence in other parts of the body. After the disease has con- tinued for some time, violent rigors set in, followed by high constitutional reaction and copious sweats, the patient being delirious, excessively restless, and tormented with thirst. The local symptoms are all materially a°-"ra- vated, as is shown by the severity of the pain, the rapid increase of °the swelling, the extraordinary heat, and the deep discoloration of the surface. If the pus be not speedily evacuated, hectic irritation supervenes, the appe- tite declines, the sleep is interrupted, the surface is drenched with perspira- tion, colliquative diarrhoea comes on, and death gradually closes the scene.1" Such, however, is not constantly the course pursued by the disease. In many cases ulceration takes place, and the matter, thus finding a vent, ceasea to commit farther ravages. In general, however, this does not occur until SYNOVITIS. 29 after the cartilaginous and osseous tissues have been deeply involved in the mischief, and the patient is doomed to carry out a miserable existence, with a stiff joint and a deformed limb, or to perish from the remote effects of tbje malady, after many months or perhaps several years of great suffering. When a joint has once been inflamed, from any cause, it remains weak, and predisposed to disease, for a long time afterwards. The most trivial circumstance will then "be able to induce a relapse, and re-awaken the symp- toms with all their primitive severity. A frequent repetition of the morbid action is sure ultimately to lead to disorganization of the component struc- tures of the joint, and to complete loss of function. At all times, however, synovitis is a dangerous malady ; plastic matter is generally poured out in considerable quantity, and there are few cases, hqwever slight, in which there is not a strong tendency to adhesion of the opposite surfaces. In this respect, there is the greatest resemblance between inflammation of the serous mem- branes of the joints, and of the serous membranes of the viscera; in neither can this action go on to any extent, or for any length of time, without causing a flow of plasma, and wherever this substance exists, even very sparingly, there is danger of adhesion. Treatment.—In discussing the treatment of an affection so various in its origin as synovitis, it is impossible to do more than to lay down a few broad general principles for the guidance of the surgeon. When the case is one of Qrdinary character, depending upon traumatic causes, or ordinary constitu- tional derangement, as a depraved condition of the secretions, or, finally, upon a suppression of the cutaneous perspiration, it will generally yield to the judicious application of the more common antiphlogistic measures, such as would be indicated in common inflammation of other parts of the body. If the symptoms be at all,urgent, and the patient young and robust, blood must be freely taken from the,arm, and the bowels be opened with an active purge, followed by the antimonial and saline mixture, with the addition of a sufficiency of morphia to promote perspiration, allay pain, and induce sleep. Mercury is administered if there is danger of structural lesion, or evidence of plastic effusion, and is carried to the extent of rapid but gentle ptyalism, with the hope of saving texture, and preventing adhesion. The diet is light and spare ; the drink cooling and acidulated. As it respects the local means, no time is lost in placing the joint at rest, in an easy, elevated position, over a pillow, or bolster, a piece of oil-cloth being spread upon the bedding to protect it from the dressings. If the patient be a child or rebellious subject, it may be necessary to put the limb in splints, or other suitable apparatus for the purpose of more certainly insuring its quietude, a matter of paramount importance in every case of inflamed joint, and therefore on no account to be slighted. The rest must be absolute and unconditional. If the affected surfaces are permitted to rub against each other, the effect must inevitably be to aggravate and protract the morbid action. There can be no half-way measures in such a case; the thing must be done right, or it might as well not be done at'all. If perfect repose of a part is ever necessary in the treatment of inflammation, it is here, and it is therefore impossible to urge too strongly the importance of this measure upon the attention of the reader. From a neglect of this precaution I am satisfied that many joints are destroyed that might otherwise be pre- served and restored to usefulness. Of direct topical applications the most important are leeches and fomenta- tions. Leeches, however, are, as a general rule, necessary only in the more urgent cases, attended with great pain, heat, and swelling, and then they should be employed freely, in such numbers and in such a manner as the violence of the disease and the condition of the system may seem to indicate. Cupping is not to be thought of in inflamed joints, as the percussion attend- 30 DISEASES AND INJURIES OF THE JOINTS. ing the operation would cause more injury than benefit, to say nothing of the pain it would produce. In young and otherwise healthy subjects, especially q\uring the hot weather of summer, cold applications, simple or medicated, will sometimes be exceedingly grateful and beneficial, promoting evaporation, allaying pain, and opposing swelling; but in general warmth combined with moisture will be found to be most soothing and agreeable, and should there- fore have the preference. The best plan, however, in all cases is to consult the feelings of the patient, or to change the applications whenever they cease to be beneficial. My constant practice is to medicate the dressing largely with opium or laudanum, and I can hardly imagine an instance of synovitis where they can properly be dispensed with. When these means fail, or when the disease seems to be incjined to make rapid progress, there is no remedy so capable of affording relief as a blister, large enough to cover in the whole joint, well sprinkled with morphia, and retained, until it has produced thorough vesication, the. parts being dressed afterwards with a light emol- lient poultice or cloths wrung out of tepid water, with a piece of oiled silk over its surface to confine heat and moisture. The application is of course always premised here, as elsewhere, by proper depletion. • If matter should form, it is to be dealt with in the same manner as when it is deposited in other parts of the body. It is folly to look upon it in any other light. It is pent up; it is not amenable to the action of the absorbents, and must therefore be evacuated, and that early, before it has had time to cause serious structural evil. The incision need not, nay, must not, be direct, but subcutaneous, and small, not large ; and when this precaution is observed and the orifice is immediately closed to prevent the admission of air, nothing but good can result from it. A timid, cautious course will not answer here ; as long as the pus is confined, just so long will it keep up pain, and do mischief to the parts with which it lies in contact; impairing and ultimately destroy- ing their vitality, and thus putting both limb and life in imminent peril. The opening is of course made at a dependent part, and is repeated from time to time until the matter ceases to accumulate, the joint being well supported in the interval by the bandage, or by a roller and adhesive strips. The surgeon need not always despair of effecting a good cure even after suppuration has taken place, if the above measures be cautiously carried out; the probability will certainly be that the joint will be stiff, but it should be recollected that an anchylosed joint is always better than no joint at all, pro- vided of course that it be put in a proper position for future usefulness. When the disease has passed into the chronic stage, our main reliance for dislodging it must be upon the steady, persistent use of the bandage, the douche, stimulating lotions, and friction. The joint, in the first place, is washed every morning and evening with warm water and castile soap, and then douched, when, being dried, it is thoroughly rubbed with some embro- cation, or painted with equal parts of tincture of iodine and alcohol, and finally it is put up in a roller, extending from the distal portion of the limb upwards, so as to afford gentle and equable compression to every part. Gradually the joint is moved and manipulated, at first very cautiously, and afterwards, as it becomes tolerant of the operation, more and more freely, until we succeed in restoring it to its original functions. Exercise must'be taken upon crutches in the open air, but care must'be used never to carry it to fatigue; and for a good while the limb must not be permitted to sustain the full weight of the body. In some cases the joint may be advantageously strapped with gum ammoniac and mercurial plaster, or a plaster made of opium and galbanum, to promote the absorption of effused fluids, and lend support to the weakened structures. If the case prove obstinate, the remain- ing symptoms may be scattered by the use of iodide of potassium with a minute quantity of bichloride of mercury, given three times a day, and pushed SYNOVITIS. 31 to gentle ptyalism. When anchylosis is found to be unavoidable, all motion of the joint should be prohibited, and the limb be placed in the position .in which it is most desirable it should be in that event. I have said nothing here of counter-irritation by tartar emetic pustulation, vesication with, croton oil, and the use of issues, the seton, and the moxa; because, although sometimes serviceable, these means seldom afford the relief that has been so generally ascribed to them. I have certainly not, in my own practice, found them of much advantage, while occasionally I have thought they had acted decidedly prejudicially. Pustulation with tartar emetic is not only extremely painful, but not unfrequently, in delicate persons, it creates nausea and other disagreeable effects, rendering its continuance improper. The use of croton oil is hardly less objectionable. An issue may sometimes be established beneficially near the affected joint with the actual cautery, or the hot iron may be drawn linearly over the joint, at several points, in a ver- tical direction. The seton I never use in any articular disease. • In rheumatic and gouty affections of the joints, our reliance must mainly be upon the use of colchicum, whose virtues here are unrivalled. It is not to be understood, however, that colchicum is infallible; there are, undoubt- edly, cases wherein it either entirely fails, or in which its effects are but little apparent; but in general it will answer an admirable purpose, promptly re- lieving pain, depurating the blood, and expelling or neutralizing the arthritic poison. A little preliminary treatment by way of purgation, if not also by venesection, will usually be proper, and then the colchicum, given in drachm doses, with a grain of morphia, at bedtime, and followed by a gentle laxative in the morning, will seldom disappoint our highest expectations. The pain will speedily vanish, fever, swelling, and stiffness will subside, the lithates will disappear from the urine, and health will soon resume its wonted sway. Where there is much arterial action, as evinced by a full, bounding, and fre- quent pulse, the tincture of aconite will come in play, in doses of from three to four drops every three hours, or the saturated tincture of veratrum in from four to eight drops, either alone, or, as I generally prefer, in union with a minute quantity of antimony, and the sixth or eighth of a grain of morphia, so as to produce a more powerful diaphoretic impression. In the use of these several articles, great caution is needful that the dose be not carried too far, or the remedy continued longer than is necessary. Their agency is potent, and demands vigilance to keep it in proper check. Along with these means, with a view of neutralizing the acid state of the blood, free use should be made of alkalies, of which the bicarbonates of soda and potassa, in the proportion of twenty grains of the former to ten of the latter, are the most eligible. The medicine should be repeated at least every six hours, in two ounces of soft water. When the disease is rebellious, calomel and opium will be found service- able, but the former of these articles should be used with great caution. As a local application, nothing will be found more beneficial than soap liniment and laudanum, in the proportion of two parts of the former to one of the latter, well rubbed in twice a day, and retained constantly upon the affected joint with a piece of flannel, covered with oiled silk. This may be succeeded, if the disease seems to be inclined to linger, by a fly-blister. In syphilitic synovitis, the great remedy, as stated elsewhere, is iodide of potassium, aided, in obstinate cases, by mercury, carried to gentle ptyalism. Other means, both general and local, and such as have already been adverted to, are not to be neglected. 32 DISEASES AND INJURIES OF.THE JOINTS. SECT. IV__DROPSY OF THE JOINTS. By this expression is meant an accumulation of fluid in the interior of an articulation, generally a result of chronic disease of the synovial membrane. It was formerly supposed that this affection occurred only in the ginglymoid joints, but more careful examination has taught that it is also occasionally met with in the orbicular, particularly in that of the shoulder. Of the gin- glymoid joints, those most liable to be attacked are the knee, elbow, and ankle, especially the first, which is probably oftener dropsical than all the other articulations together. The causes of artitular dropsy are various ; some being local, others con- stitutional. Among the former may be classed different kinds of accidents, as sprains, blows, concussion, dislocation, and the presence of inter-articular concretions, making a direct impression upon the synovial membrane, and inducing an inordinate secretory action in its vessels. Severe and long con- tinued exercise, producing excessive fatigue in the joints, may, no Qoubt, excite the disease. The constitutional causes are not always very obvious. In most of the cases of this disease that have fallen under my observation, it was associated with, or directly dependent upon, a rheumatic state of the system, as was clearly evinced by the consentaneous existence of rheumatic suffering in other parts of the body. Gout occasionally produces a similar effect, but much less frequently. In tertiary syphilis, it is not uncommon to meet with dropsy in several of the joints simultaneously, especially in those of the knee and elbow, and I believe that this effect will be more certainly brought about if the individual has been subjected to severe courses of mercury for the cure of that malady in its primary stages. A strong predisposition to the disease is sometimes observed, and then the slightest causes are generally sufficient to call it into action. In weak, strumous subjects, it is occasionally a sequel of typhoid fever, scarlatina, measles, and smallpox. Suppression of the cuta- neous perspiration may also induce it; and in many .cases it comes on without any assignable cause whatever. . Symptoms.—The symptoms of .this disease are generally well marked, the most prominent and reliable, in a diagnostic poiut of view, being aloss of the natural contour of the joint, and the existence of a soft, elastic, and irregu- larly circumscribed swelling. The skin ordinarily retains its normal cofor, and the motion of the articulation, although considerably impeded, is rarely attended with much pain or inconvenience. The tumor affords distinct fluc- tuation, and is most conspicuous where the ligaments of the joint are loose and superficial. In the wrist, for example, it is most apparent at the anterior and posterior aspects of the joint; in the ankle, in front of the malleolar processes, a short distance above the instep ; in the shoulder, in the space between the deltoid and pectoral muscles; and in the knee at the sides of the patella. In the latter, where the swelling is often double, its shape and consistence are materially influenced by the movements of the limb being softer and more decidedly fluctuating in extension than in flexion Pressure upon the tumor is seldom productive of much pain ; generally indeed it causes merely a little uneasiness, or a sense of tenderness. In cases of lone standing there is sometimes considerable enlargement of the subcutaneous veins, but this is uncommon. The progress of these dropsical affections is usually very chronic manv months often elapsing before the tumor attains any considerable bulk S times, however, the reverse is true; in the knee, in particular freouSv large collections occur within three or four weeks. Their march is II DROPSY OF THE JOINTS. 33 most rapid in rheumatic and gouty subjects, and after attacks of the exanthe- matous fevers. . In regard to the diagnosis, the history of the disease, the change in the contour of the joint, the fluctuating and indolent character of the swelling', and the comparative freedom of motion of the affected structures, will gene- rally serve to prevent error. . Should there, however, be any doubt after the swelling has been thoroughly scrutinized, the#difficulty may at once be decided by the insertion of the exploring needle, the nature of the escaping fluid being characteristic. Morbid Anatomy.—The pathological anatomy of these collections has not received the attention it merits, from the fact that it is rare that an oppor- tunity is afforded of inspecting the affected joint. Enough, however, is known to show that there is generally, especially in cases of long standing, consider- able opacity and thickening of the synovial membrane, with some degree of vascularity, the vessels being spread over the surface of the membrane in delicate, arborescent lines, widely separated from each other. Occasionally slight deposits or patches of lymph exist, giving the part a rough, uneven appearance, but this is infrequent. The cartilages and bones present no perceptible changes, nor do the muscles and other parts around the joint, except that "they are more or less displaced by the dropsical distension. When the accumulation is very great the capsular ligaments, pressed upon in every direction, become very much stretched and attenuated. Cases occa- sionally occur where the ligaments are so much distended as to give way, thus allowing the fluid to diffuse itself among the surrounding structures. The dropsical fluid is generally pf a pale, yellowish, straw or amber color, and of a ropy, unctuous, or sero-oleaginous consistence ; sometimes it is tur- bid, whey-like, or sanguinolent, and intermixed with flakes, shreds, or masses of lymph. Its quantity is variable, depending upon the size of the joint, the duration of the case, and other circumstances. In the knee it frequently amounts to from sixteen to twenty ounces. Prognosis.—The prognosis is always more favorable, other things being equal, when the swelling is recent and small than when it is of long standing, large, and attended with organic lesion of the synovial membrane. In the latter case the disease is often extremely obstinate, and may become danger- ous, as it is liable to be followed by anchylosis, or ruin of the articular car- tilages and bones. Treatment.—In entering upon the treatment of this affection, the practi-' tioner will generally derive his most valuable indications from a consideration of the nature of the exciting causes, which, if properly understood, are often easily removed. It must be constantly borne in mind that dropsy of the joints, like dropsy everywhere else, is not a disease, but merely a symptom of disease, and hence one of the very first*and most important objects is to endea- vor to remove the lesion upon which the presence of the fluid depends. The question will; therefore, necessarily arise, in every instance, what has been the origin of the affection? Has it been local or constitutional ? Upon the success with-which this question is answered will mainly depend the success of our remedies. When the affection is of a local nature, caused by a sprain, contusion, or other injury, local remedies alone will generally suffice to effect a cure, espe- cially if assisted by an occasional purge and a properly regulated diet. The means to be chiefly relied upon are, perfect quietude of the affected joint, embrocations, and vesicants. Without rest, absolute and unconditional, little progress can be made in any case ; it should of course be conjoined with proper elevation and an easy, relaxed position of the parts. In the milder varieties of dropsy, frictions with iodinized lotions, soap liniment, camphorated spirits, and mercurial unguents, seldom fail to make a rapid and • vol. n.—3 34 DISEASES AND INJURIES OF THE JOINTS. decided impression upon the absorbent vessels of the joint, as is shown by the speedy diminution of the size and tension, of the swelling. ^ hichever of these means be employed, they should be applied at least twice a day, being rubbed upon the whole of the affected surface with the bare hand until a full glow is produced, when the friction should be discontinued, to be re- peated in the same careful, but efficient, manner at the next operation. In the meanwhile, the parts should#be well supported with the bandage, extend- ing from the distal extremity'of the limb, the compression thus derived powerfully aiding in the reduction of the effused fluid. When it is evident, from the gradually decreasing volume of the sac, that the absorbents have been fairly roused, the inunctions may be advantageously preceded by the cold douche, or by the hot and cold, applied in immediate succession ; a plan which I have often seen productive of the most salutary effect. When, as occasionally happens, there are evidences of incited action, the surface being hot and tender, refrigerating lotions, consisting simply of cold water, or of water impregnated with acetate of lead and opium, must be em- ployed ; for as long as the capillary vessels are over-active little benefit can be hoped for from sorbefacients, properly so called. Even leeching and brisk purgation may then be necessary. • • In obstinate cases, I have found no topical remedy at all comparable to vesication with cantharides, left on until the epidermis is thoroughly raised, the discharge being afterwards promoted by emollient dressings, and the blister reapplied as soon as the surface is partly cicatrized. This method is much more salutary than that of keeping open the sore by means of irritating salves ; it seems to produce a more direct .effect upon the absorbent vessels, and is at the same time much less painful, an object of great importance in the treatment of all chronic maladies. I have no patience, in this disease, with pustulation with tartar-emetic oint- ment and croton oil, so much vaunted by certain practitioners, believing it to be much more productive of harm than of benefit; and, as to the moxa, issues, and setons, I have never had any reason to employ them, having al- ways succeeded with other and milder means. When the affection is clearly of a rheumatic, gouty, syphilitic, or strumous origin, remedies calculated to meet these several contingencies are clearly in- dicated, and nothing short of their exhibition will be likely to be of any per- manent benefit. Colchicum, mercury, iodide of potassium, and other kindred • articles, are then the means chiefly to be relied upon for relief. When the dropsy is symptomatic of fever, or some of the eruptive diseases, it often dis- appears spontaneously, as the patient improves in health and vigor, or readily yields to mild measures, particularly tonics, and change of air. Ordinary hydragogue medicines do little or no good in this affection in any of its forms. As the joint will necessarily remain weak for a long time after the removal of the fluid, it should be supported with a laced-cap, fig. 2, or suitable band- age, kept cool by frequent ablutions with alcohol and water, and not be exposed to too much fatigue. Finally, should the disease resist the means now suggested, or continue to increase, so as gradually to impede the motions of the joint, Fig. 2. accompanied with wasting and coldness of the limb, relief should be attempted by evacuation of the fluid by subcutaneous puncture. The operatiou may be performed either with a de- licate trocar or bistoury, inserted in such a manner as to make a valve-like opening, which should be closed, the moment the fluid has been drawn off, with collodion, a compress and band- age, the object being to exclude the entrance of the air. The instrument should be introduced at the most dependent and superficial portion of the swelling, at least an inch and a half beyond its MOVABLE BODIES WITHIN THE JOINTS. 35 boundaries, its point being carried along the cellular tissue until it reaches the sac, which is then pierced in the usual manner. Thus performed, no pos- sible injury can result from the operation, while, by removing the fluid, over which the absorbents have no longer any control, it affords the only chance of relief. For some days after the operation the limb is kept perfectly quiet, light diet is enjoined, and every precaution is taken to prevent inflammation. Re-accumulation is guarded against by the means already indicated. I have not been so bold as to use injections for the permanent cure of this affection, convinced that the practice must be fraught with danger. The article which has been used for this purpose, by Yelpeau, Bonnet, and others, is tincture of iodine, in the proportion of one part to two, three, or four of water, introduced subcutaneously, with a syringe, to the amount of from two to four ounces, and retained for one or two minutes, the joint being pressed slightly during its sojourn, in order to bring the solution fully in contact with ■ the diseased sac. It is then permitted to flow off spontaneously, when the opening is carefully closed, and the case treated on general principles, the great object being to keep the resulting inflammation within proper limits. Of the safety, and, consequently, the propriety of this operation great doubt is entertained by many practitioners, and, I think, justly so ; for, although it has unquestionably succeeded in some cases, yet it is equally certain that in others it has been followed by such a degree of inflammation as to imperil both limb and life. Unfortunately we have no reliable statistics to serve us as guides in this matter. ' SECT. V.—MOVABLE BODIES WITHIN THE JOINTS. Various kinds of bodies, mostly movable, but sometimes adherent, are liable to form in the cavity of the joints, where, interfering with the functions of the opposing surfaces, they become a source of much annoyance, and some- times even of intense suffering. Ambrose Pare, in 1558, seems to have been the first to call attention to this subject, which has since been made a frequent object of inquiry by some of the most able and distinguished surgeons. 1. Those bodies, usually known under the name of inter-articular cartilages, or osseous concretions, have been met with in various articulations, particu- larly in those of the knee, elbow, wrist, and jaw, the first, however, being apparently their favorite seat, for it is there that they occur most frequently, and that they attain their greatest bulk. The orbicular joints rarely suffer from them; a circumstance which does not admit of easy explanation, although it may be assumed that it depends mainly upon the conformation of the articular surfaces opposing their development in the one case, and pro- moting it in the other. It is difficult to determine why the tibio-femoral articulation should suffer so much more frequently in this way than other joints of its class, unless the fact is attributable to its larger size and its greater liability to all kinds of injury calculated to excite inflammation in its lining membrane. The size, number, form, color, consistence, and structure of these bodies are liable to much diversity. In the knee, where they attain their largest bulk, they sometimes acquire the dimensions of the patella, or of a hen's' egg, though commonly they are much smaller. Their number is generally in an inverse ratio to their volume. When very large there is often only one, whereas under opposite circumstances there may be as many as a dozen, twenty, thirty, or. even more.- In one case, as many as sixty were found. The largest number I have ever known to be removed from one joint was thirty-eight, varying from the volume of a pea to that of a pullet's egg. They are, for the most part, of a whitish, grayish, or pale straw color; while 36 DISEASES AND INJURIES OF THE JOINTS. their consistence, like their structure, ranges from that of fibro-cartilage to that of bone, with every possible intermediate gradation. Their shape is generally very much modified by that of the joint in which they are developed. Thus, in the knee they are often, if, indeed, not commonly, of an irregularly flattened figure, not unlike that of the patella, or they resemble a disk, .convex on one side, and concave on the other, in conformity with the outline of the condyles of the femur and the head of the tjbia. In many cases, again, even in the knee, they are .of a lenticular, rounded, or ovoidal shape. Consisting usually of a single mass, they are sometimes marked off into several lobules, connected together by a kind of condensed cellular substance. Their surface may be perfectly smooth, or partly smooth and paftly rough, and I have seen specimens which presented numerous hollows and even distinct perforations, giving them a porous aspect. Their weight depends altogether upon their structure. Structure and Development.—The structure of these bodies varies. In their earlier stages it is generally fib'ro-cartilaginous, but as they advance in age they assume the character of cartilage, and ultimately that of osseous matter. The process of conversion from fibro-cartilage to bone is generally very gradual, and almost always begins in the centre of the concretion, though occasionally it displays itself simultaneously both &i the centre and at the periphery, or first at the surface and afterwards in the interior. When several such bodies coexist it often happens that they exhibit material differences in their development; some being comparatively soft, evidently from their car- tilaginous nature, and others very hard and osseous. The mode of development of these bodies has excited much discussion, and even now, notwithstanding the time and pains that have been expended upon it, the question can hardly yet be said to-be definitely settled. Without recounting any of the many speculative views that have been advanced upon the subject, which the scope and character of this work forbid, it must be sufficiently apparent to every pathologist that they invariably take their rise in plastic effusion, excited nnder the influence of inflammation. This matter no doubt soon becomes organized, and being constantly compressed by the opposing surfaces of the joint, is at length moulded into the peculiar shape which is found to distinguish these bodies when they have attained their maturity. When the friction is very great their surface will generally be proportionately smooth or even polished, and their consistence will also be more dense than when the pressure is less. The fact that these bodies are susceptible of various transformations shows that they have an appropriate circulation, and also that this circulation continues in force long after they lose their attachment to the synovial membrane, upon the free surface of which it is evident that they are originally developed, and not beneath it, in the subserous tissue, as has sometimes been alleged, the excessive closeness and density of that substance being altogether incompatible with such an occur- rence. At what period they become loose, or floating, is not determined; the circumstance probably depends very much upon the amount of friction to ^which they are subjected in the different movements of the articulation An- other cause which doubtless contributes to their detachment is the atrophy which their vessels experience after their development has reached the osse- ous, or cartilago-osseous point. Their primitive connection is usually effected through the medium of a short, narrow pedicle. The size and shape of these bodies are well represented in fio- 3 from a drawing of several in a collection of thirty-eight, for which 1 am°indebted to Dr. John T. Berry, of Kentucky, who removed them, without any untoward occurrence, from the left knee of a colored man, upwards of thirty five vears of age. When quite young, he received a slight injury upon the ioint which, though not painful, was soon followed by considerable enlargement' MOVABLE BODIES WITHIN THE JOINTS. 37 Two years prior to the operation performed for his relief, he perceived a small, round, movable tumor, immediately above the external condyle, which Fig- 3. Fig. 4. in the articulation. Occasionally, however, Attached articular concretions. the external one changed its position, slip- ping round to the anterior surface of the thigh, above the patella, where it interfered so much with his progression that the man was immediately ob- liged to sit down, and push it back to its original position. An incision being made into the external tumor, the concretions were readily extracted, having all been contained in one sac, of a dense, firm consistence, which occu- pied the lower part of the front of the thigh, and communicated with the cavity of the joint. There were thirty-eight altogether, from the volume of a pea to that of a pullet's egg, of a whitish, glistening appearance, rough or pitted on the surface, and of various configurations, some being spherical, some oval, and others lobulated and extremely irregular. Fig. 4 exhibits several bodies of this kind as they lie in the joint attached to the synovial membrane. Symptoms:—The symptoms which announce the presence of these inter* articular bodies are often so well marked as to render it impossible to be de- ceived by them. This is particularly true when they occur in the knee. There are, however, on the other hand, cases where the nature of the disor- der is so obscure as to elude, at all events for a time, the most careful exami- nation. In general, it will be found that the intruder, if large, will cause but little pain, whereas if it be small, and susceptible of slipping about, or of becoming wedged in between, the articular surfaces, it will occasion severe suffering, followed, if the accident be frequently repeated, by violent syno- vitis. When, for example, the inter-articular substance gets behind the patella, as th» patient is standing or walking, he is often seized with a sudden pain, and is instantly compelled to sit down, in order to save himself from falling. In the night, his sleep is liable, to be disturbed by any inadvertent movement of the limb that may favor displacement of the concretion ; and when the disease has existed for a long time, and is attended with much re- laxation of the ligaments, any accident of the kind, however trivial, is apt to be succeeded by excruciating agony, sometimes carried to such an extent as to produce fainting. When the extraneous substance gets in the habit of slipping about, it is 38 DISEASES AND INJURIES OF THE JOINTS. sure not only to create pain, keeping the joint constantly tender and uncom- fortable, but also enlargement, both by interstitial deposits in the surround- ing structures and increase of synovial fluid. The intumescence, however, is rarely so great as to prevent the surgeon from feeling the concretion, or pushing it about from one point to another. In the knee, it generally forms a marked projection on the side of the patella, more frequently on the exter- nal than the internal, its outline being distinguishable both by the sight and touch. Cases occur in which, retreating to a particular part of the joint, it becomes comparatively harmless, the patient being so comfortable as to ima- gine he has got rid of it. After some time, however, usually very brief, it leaves its lurking place and goes to some other, thus causing a renewal of all the former trouble. As the affection progresses, the joint becomes more and more tender, swollen, and feeble; the synovial membrane, constantly fretted by the fric- tion of the concretion, pours out an additional quantity of its appropriate secretion ; the ligaments become greatly relaxed, and the patient, at first merely limping, is at length rendered permanently lame and helpless. Diagnosis.—The most important diagnostic signs are the suddenness with which the joint is deprived of its use, the severity of the concomitant pain, the ability of the surgeon to feel, see, and push about the concretion, and the facility with which the patient can generally relieve himself by his own efforts. The chronic nature of the disease, the absence of external injury, and the frequent recurrence of the symptoms from the most trivial circumstances, afford important collateral evidence of the character of the affection. Although the complaint under consideration is not generally dangerous, yet, as it often materially interferes with the movements of the joints in which it occurs, and does not admit of permanent relief, except by a surgical ope- ration, which is itself always hazardous, we cannot be too cautious in giving our prognosis. The removal of the concretion, by the absorption of its sub- stance, is impossible. Treatment.—The treatment is palliative and radical. When the concretion . is moderately large, or if, whatever its size may be, it is inclined to remain quiet, and not to occasion any material inconvenience, or to produce any serious embarrassment in the functions of the joint, the most judicious plan will be to let it alone, care being taken to support the parts with a laced- cap, or some other suitable contrivance, calculated to prevent the substance from slipping about, and thus doing harm. The relief thus afforded, however, is generally very transient, and we are, therefore, dompelled to adopt other and more efficient measures. Great objection has been urged against the use of the knife in the treat- ment of these inter-articular bodies, and not without just reason ; for, beyond question, all interference of the kind is eminently dangerous both to limb and life. This remark, however, is more particularly applicable to the old method of opening the joints ; that is, by direct incisions, an operation which was often followed by most serious consequences, and which should, therefore, have long ago been discarded. We have no statistics to show the mortality of'the opera- tion, but enough is known to satisfy any unprejudiced mind that it must have been very fearful, judging from the number of fatal cases and of* hair-breadth escapes that have appeared in the journals of this and other countries Even where the utmost precaution was observed in regard to the preparation of the system, and where the operation was performed with the greatest possible skill and tenderness, the result was often most disastrous ; or if the patient recovered, it was only after the most anxious attendance that his safety was finally insured. A case, it is true, occasionally got well without a solitary untoward symptom, as that, for example, communicated to me by Dr Berry MOVABLE BODIES WITHIN THE JOINTS. 39 above referred to, but it is evident that such a case cannot be used as an argument in favor of the procedure. None of these objections lie, I conceive, against the operation devised nearly simultaneously by Mons. Goyrand, of Aix, and Mr. Syme, of Edinburgh. This operation, in which the knife penetrates the joint subcntaneously, pre- vents the admission of air, and is, therefore, comparatively free from danger. Nevertheless, I should deem it a matter of paramount importance, even here, to subject the patient to a most rigid preliminary course of treatment. With this view, he should be confined to the house for at least a fortnight, with the affected joint in a perfectly quiet condition ; the bowels and secretions should receive careful attention ; and the diet should be perfectly plain and simple, all animal food being scrupulously interdicted. Such precautions are emi- nently proper in all cases, but particularly so if one of the larger articulations is concerned, where, if severe inflammation follow, the worst consequences may be expected. The subcutaneous section of the knee will serve as a type of the operation upon the other joints. The limb being extended upon a table, the foreign body is brought to the upper afid outer side of the patella, beneath the large external muscle, where it is to be securely held by an assistant, while the surgeon introduces a long, narrow bistoury, from above downwards, into the synovial pouch, which is then freely divided, so as to permit the concretion to be pushed through the opening into the subcutaneous cellular tissue, or among the structures exterior to the joint, entirely beyond the serous lining. The puncture is covered with collodion, and a compress is gently bound upon the knee, immediately over the upper border of the concretion, the object being to promote speedy union of the edges of the articular wound. The limb is kept perfectly at rest,.free use being made of cold water-dressing and other antiphlogistics. When the inner wound is healed, the extraneous substance may be removed by simple incision ; or, if not in a condition to cause incon- venience, it may be allowed to remain in its new position, where it will soon become imbedded by plastic material, and prove comparatively harmless. From statistics recently collected by Mons. Hyppolyte Larrey, it would appear that the subcutaneous operation for the removal of these bodies is by no means so safe as has been generally supposed. The total number of cases was 167, of which 129 were by*direct incision, and 38 by indirect, or subcu- taneous. Of the former, 96 were cured, 5 failed, and 28 died. Of the latter, 19 recovered, 14 were unsuccessful, and 5 perished. 2. The movable joints are occasionally the seat of gouty concretions, which, from their color and consistence, have received the name of chalk-stones. They are composed of urate of soda, a peculiar fatty matter, phosphate and carbonate of lime, and a minute quantity of carbonate of magnesia. In an old man, whom I examined some years ago, I found these concretions in nearly all the principal joints of the body, in small amorphous masses, of a whitish color, and of a.soft, unctuous consistence. Sometimes they are per- fectly smooth and round; more commonly, however, they are rough and irregular, grooved or nodulated. They are generally small, but have been observed of the volume of an egg. Their origin is always connected with a gouty diathesis. • The treatment of this form of concretion is chiefly constitutional, directed to the removal of the gouty diathesis, with which its origin is so intimately associated. Colchicum and aconite, with an occasional mercurial purge, and free use of lemon-juice, constitute the chief remedies. For a long time, means should be employed to depurate the blood, or, what is the same thing, to keep up a healthy state of the digestive organs, and an active condition of the renal secretion. If the joint ulcerate, or threaten to do so, extrusion 40 DISEASES AND INJURIES OF THE JOINTS. should be effected -^in the former case, by direct incision, and in the latter by the subcutaneous method. 3. The synovial membrane is occasionally the seat of fibrous tumors. They occur in differ joints, but principally in that of the knee, where several some- times exist together, varying from the volume of a bean to that of a large almond. On one occasion, several years ago, I removed a growth of this description, which was fully as large as a pullet's egg. It was of an elon- gated, flattened, pyriform shape, and was attached, by a short, na/row pedicle, to the upper and anterior part of the inner condyle. The patient, a man of twenty-seven, had labored umder synovial irritation for many years, attended with partial anchylosis, and much pain, and tenderness, which were always aggravated upon the slightest exertion. A subcutaneous incision being made into the articulation, the tumor was detached by a few turns of the point of the knife, and immediately extracted with a very delicate, slender pair of forceps. The wound, closed with collo'dion, healed by the first in- tention, no untoward symptom occurring, as far as the joint was concerned. Some erysipelas, however, appeared on the skin, and a week afterwards a large abscess formed at the inner and middle^)art of the thigh, which some- what retarded recovery. Another tumor, doubtless of a similar nature, was found occupying the deeper portion of the joint, but, dreading farther inter ference, it was thought best not to meddle with it. The functions of the knee were much improved by the operation. The tumor, after ablation, was found to be of a pale greenish color, ex- tremely firm and tough in consistence, smooth, glistening, and somewhat vas- cular on the surface, and of a distinctly fibrous structure. 4. There is a curious growth of the synovial membrane, to which, from • -the peculiarity of its.appearance, the term fimbriated has been applied. It is chiefly observed in the large joints,.as in those of the knee and hip, and consists of in- numerable little bodies of all sizes, from that of a millet seed up to that of a pea, of a pale yellowish or whitish color, and bearing a very close resemblance to the epiploic appendages of the large intestine. Of a smooth, glistening appearance, tbey stud the free surface of the synovial mem- brane in every direction, being connected to it either by a broad base, or, as is more generally the case, by a narrow, slender pedicle. Their structure is evidently of a fibro-cellular character, originating in a deposit of plastic matter, which assumes the peculiar arrangement in question in consequence of the friction exerted upon it by the opposing surfaces of the joint in which the substance is effused. The ac- companying cut, fig. 5, for which I am indebted to Mr. Pirrie, affords an-excellent illustration of this form of morbid growth. The symptoms occasioned by the fim- briated synovial membrane are altogether of a mechanical character, consisting of pain and stiffness, and of a grating sensa- tion during exercise, along with more or less swelling in and around the joint from Fimbriated growth of the synovial mem- brane. TUBERCULOSIS OF THE JOINTS. 41 inflammatory deposits. There are no diag- nostic symptoms, and the treatment must, therefore, be conducted upon general anti- phlogistic principles. 5. Fibroid bodies, of the size and shape of cucumber, squash, or melon seeds, occasion- ally form' in the joints, doubtless in the same manner, and from the same causes as the larger concretions. The annexed cut, fig. 6, from Druitt, affords a beautiful illustration of a remarkable case of these peculiar growths. SECT. VI.—TUBERCULOSIS OF THE JOINTS. 1. GENERAL OBSERVATIONS. Fig- 6. The synovial membrane of the knee- joint studded with numerous melon-seed shaped bodies, the patella being turned down. Tuberculosis of the joints, formerly known as white swelling, and still described under this name by some of the French writers, is an extremely common affection. Beginning either in the areolar substance of the articular extremities of the bones, in the articular car- tilages, or the synovial membranes, or, as per- haps not unfrequently happens, simultane- ously, or nearly simultaneously, in all these structures, it is almost peculiar to children under ten years of age, and generally pursues a chronic course, although occasionally it proceeds with so much rapidity as to entitle it to the distinction of an acute malady. However this may be, it seldom stops until it has produced the most extensive textural ravages, con- sisting in the destruction, either partial or complete, of the affected articulation. Constitutional involvement is usually well-marked, especially in the latter stages of the complaint, when it is also not uncommon to find serious lesion of some of the internal viscera, as the lungs, spleen, and mesenteric ganglions. The disease, as the. name'imports, is essentially of a strumous nature, and can therefore occur only in persons of a strumous diathesis. The joints which are most prone to suffer from tuberculosis are the movable ones, particularly the hip, knee, ankle, elbow, and wrist. Those of the tarsus are also remarkably liable to it. Sometimes several joints suffer simultaneously, and instances occur in which the disease would seem to be hereditary. Etiology.—The exciting causes of this affection are, in general, exceedingly obscure. Indeed, in the great majority of instances they are utterly inscru- table. The surgeon, it is true, is often told that the patient, perhaps weeks or months before the appearance of the characteristic phenomena, received some injury, as a blow, fall, or kick; or that the affected joint had been sprained, bruised, or twisted; but my experience is that such information is usually little reliable, or that, if such an occurrence really did happen, it exerted little, if any, influence in developing the complaint. Unless very severe, such accidents would no more provoke tuberculosis of a joint than a similar injury of the chest would produce tuberculosis of the lungs, or of the head tuberculosis of the arachnoid membrane. Nothing is, of course, impossible, and it would, therefore, be folly to deny that external violence might not occasionally induce strumous disease in an articulation, but such an event is certainly infrequent, if not exceptional. Exposure to cold, intense or protracted, is a powerful cause of-this disease, 42 DISEASES AND INJURIES OF THE JOINTS. and is particularly apt to provepernicious in persons of feeble constitution, ill-fed, and with an impoverished state of the blood. The influence of this agency in exciting pulmonary phthisis has long been recognized by practi- tioners. Tjiving in damp, under-ground, ill-lighted, and ill-ventilated apart- ments operates in a similar manner. Simple suppression of the cutaneous perspiration, suddenly induce^, as when an individual is exposed to a strong current of air, is also apt to produce the disease, especially in one predisposed to its occurrence. In many cases tuberculosis of the joints appears to be caused by the use of unwholesome food, chronic disorder of the digestive apparatus, imperfect assimilation, or inadequate nutrition, however occasioned. Protracted courses of mercury, establishing a severe drain upon the system, followed by the ab- straction of the plastic elements of the blood, may lead to similar results. The same is true, though the circumstance does not always readily admit of proof, of the exhaustion consequent upon copious and protracted hemor- rhages, infantile cholera, chronic diarrhoea, scarlatina, measles, smallpox, and of typhoid, intermittent, and other fevers; in short, of everything that has a tendency to enfeeble the system and degrade the blood. It has frequently been asserted that rheumatism is a common cause of this "disease, but I have never seen an instance corroborative of the truth of the statement. The fact is, it is not at all probable that that affection ever exerts such an influence; for, in the first place, it is well known that tuberculosis is exceedingly rare in rheumatic subjects, and, in the second, that, when disease of the joints shows itself in persons of this*description, it is very different from the strumous disorder under consideration. Persons of fair complexion, light hair and eyes, a delicate skin, and a Ian- ' guid circulation, with a tendency to eruptions of the scalp and enlargement of the lymphatic ganglions, are most prone to tuberculosis of the joints. In many cases the strumous diathesis exists in a most marked degree, the tumid lip and belly, the long eyelashes, the cold extremities, the flattened shape of the fingers, and the disordered condition of the digestive organs, affording unmistakable evidence of its presence. No oue who has been in the habit of meeting with this disease can have failed to notice the different temperaments of those who are most prone to its attacks. These are, according to my observation, the sanguine and the lymphatic, or a combination of these. In the former, the characteristics are, a rosy state of the countenance, a well-developed muscular system, with a tendency frequently to a certain degree of embonpoint, a vigorous circulation of the skin, warm extremities, and an active state of the intellect. In the latter, on the contrary, everything is reversed. The face is pale, often swollen and pasty, the muscles are soft and flabby, the feet are habitually cold, the cutaneous circulation is feeble, the pupils are dilated, and the mind is sluggish. In both, but more particularly in the lymphatic' the belly and upper lip are often remarkably tumid, and most expressive of the tubercular. diathesis. These two varieties of temperament, with their modifications, deserve careful consideration, as'they form the basis of important therapeutic indications in the disease in question. Morbid Anatomy and Pathology.—The morbid changes induced by this disease vary according to the different stages of its progress. As it never proves fatal in its incipiency, all that we know of these changes at this period, has been learned accidentally, by examining the bodies of those who have died of other maladies. Enough, however, has been ascertained to show that they do not differ materially, if any, from those of ordinary inflammation The synovial membrane, which is commonly first implicated in the morbid action, affords evidence of slight vascularity, a few delicate, straggling- vessels loaded with blood, being observable upon its surface, and in most cases it TUBERCULOSIS OF THE JOINTS. 43 is somewhat opaque and softened, not uniformly, but at certain points. An appearance of thickening is often imparted to it, from a deposition of lymph, which, being poured out, perhaps even quite freely, soon assumes a pulpy consistence and a pale yellowish color, though occasionally it verges upon greenish. Sometimes it is shreddy, tomentose, or filamentous. The articular cartilage, if seriously involved in the inflammation, is of a dull whitish, or slightly grayish aspect, and somewhat thickened, softened, and partially sepa- rated from its osseous connections. The cancellated structure of the bones is abnormally vascular, light, porous, humid, and at the same time easily broken and cut. Not unfrequently its cells are distended with yellowish tubercular matter, of a semi-solid, caseous consistence ; or, this substance presents itself in the form of distinct masses, free or encysted, and, perhaps, not larger than a millet-seed. The ligaments usually suffer early, being abnormally red, tumefied, and softened. The synovial fluid is generally increased in quantity, but rarely to any considerable extent. As the malady advances, the alterations above described become more distinctly defined ; the disorganizing process being now in full play, its de- vastating effects are plainly visible in every portion of the joint. The lymph gradually-increases in quantity, and is often intermixed with a-little sero- purulenit matter, or thick greenish-looking pus. The synovial membrane is partially destroyed, and what remains is of an opaque, muddy, and ragged appearance. The cartilage is ulcerated, pulpified, discolored, perforated, and almost completely detached. The bony structure is very red, soft, cari- ous, rough, and easily crumbled. The ligaments exhibit well-marked signs of inflammation, being loose and spongy at one point, attenuated at another, and perhaps thickened or hypertrophied at a third. The microscopical appearances of ulcerated cartilage and carious bone, the result of changes wrought during the progress of strumous disease of the joints are well shown in the annexed cuts, figs. 7 and 8. Fig. 7. Fig. 8. Section of a strumous tibia, the upper portion exhibitrng a mere pultaceous mass, interspersed with dark cells. Nucleated cells are often found in the lacunse ; a very large one, the 1.85 of a line in diameter, is seen in the lower right corner of the cut. The disease having reached its acme, the structures of the joint are com- pletely subverted, with hardly any traces of their original appearances. Pus Section of a strumous ulcer of a cartilage, mag- nified 500 diameters. 44 DISEASES AND INJURIES OF THE JOINTS. is now usually seen, often, indeed, in large quantity, with all the qualities ot strumous matter. This, however, is not always the case ; for, at times, it^ is thick and pultaceous, caseous, ichorous, or sero-sangninolent. In some in- stances it is very thin, and almost black, from the effects evidently of the necrosed condition of the bones. If death takes place after a process of recovery has been set up, the joint will be found to be filled by a white, fibrous, organized substance, the extre- mities of the bones being anchylosed, or firmly attached by new matter to the surrounding structures. It is very rare for a new socket to be formed, and yet this is not impossible. In time, the artificial joint may admit of consi- derable motion, but, in' general, this is extremely restricted. Occasionally an imperfect ligament is formed round the bony remnants, and the surface of these bony remnants may even become slightly tipped with cartilage. Finally, osseous growths—short, irregular, and friable—occasionally make their ap- pearance upon the bones, in the vicinity of the former disease. The bodies of those who die of strumous disease of the joints usually ex- hibit serious pathological changes in some of the internal organs. These changes are the direct result of the tubercular cachexy, which is generally so well marked in the latter stages of the local malady, and they exist in various forms and degrees in different structures. The most common are tubercular deposits and dropsical effusions, which are rarely entirely absent in any case, especially if of long standing. Tubercles of the lungs are very common ; they often exist in great num- bers, especially in "the snmmits of these organs, and they always exhibit the same characters as in ordinary phthisis. Cavities sometimes form, but death usually occurs before.they attain any considerable magnitude. The bronchial ganglions commonly participate in the pulmonary disease, being enlarged and tuberculized. Occasionally extensive adhesions are found between the lung and costal pleura, with or without serous and other "effusions. The heart is seldom affected. The peritoneum is sometimes extensively tuberculized, and considerable quantities of water are often found in its cavity. In children, the lymphatic ganglions of the pelvis and mesentery are apt to suffer from strumous de- posits, and similar changes are occasionally witnessed in the spleen. The* Jiver is often cirrhosed and hypertrophied. Now and then the glands of Peyer suffer. The pancreas, stomach, and genito-urinary organs are usually sound. The blood is very thin, and deficient in fibrin and coloring matter. The lower extremities, and even the hands, face, and genital organs are, at times, anasarcous, especially when the system has been worn out by tuber- cular disease of different parts of the body. Tuberculosis of a joint, as the name correctly implies, is essentially a scro- fulous disease; but, like phthisis, it is a mere local'expression of a consti- tutional vice. Take away this vice, this strumous dyscrasia, and in either case no local disorder can arise. The existence of tubercular disease in an organ does not necessarily imply in that organ the existence of tubercular deposits. In strumous corneitis, for example, there is nothing of the kind, and yet no one, at all familiar with the character of that malady, would deny it such a parentage. In certain diseases of the skin there is undoubtedly scrofulous action, without so far as can be determined, any secrttion of tubercular matter. When the disease begins in the synovial membrane of the joints it probably deports itself in the same manner as when it invades the tunics of the eye; and the same thing probably occurs when it takes its rise in the cartilaginous tissues. When on the contrary, it commences in the osseous structures, there is often a genuine deposit of this kind, similar to that which is so frequently met with in the TUBERCULOSIS OF THE JOINTS. 45 short bones, as those of the spine'and foot, and also in the articular extremi- ties of some of the long bones, independently of articular implication. Symptomatology.—In regard to the symptoms of this disease they may, for the sake of more definite description, be divided into three stages. In the first stage, the patient's suffering is generally very slight, being usu- ally referred to the effects of cold, rheumatism, or some slight external injury. The chief complaint consists in some trivial pain, either in or about the joint, not fixed or steady, but wandering and intermittent, and liable to occasional exacerbations. If any'swelling be present, it is also generally very insignifi- cant. The joint is usually somewhat stiff, and the patient is easily fatigued by exercise. The general health is unimpaired, or only slightly implicated. By degrees these symptoms assume a more threatening character; for the disease has now attained its second stage, as is indicated by the changes wrought in the affected structures. The pain is now more severe, as well as more localized and deep-seated, and generally»requires active means for its subjugation. The patient is annoyed with spasmodic twitches, especially at night, and the affected limb becomes sensibly wasted and flabby. The joint is the seat of more or less swelling, attended with marked deformity and fluc- tuation, the resujt of the presence of an undue quantity of synovial fluid, or of this fluid'and of lymph. The parts feel abnormally hot, and there is com- monly a peculiar glossy, shining appearance of the skin, which induced the older surgeons to call this disease "white swelling." There is also, in this stage, usually some degree of enlargement of the subcutaneous veins. The constitutional symptoms keep steady progress with the local affection. The appetite and sleep are disordered, the bowels are irregular, and there are occasional paroxysms of fever, with evidences of emaciation and general dis- comfort. In the third stage of the disease, the symptoms,-both local and general, are strongly denotive of the horrible ravages of the morbid action. The joint and surrounding parts are swollen and enlarged to their utmost, hot, tense, discolored, immovable, and exquisitely tender and painful, fluctuating under pressure, in consequence of the presence either of pus, or of synovial fluid, or both. More or less displacement of the articulating surfaces gene- rally exists, adding thus still further to the deformity. The pent-up matter, gradually approaching the skin, is at length spontaneously evacuated, much to the relief of the part and system, but the resulting sinuses, always slow in healing, often continue for years, especially if there be much diseased or dead ' bone. The constitutional symptoms which accompany this stage are those of hec- tic irritation. The patient, at least for a time, has regular vesperal exacer- bations, the face is flushed, the pulse is excited, the sleep is impaired, and the surface, during the night, is drenched with copious sweats. Rapid emaciation ensues, the strength declines, and the bowels are harassed with colliquative diarrhoea. Thus life may be gradually worn out by exhaustion, or, the discharge diminishing, reaction may take place, followed, sometimes even in apparently desperate cases, by ultimate recovery. Suppuration, however, does* not always take place in this stage of the complaint, or, if it do, there is either very litfle matter, or what there is is so soon absorbed as not to produce any characteristic symptoms. This is the case occasionally even when the greatest ravages have been committed. Sometimes the pus is situated altogether externally, but this is unusual. In other cases, again, also infrequent, it is formed both externally and inter- nally. However this may be, the structures over and around the affected joint always participate in the morbid action, becoming hard, condensed, and enlarged from interstitial deposits. The matter in scrofulous disease of the joints is generally more fluid than 46 DISEASES AND INJURIES OF THE JOINTS. ordinary pus, and also of a more greenish tinge. In fact, it very olosely re- sembles the content^ of a cold abscess, or the pus of a pulmonary cavern. It is often intermixed with small whitish particles, not unlike grains of soft boiled rice, with flakes of lymph, or even with small clots of blood, especially when the antecedent inflammation has been unusually severe, or the parts have been roughly handled. Now and then it contains the debris of articu- lar cartilage, ligamentous tissue, or osseous matter. The pus, when long confined, is sometimes very fetid. In general, however, it is entirely free from odor. Received into a vessel, and permitted to stand for a while, it gene- rally separates into two parts, one at the bottom, solid and granular, the other at the top, fluid, and of a pale whey-like or oleaginous aspect. When an abscess of this kind has once fully emptied itself, the subsequent discharge is often of a gleety character, ichorous, or thin and bloody. The quantity of matter may be very small, or so abundant as gradually but surely to exhaust the system* At times the suppuration is almost entirely suspended, perhaps, indeed, for several months, when, either suddenly or gra- dually, it reappears, and becomes as profuse as before. Once established, it has no special limit as to its duration, but may last, with hardly any inter- ruption, for years. Whenever the discharge is unusually protracted, it may be assumed, as a general rule, that there is serious and obstinate caries of the bony structures of the joint, especially when it is attended with the occasional escape of gritty substance. Prognosis.—Tuberculosis of the joints is essentially a chronic disease, which, after having endured for an indefinite period, terminates either in re- covery or in death. The recovery may be complete, both as it regards the part and system, or, the local action disappearing, the joint may be left weak and anchylosed, and the general health regain its original vigor ; or, as not unfrequently happens, particularly after the process of disorganization has commenced, both the articulation and the constitution may remain for a long time, if not permanently, in a degraded and crippled condition. Many circumstances, mostly of an individual nature, conspire to influence the prognosis in this disease. So much, in truth, is this the case, that it is im- possible to lay down any definite rules for the guidance of the practitioner. Much will, doubtless, depend,-in every instance, upon the state of the constitu- tion, the presence or absence of complications, and, above all, the duration of the malady. »Age also exercises an important influence. It is a well known fact that, other things being equaj, children will live longer, and also stand a much better chance of recovery, than young adults and middle-aged sub- jects, in whom, .especially the latter, the disease often proceeds with extra- ordinary rapidity, sometimes ending fatally in a few months. When the ' constitution is naturally feeble, or when it has been rendered so by the in- tensity of the local suffering, the probability of an unfavorable termination will be much increased. Imperfect alimentation, however induced, is another source of mischief, both as it res'pects the part and system. Intercurrent maladies, such as typhoid, intermittent, and eruptive fevers, diarrhoea dysen- tery, and erysipelas, often retard recovery, or hasten the fatal crisis ' These and other diseases, by establishing a drain upon the system, already exhausted by the local suffering, are, I am satisfied, the principal causes of the mortality in strumous affections of the joints. When the disorder proves fatal with- out such intervention, it will generally be found that death is 'directly due to the depressing effects of tuberculosis of the lungs, lymphatic ganglions spleen or peritoneum, which is so liable to show itself under such circumstances ' Much of the mortality of this disease, as well as most of the bad effects both temporary and permanent, which it entails upon the affected articula' tion, results from neglect of appropriate management, prior to the commence" ment of the disorganizing process. Properly treated at its beginning it is, TUBERCULOSIS OF THE JOINTS. 41 at least in the majority of cases,-as amenable to our remedial agents as any ordinary chronic inflammation, although not generally so promptly. The morbid action gradually receding, the effused materials are by degrees ab- sorbed, and the parts restored to their normal functions. Arrived at its second stage, hardly any course of medication, however judiciously applied, will completely avert permanent rigidity, although life may not be at all in jeopardy. The morbid impression has already advanced too far to admit of easy recession; a certain amount of organic lesion is present, and the patient may congratulate himself if he ever completely regains the use of his joint. In the third stage, when the osseous, Cartilaginous, and other structures are disintegrated and broken down ; when, perhaps, the interior of the joint is' converted into a large chronic abscess; when the limb is stiffened or immov- able, and, finally, when the constitution is worn out by pain and hectic irri- tation, there will not only inevitably be loss of function, but also danger of loss of life. If, under such circumstances, the patient survive, his recovery will be effected at the expense of much suffering, too often eventuating in premature decay and dissolution. Treatment.—In the treatment of this affection, it must be remembered that, as it generally, if not invariably, is merely a local manifestation of a constitu- tional vice, topical remedies alone will not avail: to prove efficient and truly useful they must be combined with and aided by means addressed to the general system, with a-view to the improvement both of the solids and fluids. It would be idle, in the present state of the science, to insist upon a course so palpably proper in itself and so long sanctioned by experience. As well might the practitioner expect to be able to cure consumption, or to amelio- rate the condition of a person thus affected, by the exclusive employment of counter-irritation and other external measures, as to cure tuberculosis of the joints without the aid of constitutional remedies. Again, in treating this disease it should not be forgotten that it consists of different stages, which, although they run imperceptibly into each other, are, nevertheless, of vast importance in a practical point of view. Whatever may have been the duration of the malady when the treatment is commenced, the first and most essential element in its management is re- pose not merely of the joint, but also of the body, repose absolute, uncon- ditional, and persistent. Upon this subject there must be no compromise between the patient and his attendant. The contract entered into at their first interview must be observed with the most scrupulous fidelity; it must be both binding and permanent. The slightest departure from this injunc- tion would in any stage of the complaint be of great detriment to the patient's limb, while in its more advanced stage,' when the bones and cartilages are destroyed and matter exists in the joint, it might seriously jeopard his life. Recumbency must be observed for months upon months, when the disease is seated in the inferior extremity. Too much stress cannot be placed upon this point, when it is remembered how important it is to keep parts, compa- ratively insignificant, perfectly at rest when in a state of suffering. Iu in- flammation of the fingers and toes repose and elevation of the affected structures are instinctively sought, and, if possible, maintained until the morbid action has been in great degree subdued and function restored. Now, if this be necessary in ordinary inflammation and in textures which have no important uses and sympathies, how much more necessary is it when the malady is of a specific nature and the organ involved is so important as that of a large joint ? These facts are well known to practitioners, but the com- mon people are ignorant of them, and hence they should always be tho- roughly explained to the patient and his friends at the very threshold of the treatment. The local remedies must be regulated by the progress of the malady and 48 DISEASES AND INJURIES OF THE JOINTS. the constitution of the patient. ' If the disease be in its first stage, if the pain be violent and frequent in its recurrence, and if the general health remain unimpaired, we can scarcely fail to derive special benefit from the application of leeches," or, in their absence, from the use of a large blister. The leeches should be scattered over the affected joint, and, after they have dropped off, the flow of blood should be promoted for some time with cloths wrung out of warm water and frequently renewed. Their number must depend upon circumstances, but, in general, from six to eight wilr be sufficient for a child from three to six years of age. Sometimes a blister may be applied advan- tageously within a few days after the leeching, and I much prefer this mode of counter-irritation to the employment of liniments, embrocations, croton oil, tartar emetic ointment, and iodinized lotions, which is always attended with friction, and for that reason often prejudicial to the inflamed structures. By these means, aided by a plain, simple diet, consisting mainly of farinaceous articles, with milk, weak tea, or milk and water, at breakfast and supper, and an occasional purgative of from two to three grains of blue mass with double that quantity of jalap, most of the cases that are brought under the notice of the practitioner may be radically cured in a few months. If fever be present, or if decided plethora exjst, as denoted by the state of the pulse and face,. the antimouial and saline mixture may be given in such doses and at such intervals as the nature of the case may seem to require. When the pain is so severe as to interrupt sleep, opiates must be used with warm anodyne poultices or fomentations, or, what I have found to be of greater benefit, a lotion composed of three parts of soap liniment and one of acetated tincture of opium with from half a drachm to a drachm of carbonate of potassa to the ouuce, applied by means of a fold of flannel, kept constantly wet, and covered with gutta-percha. Cold applications are/generally inadmissible both in this and in the other stages of the disease. Where the skin is unusually dry, or the system more than commonly irritable, the warm bath, carefully adminis- tered for half an hour at a time, with a Dover's* powder at night, is sometimes highly beneficial, but great care must be used in its administration lest the affected joint sustain injury. As permanent anchylosis cannot always be avoided in this disease, great care should be taken to place the affected joint in the best position for future usefulness. Thus, in tuberculosis-of the wrist the hand should be extended, while in disease of the elbow the forearm should be flexed at a right angle ' with the arm. When the shoulder is involved, the elbow should be confined to the antero-lateral part of the chest, a tolerably thick pad being fastened in the axilla. In hip-joint disease the thigh is inclined a little forward, and somewhat separated from its fellow; the leg is slightly flexed when the knee is affected, and the foot is bent at a right angle with the leg in tuberculosis of the ankle. Such is an outline of the treatment which, according to my experience, will usually be found most serviceable in the earlier stages of the complaint. There is, however, not a little diversity in regard to the nature of the internal remedies required in different cases. As already stated, there are two distinct classes of patients, the plethoric and the anemic, those with an apparently rich blood and those with an impoverished blood, and hence two very oppo- site courses of treatment are frequently necessary, the former demanding per- haps a certain amount of depletion, while the latter will be most benefited by tonics. I have not met with any cases where I thought the use of the lancet was indicated, and yet I am not prepared to say whether, when the inflammation and.pain are very great, in a strong, robust child, soon after the commencement of the malady, venesection, to a small extent might not be highly beneficial, tending to retard the suppurative crisis, and'to prevent the destruction of the osseous and cartilaginous tissues; in general however TUBERCULOSIS OF THE JOINTS. * 49 the remedy would be too harsh, and I am satisfied that the morbid action may be sufficiently repressed by the antimonial and saline mixture, in union with a minute quantity of tincture of veratrum viride, assisted, perhaps, by the application of a few leeches to the seat of the disease. In the anemic, a not uncommon class of cases, tonics and stimulants are often required at the* very commencement of the disease, consisting either of quinine and iron, or, what is peculiarly valuable under such circumstances, cod-liver oil, in such doses as shall not prove offensive to the stomach. The diet should of course be of a corresponding character, and the patient should, if possible, be induced to use milk-punch, wine, ale, or porter, in order to rebuild the system, and thus enable the affected parts the more effectually to resist the encroachments of the morbid action. I am not an advocate, as a general rule, for confining the affected limb in splints, in the incipient stage of the disorder, with a view of securing more perfect rest of the joint. The patient himself will usually instinctively take care of this. It is only or chiefly when the limb is much out of shape, or in a position in which, if permanently retained, its usefulness would be se- riously impaired, that such a proceeding is either necessary or desirable. The restraint occasioned by all such contrivances is generally exceedingly irksome, if not positively productive of harm. When the malposition of the extremity is considerable, the first thing to be done, provided there is as yet no great structural lesion, is to rectify this by extension and counter-exten- sion, aided, if necessary, by rotation and abduction, the patient being under the influence of chloroform, and then to apply a suitable apparatus for main- taining the limb in its new relations. The best material is gutta-percha, un- dressed sole-feather, or trunk-maker's board, soaked in hot water, carefully adapted to the parts, and kept in place by a common roller. When dry, these articles form .an admirable case, which may afterwards be padded with cotton to ward off pressure, and which will thus effectually prevent motion of the affected joint. The attempts at rectifying the malposition of the limb are occasionally an- noyingly counteracted by the contraction of the'muscles. When this is the case, the most expeditious plan is to divide them subcutaneously ; the effect of such an operation upon the future welfare of the part and system is often most striking, the pain and spasm being relieved as if by magic, and the limb becoming perfectly docile and manageable. In the second stage of the affection, the most reliable local remedy, accord- ing to my experience, is a large isSue, for the purpose of securing a free and permanent discharge of matter. If the case has not been seen before it has reached this crisis, some of the means already mentioned,-as leeching and blistering, may be tried ; but, unless they are promptly beneficial, no time should be wasted fn their employment. The disease is now thoroughly es- tablished, and must be met in the most decisive manner, if we would wish to avoid its -disorganizing and destructive consequences.. The best place for making the issue is the most prominent part of the swelling, which is usually either directly over the joint or in its immediate vicinity. It is reasonable, a priori, to suppose, that the nearer the discharge is established to the dis- eased structures, the more likely will it be to be useful; and this is precisely what experience has shown to be the fact. The place of election, then, is a circumstance of great importance, and should not be overlooked. The most eligible form of issue is that made with the actual cautery. The patient being under the influence of an anaesthetic, the iron, heated white, is gently pressed upon the part until a suitable eschar has been formed; one about the size of a twenty-five, cent piece, if the patient be very young, or twice that size, if he be twelve or fifteen years old. The slough, which should not VOL. II.—4 50 DISEASES AND INJURIES OF THE JOINTS. extend beyond the subcutaneous cellular tissue, will generally drop off within the week ; and, during this period, as well as afterwards, the parts should be kept constantly covered with a linseed poultice, renewed several times in the twenty-four hours. ' The discharge, if flagging, may be promoted by savine ointment, by simple cerate containing a few drops of nitric acid to the ounce, or, what I prefer, the occasional application, for a few hours, of a small blister. In this manner I have known an abundant pyogenic discharge maintained for the greater part of a year. The cautery may, if necessary, be reapplied at. any time during the progress of the treatment. The hot iron deserves a decided preference, for making an issue in this dis- ease, over all other modes of cauterization, as affording not only a more co- pious and persistent flow of pus, but, what is of no little importance, making a much stronger, as well as a more permanent, impression upon the part and system. It is "impossible always to determine how long the suppurative ac- tion should be kept up ; but it will be found to be a good rule to let it con- ' tinue until there is reason to believe that the morbid process, for the relief of which it was instituted, has completely subsided. I have never, in any in- stance, experienced any bad effects from its protracted continuance; indeed,. quite the contrary has been the case. If the discharge becomes offensive, as it often does in warm weather, or when proper attention to cleanliness is not observed, the chlorides will come in play, with a more frequent change of dressings. Occasionally the linseed poultice oppresses by its weight, or it causes painful and itchy eruptions around the sore; when this happens it must be temporarily suspended, or be replaced by some more suitable ap- plication. Besides these advantages, the raw surface left by this kind of issue will afford an excellent opportunity for the local application of morphia, for com- bating the excessive pain and spasmodic twitchings'of the muscles, so com- mon in this complaint, and which are much more promptly subdued in this way than when this medicine is administered* by .the mouth. .The quantity necessary to produce the desired effect will, of course, depend upon circum- stances ; but, in general, from half a grain to a grain will be required for a child three or-four years old. Sometimes an injection of laudanum or an opiate suppository, will allay the pain and quiet the system more effectually than anything else. In regard to the Jatient's diet, in this stage of the disease, the same rules should govern us as in the preceding stage; but it should, if possible, be somewhat more restricted, especially if there be much pain, with occasional The bowels should also be maintained in an active condition, the best general purgative being a few grains of blue mass, with a suitable quantity of jalap or the compound calomel pill: Salines and nauseants will rarely be equired. If the patient labors under symptoms of debility, as denoted by of tL fZti1lC°UDtena,;Ce'-the C°ldneSS °f the extremities, and the disorder I digestive organs, tonics, especially quinine and iron, should be em- ployed along with a more generous diet and nutritious drinks tionVf mln^r Vjl c\aracterize,d hJ prions structural lesion, and the forma- t on ot matter, the treatment will require to be essentially modified to meet the local and constitutional contingencies. Prior to this period it wis if not decidedly antiphlogistic, at all events rather of a depress n- charac 'e intended to subjugate inflammation and establish resolutLnnSw that the' morbid action has gained the ascendency, and exhausted both pari and svs tern,, a widely different course is demanded. • P and SyS Two most important indications are presented in nlmnCf ^ this stage of the explain, The flrst ifto !.« I^ZI PZ^-, TUBERCULOSIS OF* THE JOINTS. 51 the second, to promote the speedy absorption of the effused fluid/ To fulfil either is generally no easy task; for experience has proved that there are few cases in which our efforts, however skilfully conducted, are crowned -with success. When the suppurative process declares itself by well-marked symp- toms, as rigors, alternating with flushes of heat, and followed by copious sweats, something may be done to moderate its violence by the steady and energetic use of antiphlogistics; but, in generalt it will be found that the patient is either too feeble to justify their employment, or that the disease has been so insidious in its approaches as-to defy recognition before the mis- chief has been completed. It has been seen, however, that matter does not always attend this stage, and that, when it does, it often exists only in small quantity. Now it is in the latter class of cases, more particularly, and in .those where the suppurative process can be carefully watched from its very inception, that strenuous and persistent efforts should be made to prevent its accumulation, with its concomitant mischief. For this purpose the affected joint should be painted at least twice a day with s,ome sorbefacient lotion, such as equal parts of tincture of iodine and alcohol, or a-weak solution of iodine and iodide of potassium, care being taken that, while applying it effi- ciently, it is not put on so freely as to cause pain or irritation beyond a few minutes. The object should be merely to excite the absorbents, the capil- laries being fully kept in abeyance; otherwise injury, not benefit, will be likely to result; Sometimes a large blister answers a good purpose ; retained just sufficiently long to produce slight vesication, and repeated every four or five days for several successive weeks. Thorough or protracted vesication is to be avoided, as likely to prove detrimental, from its irritating effects, both upon the part and system. If the disease has not yet advanced too far, if the abscess is still small, and, above all, if the suppurative process be attended with grestf pain and constitutional disturbance, I know of no remedy so well calculated to fulfil the present indication as the actual cautery, applied in such a manner as to produce a broad but superficial issue. Experieflce has taught me that, even in this stage of the malady, when everything is appa- rently most unpromising, more benefit will, in general, accrue from this mode of counter-irritation than from any other with which we are acquainted. It will not only, in many cases, promote the absorption of the pus that is already effused, but materially curtail the suppurative process, and at the same time greatly ameliorate the local distress. If the accumulation be very large, the remedy must, of course, be dispensed with, and artificial evacuation encouraged. Along with the local reraedfes just pointed out, should be used certain internal means, to aid and expedite their sorbefacient action. At the head of the list may be placed mercury, especially the iodide and bichloride, ad- ministered in small quantities several times a day, and properly guarded by opium, to prevent them from griping and purging; the iodide of potassium aud Lugol's solution are also valuable remedies. Ptyalism is of course avoided, and the strength is sustained with tonics, a generous diet, and nutri- tious drinks. If these means fail, or if the abscess be already very large when we are called to the case, the matter should be evacuated artificially. I am aware that, upon this subject, there is generally a great deal of repugnance evinced by practitioners, on the supposition that any interference of this kind will only tend to aggravate the local disease, and cause hectic irritation. To such a view, however, I cannot subscribe. On the contrary, I can see no just reason why the general rules of surgery should be departed from in this disease any more than in others. It is well known that matter, wherever and whenever existing in large quantity, invariably does harm; for, not only 52 DISEASES AND INJURIES OF TftE JOINTS. is it apt to burrow extensively among the surrounding parts, but it must necessarily, by the pressure which it exerts upon the inflamed surfaces with which it is in contact, increase the pain, and effectually prevent the restorative process. That this is the case in regard to extensive purulent collections generally is a fact so well established as to require no argument in its sup- port, and if there be any exceptions respecting such accumulations in the joints, I am not aware of them. My conviction is that practitioners, influ- enced by the dogmas of the schools rather than by their personal experience and the dictates of common sense, have seriously erred in their treatment of strumous abscess of the articulations, and been thus directly instrumental in the production of much mischief. In their endeavor to avoid too early an outlet, they have too frequently allowed themselves to wander into the oppo- site extreme, and neglected to make any opening at all: in other words, in, attempting to steer clear of Scylla, they have unwittingly rushed into Cha- rybdis. The proper plan, undoubtedly, is, in all cases where the absorption of the matter is no longer a probable event, to promote its escape by the lyiife. It is the one which I have invariably pursued in all joint diseases for upwards of twenty years, and in no instance have I had any reason to regret it. In this manner vast suffering is avoided, as well as much structural lesion prevented, as is abundantly shown by the numerous and tortuous sinuses which so frequently form in the hip when the disease is left to pursue its own course. The artificial opening, however," is not to be made heedlessly, or without due attention to the permanent exclasion of the air, which, although in itself innocuous, often proves pernicious, from its tendency, when brought in contact with the pent-up fluids, to favor decomposition, and, consequently, the development of hectic irritation. These effects may generally be prevented by giving the opening a valvular form, as in evacuating chronic abscesses in other situations, by making a puncture rather than an incision, andi>y closing the orifice, immediately after the operation, with adhesive strips, supported by a light compress and bandage. If the quantity of matter be unusually large, a portion only should be drawn off at a time, the process being repeated in a few days until the whole is removed; but ordinarily the sac may be emptied advantageously at the first operation. As soon as the fluid has been evacuated, whether partially or completely, a full opiate should be administered, in order to prevent undue reaction; and, if the joint becomes painful, warm anodyne fomentations should be used, until relief is afforded. Afterwards, with a view of moderating suppuration, . the parts are painted regularly once a day^vith some sorbefacient lotion, a linseed poultice or the warm water-dressing being used as the permanent application. , If sinuses form, whether as a result of spontaneous or artificial evacuation, the best plan is not to interfere with them, as the pain and loss of blood con- sequent upon the employment of the knife would more than counterbalance any good effects from the operation. If loose fragments of bone, or pieces of cartilage, present themselves, they should, of course, be promptly ex- tracted. > r r j The violence of the suppurative action having been subdued, the plastic deposits are best dealt with by sorbefacient plasters, applied so as to embrace the whole of the affected surface, and steadily worn for many weeks Of these plasters, the most useful, for this purpose, is the ammoniac and mer- curial, under the influence of which the induration and swelling often disap- pear with astonishing rapidity. If much pain be present, a suitable quantity of morphia, opium, or cicuta may be incorporated with its ingredients During the latter part of this stage tonics and stimulants are usu-illy indi- cated, aud often imperatively demanded, by the exhausted state of the system' TUBERCULOSIS OF THE TEMPORO-MAXILLARY JOINT. 53 The patient, emaciated and anemic, must be supported with quinine and iron, cod-liver oil, a generous diet, and nutritious drinks, as milk-punch, wine-whey, ale, or porter. If night-sweats be present, the most suitable remedy will be the aromatic sulphuric acid, either alone or in union with Huxham's tincture of bark. Diarrhoea and pain must be checked with opiates. The patient's apartment should be frequently ventilated, and the surface of the body should be daily washed with tepid salt-water, followed by dry frictions. Exercise in the open air is now generally of paramount im- portance, and must on no account be neglected. In the event of a cure, whether spontaneous or artificial, the surgeon must be careful, when the proper time arrives, to institute passive motion with a view of preventing permanent anchylosis. The principles upon which it should be conducted are the same as in dislocations and fractures of the joints. Much judgment, however, is necessary, otherwise the operation may readily re-provoke disease. The best plan is to repeat it, at first, only about every fourth day, until the parts have become somewhat accustomed to it, when it may be employed more frequently. As the proceeding is always very painful, especially for some time, it is highly important that the patient should be well anaesthetized. Indeed, without this precaution, it will be quite impossible to overcome the action of the rigid and contracted mus- cles, or to break up the morbid adhesions in and around the joint. When the extremity of the bones is necrose.d, or so completely carious as to forbid all hope of recovery by time and ordinary means, the soft parts being riddled with sinuses and the discharge copious and exhausting, resec- tion of the diseased parts will be demanded, and should, if life be not too far exhausted, be promptly executed, as most likely to rescue the patient from impending death. The object of the undertaking, of course, is to remove all the ulcerated structures, and the surgeon should, therefore, endeavoK to ex- ecute his task in the most thorough and effectual manner. The disease being thus arrested, the part and system will be placed in a much better condition for gradual and permanent recovery, provided the shock of the operation is not so severe as to destroy life, either immediately or consecutively. With proper care after the excision, it may even be possible to preserve a certain degree of motion between the contiguous bones. Resection is more particularly applicable to strumous disease of the hip and shoulder joints. Good cures, however, occasionally result when the operation is performed upon some of the-other joints, though I believe that ampptation is always preferable when there is extensive organic lesion, and life is rapidly ebbing away from protracted suffering. 2. TUBERCULOSIS OF PARTICULAR JOINTS. 1. TEMPORO-MAXILLARY JOINT. It is not often that this articulation is invaded by this disease, and then almost exclusively in young persons of broken-down constitution, from the effects of cold, mercury, or irritation of the teeth. It is distinguished by a puffy swelling in front of the ear, or in the temporo-maxillary region, by tension and discoloration of the skin, and by a dull, heavy pain in the joint, in- creased by pressure and motion of the jaw. During the progress of the dis- ease, the auditory canal becomes greatly diminished, if not entirely closed, and the seat of a very fetid, purulent discharge, attended with loss of hearing, especially when there be much involvement of the temporal bone. Finally, abscesses and fistulous openings form, exposing this bone and the condyle of the jaw in a carious or necrosed condition. 54 DISEASES AND INJURIES OF THE JOINTS. In the treatment of this affection special care must be taken to guard against anchylosis, otherwise, when recovery occurs, the functions of the joint may be permanently lost. Dead bone must be extracted as soon as it is sufficiently detached, and the condyle of the jaw may,.if necessary, be resected, "\yiien there is much involvement of the temporal bone, the patient may die from an extension of the disease to the brain. 2. CLAVICULAR JOINTS. The joints formed by the junction of the clavicle with the sternum and the scapula are occasionally involved in tuberculosis, but the disease is. very un- common. It is met with chiefly in young subjects, and is characterized by the usual phenomena. When it attacks the sterno-clavicnlar articulation, the most prominent signs are a soft, puffy and elastic swelling at the seat of the disease and a fixed pain at the same point, aggravated by pressure and motion of the scapula, and also somewhat by forced inspiration and expiration. The head of the collar bone often presents the appearance of being enlarged. In time an abscess forms, and, ff its evacuation be neglected, j;he matter may descend into the anterior mediastinum and thus occasion fatal consequences. Luxa- tion of the clavicle can occur only when there is complete destruction of the connecting ligaments, permitting the end of the bone to project upwards or backwards : in the latter case, itr may compress the trachea and oesophagus. Tuberculosis of the scapulo-clavicidar joint is very uncommon, and is cha- racterized by the same symptoms as the preceding disease. Care should be taken not to confound these affections with rheumatism, to which both these joints are liable. The treatment requires nothing peculiar. Resection of the clavicle may be performed if this bone is extensively necrosed, or otherwise diseased, or if it injuriously compresses the trachea and oesophagus. 3. OCCIPITO-ATLOID AND ATLO-AXOID JOINTS. Tuberculosis of these articulations, first accurately described by Schupke, in 1816, and since then specially investigated by Berard, Teissier, and Schcenfeld, is met with chiefly in children and young adults, either without any assignable cause, or as a consequence of cold or injury. Although it is essentially similar to Pott's disease, it requires separate notice on account of the peculiarity of some of its effects. The disease, whether beginning in the synovial, cartilaginous, or osseous tissue, often commits the most frightful ravages, destroying sometimes the greater part of the arch of the atlas, the whole of the odontoid process, and perhaps even the margins of the occipital T5one. What is remarkable, the anterior portions of these structures generally suffer much more than the posterior. In consequence of the destruction of these ligaments, the occipital bone may be dislocated forward, backward, or laterally, displacement by rotation being extremely rare. In whatever direction the accident may occur, the encroachment of the parts upon the spinal canal is seldom sufficient to cause any serious compression of the cord. The atlas is more frequently luxated than the occipital bone, being thrown either forward or to 'one side. Occa- sionally the displacement is by rotation. Dislocation backward is impossible on account of the obstacle offered by the odontoid process. In the more severe forms of the disease the displacement is sometimes of a mixed cha- racter. The spinal cord is variously altered, according to the nature and extent of TUBERCULOSIS OF THE CERVICAL JOINTS. 55 the osseous involvement. In some cases it retains its normal structure, while in others it is softened and broken down. The dura mater is generally thick- ened, engorged, fungous, ulcerated, or even perforated, and the arachnoid membrane inflamed and incrusted with lymph. • The symptoms of this disease are as follows :—At its commencement there is a dull, aching pain, circumscribed, deep-seated, and much increased by motion and pressure. A sense of weight and fatigue is experienced in the upper part of the neck, and the patient at length finds it difficult, if not im- possible, to support his head in Walking. Gradually other symptoms super- vene, the most distressing of which are pain and difficulty in deglutition, dependent upon inflammation of the pharynx. The neck now becomes de- formed, owing to the joint agency of the displacements above alluded to, and to interstitial deposits. The posterior muscles are remarkably firm and rigid, and the head is immovably fixed, not unfrequently in a very vicious position, being either bent forward toward the sternum, drawn backward, or inclined to one side. When the disease is fully developed, the pain, all along sufficiently distressing, is greatly increased in severity, and radiates .about in different directions, up into the head and down the neck into the shoulders. If abscesses form, the patient, in addition to the dysphagia, will experience difficulty in speaking, expectorating, and breathing, in consequence of the obstruction of the fauces from the accumulating fluid, and from the same cause the tongue is sometimes partially protruded from the mouth. The matter is discharged either into the mouth or at the back of the neck; often by several apertures. Occasionally large pieces of bone come away with the pus. When the spinal cord and its membranes are seriously involved, there will be, in addition to the symptoms here enumerated, great embarrassment of respiration, lividity of the face, and paralysis, first, of the superior, and afterwards of the inferior extremities; together, in short, with all the pheno- mena of a gradual but surely fatal asphyxia. In some cases the patient perishes suddenly from an accidental twist of the neck crushing the spinal cord. The deformity of the neck consequent upon this disease is deserving of special notice in a diagnostic point of view. The affected part is much broader than usual, and also more protuberant or irregular. When the occipital bone is thrown forward upon the atlas, the depression which naturally exists at the upper part of the neck, between the attachments of the two trapezial and the two splenial muscles, is effaced, and the finger easily recognizes the posterior arch of the atlas. If, on the contrary, the bone is forced backward, the hollow in question will be found to be increased, and the spinous process of the axis less distinguishable. The displacements of the atlas are generally easy of recognition. Teissier, who has studied the subject with much care, states that when this bone is dislocated forward, the spinous process of the axis forms a prominence more marked and nearer to the occipital protuberance than in the natural state, at the same time that the swelling is abruptly interrupted at its upper part, where it is surmounted by an excavation. When the displacement is lateral, the spinous process of the axis will be found to be more in the direction of a vertical line, extending from the external occipital protuberance. Finally, adds this author, it may also happen that one of the articular processes of the axis may form a projection in the neck, either on the right Or left side of the middle line. It is important to remember that tuberculosis of these joints may be simu- lated by the effects of rheumatism and of external injury, causing pain and stiffness of the neck, with partial, if not complete, immobility of the head. When the disease is far advanced, the diagnosis is unmistakable. 56 DISEASES A^O INJURIES OF THE JOINTS. When recovery takes place, the neck generally remains deformed and pro- tuberant, with great impairment of its functions, the affected bones being completely soldered together by new osseous matter. In the treatment of this affection, in addition to the employment of the usual remedies, the greatest attention must be paid to rest, both of the part and system, and to its support by means of suitable apparatus. The head should lie on a level with the trunk with a thin, elastic pillow under the neck, and care should be taken that it be not suddenly moved in any direction, especially in the more advanced stages of the complaint, lest," the ligaments having given way, the bones should become displaced, and thus instantly and fatally crush the spinal cord. The recumbency must be steady and protracted. A circular issue should be established, at an early period, with the actual cautery, directly over the diseased joints, and a free discharge of matter in- vited. Advancing abscesses should be promptly opened, in particular if they point towards the fauces; if neglected, they may suffocate the patient by their pressure upon the mouth of the larynx, or, bursting unexpectedly, the matter may pass into the windpipe, and so induce fatal asphyxia. If an at- tempt at reposition of the dislocated bones should be deemed advisable, the operation must be performed with the greatest possible care and gentleness. Should recovery take place, the neck and head must be supported for a long time by machinery, so as to afford the parts a proper opportunity for safe and perfect consolidation. 4. SACRO-ILIAC JOINT. This joint is liable to a strumous affection, analogous to hip-joint disease and white swelling of the knee, which was first accurately described by Boyer. The best accounts of it, however, that have yet appeared, have been given by Nelatort and Erichsen, especially the latter. Its great rarity, and its liability to be confounded with coxalgia and other lesions, are no doubt the reasons why it has hitherto attracted so little notice. The disease, which is essentially very chronic, is most common between the ages of twelve and thirty. Young children seem to be entirely exempt from . its attacks. Its causes are the same as those of scrofulous affections in general. In the great majority of cases the lesion comes on without ajiy assignable reason; but an instance now and then occurs in which it is trace- able to direct violence, as a blow, kick, fall, or sprain, or to the effects of cold, or suppression of the cutaneous perspiration. Injury done to the pel- vic bones and joints during pregnancy and parturition, probably predisposes to its production, especially when there is a strong strumous diathesis. Cer- tain occupations may also possibly favor its development. Thus, Hahn has narrated three cases which all occurred in tailors. The pathology of the affection is not well understood. In its earlier stages, it is generally limited to the synovial and cartilaginous eleme'nts of the sacro- iliac symphysis, these structures becoming eroded, and .eventually brc*ken down into a softened, pultaceous substance, presenting a condition of things not unlike what occurs in the so-called pulpy degeneration of strumous joints, especially that of the knee. As the morbid action progresses, the osseous tissues also suffer, as is evidenced by their rough and denuded appearance by their abnormal vascularity, and by their infiltrated, spongy, and disinte- grated character. Caries and necrosis are, however, seldom- met with even in cases of long standing, and the ligaments also retain for a long time their integrity. The most important symptoms are pain, swelling, lameness, and deformity . of the pelvis and limb. To these are superadded, in time, the formation of abscesses and sinuses, and the occurrence of hectic fever. TUBERCULOSIS OF THE SACRO-ILIAC JOINT. 57 Pain is an early symptom, seated in the course of the sacro-iliac symphy- sis, increased by pressure and motion, and accompanied by a sense of weak- ness in the lower part of the back and sacrum. The patient feels as if he would drop apart; and finds, it extremely difficult to support himself in walking, very much as in sciatica, or rheumatism, for which, at this stage, the disorder is often mistaken. As the disease advances, the pain becomes more fixed and severe, and assumes a dull aching or gnawing character. It does not, except in rare instances, extend down the limb, nor is it aggravated by moving the thigh, unless the surgeon neglects to steady the pelvis, when it is often qufte severe. The gluteal region is somewhat flattened, and tender on pressure,, especially as the finger approaches the seat of the disease. The swelling, originally very slight, gradually increases in extent, and, in time, becomes a prominent feature. It is puffy, elongated from above down- wards, and situated in the line of 'the affected joint; not materially involving the gluteal region, nor invading the natural hollow behind the great tro- chanter. When abscesses occur the form and size of the swelling are greatly changed. Lameness is an early and prominent symptom. The patient, at first, merely limps, and is soon fatigued by exercise. In a very short time, however, his movements become much constrained, and he supports himself with great difficulty, leans forward, and employs a cane or crutch. He can put his foot on the ground, but is unable to bear his weight upon it, nor can he twist himself suddenly round without great suffering. At length his locomotive powers are completely crippled, and he is obliged to keep his bed. The limb on the corresponding side is, from the very, first, longer than the other, the increase in length varying from six lines to an inch or even an inch and a half, according to the duration and violence of the morbid action. The change, however, is not real, but, as in coxalgia, merely apparent, de- pending upon the alteration in the position of the pelvis, which is not only considerably, depressed, or lower than on the sound side, but also tilted for- ward and rotated downward so as to impart an unusual degree of prominence to the anterior superior spinous process of the ilium. The limb itself is attenuated, flabby, and enfeebled. In progression, it is generally somewhat abducted, flexed at the knee, and projected a little forward, the weight of the body being thrown entirely upon the sound side. Upon taking hold of the limb it can be moved in any direction. By and by, after months of suffering—sometimes, indeed, not until after a year or a year and a half—matter begins to form, preceded by an'increase of local and constitutional disturbance, ultimately eventuating in severe hectic irritation. The swelling over the joint gradually increases in size, and the .fluid, which is always of a scrofulous character, slowly burrows among the neighboring parts, spreading Underneath the gluteal muscles, in the direction of the great trochanter, extending into the loin, or passing into the pelvis, by the side of the rectum or the rectum and vagina, in the former of which it occasionally finds an outlet. When this is the case, flatus may enter the cavity of the abscess, and so cause it to become tympanitic. Sometimes the matter, after having passed into the pelvis, issues at the sciatic notch, and thus gets, as has been observed by Mr. Erichsen, under the gluteal muscles. The diagnosis of this disease is often difficult, and therefore requires care- ful study. The affections with which it is most liable to be confounded are coxalgia, neuralgia of the hip, sciatica, and caries of the spine. From coxalgia it is distinguished, 1st, by the peculiar shape and situation of the swelling; 2dly, by the character and situation of the pain, which does not affect the limb or knee, as in hip-joint disease'; 3dly, by the tardy progress of the morbid action; 4thly, by the rotated appearance of the pelvis and the ab- normal prominence of the anterior superior spinous process of the ilium; 58 DISEASES AND INJURIES OF THE JOINTS. 5thly, by the persistence of the ileo-femoral crease; and lastly, by the pre- servation of the movements of the hip-joint. In both diseases there is short- ening of the limb, but in the sacro-iliac it is never real at any time, while it is always so in the latter stages of coxalgia, owing to the-partial destruction of the head and neck of the femur. Coxalgia is nearly always a disease of early childhood, while sacro-iliac disease is seldom observed until after the fifteenth year. Neuralgia of the hip occurs chiefly in young females, of a nervous tem- perament and hysterical habits, and is, in general, easily distinguished from disease of the sacro-iliac synchondrosis : first, by the character of the pain, which is more widely diffused, as well as more superficial and irregular, than in coxalgia; secondly, by the want of intumescence in the course of the joint; thirdly, by the coexistence of neuralgia in other parts of the body; and fourthly, by the history of the case. -Another important point is the absence of abscess, which nearly always occurs in the latter stages of sacro- iliac disease. The discrimination between sciatica and this affection is seldom difficult. The chief signs of distinction are that, in the former,.the pain-is confined chiefly to the lumbar region, while in the latter it is seated more particularly in the line of the sacro-iliac joint. Besides, it is generally more easily ame- nable to treatment, and is very frequently connected with a gouty or rheu- matico-gouty state of the system. Moreover, in sciatica, there is no deformity of the pelvis or change in the length of the limbs. It is barely possible that sacro-iliac disease might be confounded with disease of the spine; but such an occurrence will readily be avoided if the surgeon keep clearly before his mind the distinction between the real symp- toms of the two disorders. In the former, there is always more or less intumescence in the line of the. sacro-iliac joint, with marked deformity of the pelvis and elongation of the limb on the affected side; in the latter, all these phenomena are wanting, and the vertebral column is stiff, tender jon pressure, and excurvated. The most common site of the disease is the dorsal portion of the spine, and if an abscess form the master never gravitates in the direc- tion of the sacro-iliac junction. The prognosis of this disease is always unfavorable. Now and then, it is true, a case recovers, but such an occurrence can be regarded only as a rare exception. In general, the patient, after having lingered for months, with an occasional intermission of suffering, is finally .worn out by the profuse drain and hectic irritation, or by some intercurrent disease, as purulent infec- tion, or tuberculosis of the lungs. In regard to the treatment of sacro-iliac disease, the same remarks are applicable as to the treatment of coxalgia. The principal remedies are rest and recumbency, with leeches and blisters in the early stage of the malady, followed, if the amelioration be not prompt and decisive, by°the establishment of a long issue, with the actual cautery, in the line of the affected joint. Of course no severe counter-irritation is admissible after the parts have become seriously disorganized. If abscesses form, no time must be lost in letting out their contents by a valvular- incision. The strength is supported by tonics, and the constitution improved by alterants, as iodide of "iron iodide of potassium, and bichloride of mercury, aided by cod-liver oil 5. "WRIST-JOINT. The characteristic features of tuberculosis of the wrist-joint are well de- picted in the annexed engraving, fig. 9, the disease having already made considerable progress. It will be observed that the greatest amount of swell- TUBERCULOSIS OF THE ELBOW-JOINT. 59 ing and distortion is on the dorsal surface of the hand,-although there is also a good deal of fulness in front and in the hollow of the palm, which is often completely effaced, especially when the matter gravitates in that direc- Fig. 9. Tuberculosis of the wrist-joint. tion. The thumb and fingers are tumefied, stiff, and straight, or nearly so, and have a peculiar elongated appearance. Every attempt to move them excites severe pain, or pain and spasm. A sense of fluctuation, often very faint and perplexing, is'usually perceptible, being most distinct on the back .of the joint, and caused either by a fungous condition of the synovial mem- brane, or by the presence of an unnatural quantity of synovial fluid, or both. The muscles of the limb are wasted and flabby. If matter forms, it generally experiences great difficulty in finding an outlet, and hence it is very apt to travel up the forearm and down along the dorsal surface of the hand. Dis- location of the bones, in any direction, is very uncommon. The head of the ulna, however, is often abnormally prominent, but Of the radius the styloid process alone is distinguishable. The treatment consists in placing the limb in an easy, straight position upon a carved splint, and in employing the other measures called for in tuberculosis of the other joints. If matter forms, an early outlet should be afforded, lest it diffuse itself extensively ainong the soft parts and the bones, and so endanger limb and life. Resection is sometimes available, though, in general, preference should be given to amputation. 6. ELBOW-JOINT. Tuberculosis of this joint, fig. 10, generally begins in the structures of the humerus, from whence it may gradually spread to the ulna and radius, involving the whole articular structures in ruin. Pain, stiffness, and swell- ing in and around the joint are the prominent symptoms of the disease. The skin is tense, glossy, and more or less red at the focus of the morbid action ; the parts are intolerant of manipulation and motion, and the swelling presents itself in the form of two cones, united on a level with the crease of the elbow, one apex looking upwards, the other downwards. The osseous prominences are completely effaced, except that formed by the olecranon process, on each side of which there is usually a good deal of fluctuation, causted by the presence of a large quantity of synovial fluid. The limb is wasted both above and below the joint, and the fingers are stiff, swollen, and almost useless. The biceps muscle is rigidly contracted, so as to render extension difficult, if not impossible, and the forearm is bent nearly at a right angle with the arm. When matter forms, it is usually discharged at the back part of the joint, at the side of the olecranon process, or at the lower part of the arm ; seldom in the forearm or in front of the joint. The ulna, owing to the solidity of its connections, is hardly ever dislocated, but it is not uncom- mon for the radius to abandon its relations with the humerus when there is 60 DISEASES AND INJURIES OF THE JOINTS. much disease of their ligaments. In the worst forms of the disease, the bones are involved to a great extent; far, indeed, beyond their articular extre- mities. Fig. 10. Tuberculosis of the"elbow, in its earlier stages. In the treatment of this affection the same principles are to be observed as in articular tuberculosis in general. Early recourse should be had to the actual cautery,'drawn linearly along each side of the joint for four or five inches, and to proper support by means of a suitable splint, extending from near the axilla down to the fingers. The forearm should be placed in a serai- flexed position; matter should be promptly evacuated, and every means should be taken to preserve the usefulness of the limb. Amputatioa will be necessary when the disease is very extensive, or the general health is much impaired ; otherwise the affected bones may be advantageously dealt with by resection. 7. SHOULDER-JOINT. Tuberculosis of this joint is- uncommon, and is met with chiefly in young persons after the age of eighteen or twenty, beginning generally in the syno- vial membrane and other structures of the humerus to which it is nearly always limited, the glenoid cavity of the scapula rarely suffering: The disease is usually announced by more or less swelling, pain and stiff- ness in the joint, which the patient is generally disposed to' ascribe to the effects of rheumatism, cold, or'some slight injury. As it progresses the shoulder loses its natural contour, and assumes a peculiarly rounded appear- ance, owing to the presence of an undue quantity of synovial fluid. The deltoid muscle is gradually flattened and atrophied, and, in fact the whole arm is# wasted. The movements of the joint, at first merely restrained are TUBERCULOSIS OF THE ANKLE-JOINT. 61 ultimately entirely lost. If the morbid action be not arrested, abscesses at length form, point and break, leaving thus a number of fistulous openings leading down to the diseased bone, which is either carious or both carious and necrosed, not unfrequently to an extent of three or four inches. In the worst cases, there is sometimes serious involvement of the glenoid cavity of the scapula. Surgeons have occasionally noticed that the pain which attends this dis- ease, early in the attack, is most keenly felt in the elbow, just as in coxalgia it is originally seated in the knee. Such an occurrence is, however, uncom- mon, and therefore of little diagnostic value. The treatment consists of complete repose of the joint, and of the appli- cation of leeches and blisters, or, if the attack b'e obstinate, the hot iron. Matter is early evacuated, and dead .bone or cartilage removed as soon as it is sufficiently detached. In protracted cases, dependent upon the presence of carious or necrosed bone, the proper remedy is excision; an operation which, if carefully executed, is not only free from danger but nearly always success- ful, the patient regaining a good use of his limb. 8. ANKLE-JOINT. The most common cause of tuberculosis of this joint is external injury, as a sprain, twist, blow, or contusion. Among the earlier local symptoms is a swelling.just in front of each malleolus, as, seen in fig. 11, Fig. 11. filling up the hollow which naturally exists there; it fluc- tuates under the finger, and is mainly dependent upon the presence of synovial fluid, which, from the peculiar struc- ture of the joint, always ac- cumulates there in larger quantity than elsewhere. As the disease progresses, the "grooves on the side of the tendo Achillis disappear, and the whole joint becomes enor- mously enlarged, the heel and other osseous prominences losing their distinctive fea- tures. This increase of size is owing, not exclusively to mor- bid deposits in and around the articulation, but also, at least in part, to an expansion of the ends of the bones, as is easily ascertainable by exa- mination. When the disease is far advanced, the fluctua- • Tuberculosis of the ankle. tion is rendered very faint in consequence of the fungOus condition of the synovial membrane, the leg is excessively wasted, and the foot has a distorted or twisted appearance, as if it were rotated upon its axis, or partially dislocated. 'If suppuration takes place, the matter usually collects in front of the joint, diffusing itself more • or less extensively in the subcutaneous cellular tissue of that region. In the treatment of this disease the foot should be placed at a right angle 62 DISEASES AND INJURIES OF THE JOINTS. ^ with the leg and the parts be we'll supported with suitable splints, so as to maintain them in an easy, relaxed and quiet position. Linear cauterization may be performed, or, what is preferable, a small issue should be established with the hot iron just above each malleolus. Prompt vent is afforded to pus; and, if the joint cannot be saved, resection or amputation is resorted to, ac- cording to the judgment of the surgeon. 9. KNEE-JOINT. This point, owing to the great size of its synovial membrane and of its articular surfaces, not to say anything of its extensive motions and its exposed situation, is, next to the hip, more frequently the seat of tuberculosis than any other joint in the body. While the disease is most common in young persons before the age of fifteen, it is often met with in young adults, and is generally excited under the influence of external violence, as a blow, fall or twist, act- ing upon a depraved constitution. The pain which attends this disease, and which is generally very severe, even at the commencement of the attack, is almost invariably situated in the direction of the inner condyle of the femur, at the lower part of the patella, or at the inside of the head of the'tibia; seldom at the outer part of the joint. The great uniformity of this occurrence has led to various specula- tions as to its cause, but as yet no satis- Fig. 12. factory explanation has been- offered. As in coxalgia, the pain is. liable to pe- riodical exacerbations; in general, it is of a? dull, heavy, gnawing character, and is commonly worse at night than in the day, extending up and down the limb, and destroying the patient's sleep and ap- petite. The concomitant swelling, as exhibited in fig.* 12, is usually very great, being due, partly, to interstitial deposits, and partly to an inordinate increase- of the synovial fluid. It is always most con- spicuous, especially in the earlier stages of the complaint, in front and at the sides of the patella, owing to the laxity and yielding character of the tissues at these points. It is in consequence of this cir- cumstance that the depressions in this situation are generally soon completely effaced, or, what is the same thing, re- placed by soft, fluctuating bags. A simi- lar prominence, often of great size, exists just above the joint, over the lower part of the femur, bounded inferiorly by the patella, and on each side by the lateral ligament, its anterior wall being formed by the tendon of the extensor muscle. Very little tumefaction ever occurs in the popliteal Region, even in the more advanced stages of tbe disease. The skin is tense and glossy; the subcutaneous veins are abnormally large- the knee is stiff, if, not removable; and the leg, more or less flexed, is swollen and cedematous, while the thigh is remarkably atrophied. In proportion as the ligaments yield, the deformity of the joint increases, owing chiefly to the displacement of the head of the tibia, -which allows the muscles to draw the Tuberculosis of the knee, in its earlier stages. TUBERCULOSIS OF THE HIP-JOINT. 63 leg outwards, so as to give it a twisted or contorted appearance. Occasion- ally, though rarely, there is an actual enlargement of the diseased bones. The fluctuation which constitutes so prominent a symptom in the earlier periods of this complaint, often, in a great measure, if not entirely, disappears during its progress, owing to -the adventitious deposits upon the synovial membrane and the absorption of the redundant synovial fluid. Whenever this isthe case, the swelling, instead of being soft and yielding, will be com- paratively firm and resisting, but still possess some degree of elasticity, often so deceptive as to lead to the idea, that the joint contains a good deal of fluid, and which nothing but the most careful examination can dispel. Pus does not always form in this disease, even when permitted'to proceed unmolested; on the contrary, there is reason to believe that it is frequently entirely absent. When suppuration does take place, the matter may either be absorbed", or it may escape at the side of the patella, the lower part of the thigh, or over the head of the tibia; very rarely in the ham. In fche worst forms of the malady, the whole surface of the joint may be riddled with fistu- lous-apertures, leading down to the diseased bones, large portions of which are then either carious or necrosed. The treatment of tuberculosis of the knee.presents^nothing peculiar. The same rules of practice are to be enforced here as in coxalgia. Rest of part and system, local support by means of splints, and cauterization, either linear or circumscribed, are of primary importance, and must be thoroughly carried outfrom'the very beginning. Resection may sometimes be advantageously employed, but, in general, amputation of the thigh will make a better and more satisfactory cure. 10. HIP-JOINT. This affection, usually called coxalgia, femoro-coxalgia or hip-joint disease, is, according to my observation, most frequent from the third to the seventh year. Cases occasionally occur before the twelfth month, and now and then an instance is seen after puberty, or even after the age of twenty, but this is uncommon. Both sexes are liable to it, and it is sometimes witnessed in several members of the same family. The causes of coxalgia are the same as those which provoke strumous dis- ease in other parts of the body. The most common are external injury, as sprains, falls or blows, exposure to cold, inadequate food and clothing, and wasting maladies, as infantile cholera, chronic diarrhoea, scarlatina, measles, and different kinds of fevers. In very many cases it arises spontaneously, or without any obvious reason. It is seldom that both hip-joints are involved in this affection, either simultaneously or successively. During its progress, however, it becomes occasionally complicated with other strumous maladies, as Pott's disease, psoas abscess, ophthalmitis, pulmonary phthisis, and degeneration of the lymphatic glands of the neck, mesentery and other parts of the body. Symptomatology.—Tuberculosis of the hip-joint may be described as con- sisting of three stages, each characterized by distinctive symptoms and pathological changes, as well as requiring peculiar treatment. As this divi- sion is not imaginary but real, it is deserving of the greatest attention. The symptoms of the disease, in its first stage, are usually of so obscure and stealthy a character as to render it very liable to be mistaken for other affec- tions of the joint. The first circumstance which commonly attracts attention, especially if the patient be a child, is a feeling of fatigue after exercise, with slight pain in the knee, and a disposition to drag the limb, thus giving the gait a stiff, awkward appearance. iYi this manner the case may progress for several weeks, or, indeed, even for several months, with, perhaps, hardly any 64 DISEASES AND INJURIES OF THE JOINTS. perceptible aggravation. The child still goes about, taking his accustomed exercise, and manifesting the same-interest as formerly in h»s out-door amuse- ments. Gradually, however, the pain increases ; there is now a distinct imp- ing, and the sleep at night is apt to be disturbed by spasmodic twitches of the extremity. The pain is usually referred to the knee, particularly to its inner side, and is either sharp and lancinating, or dull, heavy, and aching. It is sometimes felt in the very depth of the joint, but more frequently it is super- ficial, as if it were just beneath the integuments. Exercise, or motion of-any kind, always increase's it, and it is generally worse at night than in the day; damp states of the atmosphere, suppression of the cutaneous perspiration, and disorder of the digestive organs also frequently aggravate it.. The knee, on inspection, is found to be free from swelling and discoloration, and com- monly quite tolerant of rough manipulation, as motion, pressure, and percus- sion. Occasionally the pain is of a neuralgic nature, and distinctly periodical in its occurrence, very similar, in this respect, to the paroxysms of an inter- mittent fever; the attack, perhaps, coming on early in the evening, and, after having continued for a few hours, returning about the same time the next day. This form of pain is most frequent, as far as my observation enables me to judge, in persons living in a malarial atmosphere. It is not often, however, that the pain, whatever may be its character, is confined eutirely, at this stage of the disease, to the knee; or, if it be so at first, that it remains there exclusively for any length of time. In general.it extends also to the thigh and leg, sometimes along the front, now along the sides, especially the inner, and now along the posterior surface, in the direc- tion, apparently, of some nervous trunk, as the crural, obturator, saphenous, or sacro-sciatic. I have known cases where the pain was felt most keenly at the tendo Achillis, just above the ankle-joint, and in one instance it was dis- tressingly severe over the instep. Sometimes, again, the pain seems to shift from one of these points to another, being, perhaps, most violent at one time in the knee, and at another in the thigh, leg or foot. It is proper also to add that the pain is generally not persistent, but that the patient has frequently long intervals of ease or of comparative comfort. Various explanations have been offered respecting the occurrence of pain at the knee in this disease. Thus it has been supposed to be owing to an inflamed condition of some of the principal nerves of the limb, especially the obtflrator, which, as is well known, occasionally sends a small filament to the hip-joint; but what connection has this nerve with the knee ? "None whatever; and the same is true of the other nerves of the lower extremity. Nor, in my judgment, is the opinion that it is owing to disease of the long head of the femoral muscle any more plausible. This muscle lies over, and is attached to, the capsular ligament of the hip-joint; but even supposing, what is not very probable at this early stage of the malady, that it partici- pates in the morbid action, how could it give rise to the pain in the knee, leg, and foot? Again, it has been imagined that the suffering in question is caused by inflammation of the cancellated structure of the head and neck of the thigh-bone; but if this be so, there is no positive proof of the fact. Our knowledge, then, in regard to this matter, is wholly conjectural. After some time, varying from a few weeks to as many months, the pain shifts to the hip and its neighborhood ; or, if it do not entirely forsake the knee, it is generally less constant and severe there than it was in the first in- stance, or soon after the commencement of the morbid action Commonly it is most intense and persistent directly over the articulation' deep-seated, and of a dull, gnawing character. At times it is perceived most keenly in the sacro-sciatic notch, between the great trochanter and the spine of the ilium, or in the upper and outer part of the groin.' Occasionally again it exists simultaneously at all these points, although not in an equal degree- TUBERCULOSIS OF THE HIP JOINT. 65 or, as it leaves one, it fastens itself upon another. In rare cases the pain appears in the hip before it shows itself in the knee, thigh, or. leg. Pressure upon the gluteal region, motion of the affected joint, and percussion of the knee, the leg being flexed at a right angle, or of the sole of the foot, the limb being extended, always augments the pain, and leads to the detection of its seat. As yet, there is no sensible impairment of the general health ; the appe- tite is good, and the various tissues retain their normal development. The muscles of the affected hip and limb are, perhaps, a little thinner and softer than natural, but these changes are usually slight, and hence they often elude detection. In the second stage of the complaint, the most prominent local phenomena are an increase of pain in the hip and knee, flattening of the buttock, efface- ment of the gluteo-femoral crease, and apparent elongation of the limb, with spasmodic twitching and wasting of its muscles. The pain, hitherto seated chiefly in the knee, now also affects the hip, or, if it existed there previously, as, indeed, is not unfrequently the case, it be- comes sensibly aggravated. It is particularly violent at night, often for hours interrupting sleep, and attended with the most distressing spasmodic twitches of the muscles of the limb, which thus greatly augment the local and general suffering. The pain at one time is fixed, deep, aching, gnawing, or boring in its character; at auother, erratic, sharp, or lancinating, darting about in different directions, now through the joint, then down the limb, and then through the groin, or back along the course of the sciatic nerve. Oc- casionally it is most severe in the lumbar region, in the lower part of the pelvis, in the situation of the acetabulum, or at the upper and inner part of the thigh. As before remarked, it is sometimes of a neuralgic character, coming, going, aud recurring at particular periods. Derangement of the digestive apparatus, exposure to cold, and damp states of the atmosphere, have a tendency to aggravate and protract it. The pain in the knee, instead of disappearing, generally increases in violence, at the same time that it becomes more frequent and fixed. The sleep is habitually disturbed by unpleasant dreams, and the patient often wakes up in great alarm, crying and screaming. Occasionally he is partially delirious from pain and bewilderment. He sleeps by snatches, and hence he usually feels fatigued and unrefreshed in the morning. Spasmodic twitching, jerking, or starting of the limb is a prominent symptom in this stage of the disease, and is rarely absent in any case. Sometimes, indeed, it sets in at a very early period, and continues, with more or less violence, during the whole progress of the malady. It is particularly distressing in the muscles of the thigh, but often affects also those of the hip and leg. Along with these symptoms are frequently, but by no means constantly, impairment of the appetite, and disorder of the secretions, with a certain amount of fever at night. The bowels are usually inclined to be constipated, the urine is scanty and high-colored, the skin is rather arid, especially in the forepart of the night, and the patient is disposed to drink more than common. As the case progresses, the fever becomes more frequent and severe, and is often followed by copious sweats. The patient loses flesh and strength, he is peevish and irritable, and.his countenance has a care-worn appearance. Although such is ordinarily the state of the system, in the second stage, es- pecially after the disease has made some progress, yet there are cases in which there is hardly any constitutional disturbance whatever, except what results from the loss of sleep. The local phenomena, fig. 13, at this stage of the malady are unmistakable. The buttock of the affected side is found to be remarkably flattened, so as to be in striking contrast with the sound one. It is much broader, as well as VOL. n.—5 66 DISEASES AND INJURIES OF THE JOINTS. Fig. 13. considerably larger, than in the natural state; the gluteal muscles are soft and flabby, and. the skin is preternaturally loose, apparently from the absorp- tion of the subcutaneous adipose substance. The gluteo-femorai crease, which forms so prominent a feature of this part of the body in the natural state, is completely effaced, giving the thigh and hip an appearance of continuity, or as if they were fused together. The muscles of the thigh and leg are also wasted, and this circumstance, together with the loss of fatty matter, imparts to the whole limb an aspect of attenuation, which, however, upon accurate admeasurement, is usually found to be much less than was at first supposed. The cause of this condition of the muscles is evidently twofold, namely, want of exercise and perverted nervous action, leading to atrophy of their sub- stance, as well as to the absorption of the subcu- taneous and intermuscular fat. Another remarkable circumstance noticeable in this stage of the disease is an elongated state of the limb, connected with the affected joint. So constant is this occurrence that it may, along with several of the other symptoms above described, be considered as pathognomonic. The extent of the elongation is indefinite, though, in general, it may be said to vary from half an inch to an inch and a half. In rare cases it may amount to two inches, and even two inches and a half. It is observed both in the erect and in the recumbent posture, but is commonly more conspicuous in the former than in the latter. Various explanations have been offered of this phenomenon, all, at first sight, more or less plausible. In the first place, it has been argued that it is owing to the presence of an unusual quantity of synovial fluid, the product of inflammatory action, by which the head of the thigh-bone is partially pressed out of its socket, and the corresponding limb projected beyond the level of the sound one. No one, however, has yet verified this opinion by dissection. That there is an inordinate secretiou of synovial liquor in this stage of the malady is highly probable', but that its quantity is generally so great as to cause such a result is hardly a supposable case. We do not know that there are frequently large accumulations of this kind in other joints, as the elbow and knee, without producing such an effect. In the second place, the phenomenon has been ascribed to the relaxed condition of the ligaments and muscles of the joint; but of this occurrence, if it really exist, we have no more positive proof than of the influence which has been attributed to the synovial fluid. A third opinion, and, in my judgment, the only correct one, is that the elongation in question is occasioned by the difference in the level of the two hips, that of the affected side being always lower than that of the sound side. ' Now, a careful examination of the body will not fail to satisfy us that this difference is real, and not imaginary, and, moreover, that it is always in direct propor- tion to the increase in the length of the limb. Whatever mode of examination be adopted, the result will be the same, whether the patient be recumbent or erect. In the latter case, he is necessarily obliged to support himself upon the sound limb, which, for this purpose, he maintains in a state of rigid exten- sion, at the same time throwing the corresponding hip somewhat outward Appearance of the nates and limb in hip-joint disease, in its earlier stages. TUBERCULOSIS OF THE HIP-JOINT. 67 so as to bring the axis of the trunk on a line with the sound foot, and thus take off its weight from the affected extremity. This, it will be observed, hangs loosely from the pelvis, upon which the thigh is slightly flexed, while the leg is bent on the thigh, and the foot on the leg, the knee projecting prominently forward, much beyond the level of the opposite one, and the whole member resting upon the ball of the foot and toes. If this explanation be correct, as my experience warrants me in assuming, then the elongation of the limb, so constantly witnessed in this stage of the disease, is not real but imaginary, not positive but merely apparent. Finally, there is generally, in this stage of hip-joint disease, a marked de- pression, or hollow, in the lumbar region, with a slight inclination of this portion of the spine toward the sound side, and an unusual prominence of the belly. The inferior portion of the spinal, groove is also more distinct than natural. In the third stage the nature of the disease is no longer doubtful, whatever it may have been previously. The symptoms are characteristic, being such as denote the extensive and frightful mischief that has been effected within the joint, in its several constituents. Matter now forms, and, by its pressure upon the inflamed structures, greatly aggravates the suffering. The exist- ence of the suppurative process is indicated by an increase of pain; by a sense of throbbing and tension, deep and persistent; by severe swelling of the glu- teal region, generally most prominent at the centre of the articulation; by oedema of the subcutaneous cellular tissue ; and by a remarkably turgid and enlarged condition of the subcutaneous veins. The affected joint is intolerant of the slightest motion or manipulation, and the patient is unable to raise himself up or turn in bed without the greatest agony. Every attempt to move the limb is attended with similar results. The constitutional disturb- ance is always in proportion to the local suffering, and violent rigors, fol- lowed by high fever and copious sweats, are rarely absent. Sometimes, however, the abscess forms in a quiet and insidious manner, without any of the severe symptoms that usually accompany the suppurative process in this and other varieties of inflammation. As the matter increases in quantity it gradually works its way toward the nearest surface, its. approach being de- noted by the occurrence of a circumscribed, erysipelatous blush. Here there is generally distinct fluctuation, and the parts, feeling soft and boggy, soon yield at one or more points, followed by the escape of the contents of the sac. The site at which the matter, when left to itself, obtains a vent, varies in different cases. Most generally it escapes at the gluteal region, either imme- diately over the joint, or in its immediate vicinity. The other situations at which it is most liable to discharge itself are the upper and back part of the thigh, a short distance below the great trochanter, the superior and external part of the groin, the sacro-sciatic notch, and the upper and inner surface of the thigh. Occasionally it escapes at several points, either simultaneously or successively, leaving thus a number of orifices, leading to a corresponding number of sinuses. These passages are sometimes very long and tortuous, and in old cases they are always lined by a false membrane. Many years ago I saw an instance in which there were nine distinct openings," and very recently another in which there were as many as twelve ; two at the upper part of the thigh, and one just below the crest of the ilium, the remainder being scattered over the gluteal region. The matter sometimes escapes both externally and internally. When the bottom of the acetabulum is perforated, the pus may pass into the rectum ; or, instead of draining off in this way, the fluid may collect in a sort of pouch, between the inner surface of the iliac bone and the soft parts of the pelvis. In the female it occasionally escapes by the vagina, and in both sexes by the bladder. 68 DISEASES AND INJURIES OF THE JOINTS. The changes in the limb and hip, represented in fig. 14, in this stage of the disease, are striking and characteristic. The extremity, now actually shorter than "natural, is much attenuated from the wasting of its fatty and muscular tissues, and remarkably disfigured in its appearance, the heel being considerably elevated, and the ball of the foot and toes alone touching the ground when the patient makes an effort to stand. The degree of shortening is variable, and not always by any means in proportion to the destruction of the head and neck of the thigh-bone, the acetabulum, and the connect- ing ligaments, which forms so prominent a fea- ture of the disease at this period. While in some instances it does not exceed an inch, or, at most, an inch and a quarter, in others it amounts to twice and even thrice that extent. One-third, and sometimes even one-half of this, as I have satisfied myself by careful examina- tion, is generally attributable to the elevation of the pelvis on the affected side. The posi- tion of the foot is variable. Sometimes it looks directly forwards, but most commonly it inclines inwards or outwards, the former direc- tion being by far the more frequent. These differences are unquestionably due to the ex- tent and nature of the ravages experienced by the hip-joint. When the acetabulum has suf- fered most severely, the foot usually inclines in- wards, as in dislocation of the thigh-bone up- wards upon the dorsal surface of the ilium; if, on the contrary, there has been much destruction of the head and neck of the thigh-bone, and the coty- loid cavity is only slightly involved, then the foot is generally everted, as in fracture of the neck of that bone, the external rotatory muscles tending to draw the whole limb in that direction. The thigh, as a general rule, is flexed upon the pelvis, the angle of flexion varying from the slightest perceptible change to 45°. In most cases it in- clines somewhat towards the sound limb, and occasionally, though rarely, it overlaps or crosses it. Sometimes, on the other hand, it stands off widely and in a most unseemly way from its fellow, as in the case of one of my patients, a woman, aged twenty-five, in whom the two knees are habitually upwards of fifteen inches apart; the affected limb sticks out in the most grotesque manner, and the foot, in the erect posture, is at least six inches from the floor. The thigh, moreover, is always in a painfully rigid state, depending upon the contracted condition of the muscles of the hip and limb, and the forma- tion of adhesions between the remnants of the superior extremity of the femur and the surrounding parts. By taking hold of the knee a slight degree of flexion may, perhaps, be produced, but to abduct the thigh, or to move it backwards, is generally impracticable; besides, every effort of the kind is ordinarily attended with excruciating suffering. Owing to the shortening of the hamstring muscles, the leg is commonly bent on the thigh, and, for the same reason, the flexor muscles usually draw the heel upwards towards'the leg. The great trochanter generally lies directly over the acetabulum, or in its immediate vicinity, forming a hard, firm, immovable, or' nearly immovable, prominence, the nature of which cannot possibly be mistaken. In regard to Shortening, swelling, and charac- teristic deformity, of the advanced stage of coxalgia. TUBERCULOSIS OF T*HE HIP-JOINT. 69 the head and neck of the thigh-bone, they are, as stated elsewhere, usually completely annihilated, or so much wasted as to exist only in a rudimentary form. Much has been said by writers respecting the displacements of the bone in this advanced stage of coxalgia; but the facts collected by Professor March, of Albany, in the extensive museums of the United States and of Europe, as well as in private practice, conclusively prove that dislocation of the femur, as a consequence of this affection, in any direction, is exceedingly rare. A true luxation, such as occurs in the normal state of the parts, is, in fact, impossible, from the very nature of the morbid alterations in the superior extremity of this bone. During the progress of the disease, the remnant of the neck, which is usually of a rounded conical shape, and frequently not more than three-quarters of an inch in length, ordinarily"places itself over . the acetabulum, to the margins of which, and to the adjacent parts, it be- comes, in the event of recovery, ultimately united. That it is occasionally drawn up beyond this point, especially when there has been complete destruc- tion of the upper border of the acetabulum, backwards towards the sciatic notch, forwards upon the pubic bone, or downwards and forwards into the thyroid foramen, is unquestionable. Dislocation, however, in most of these directions can take place only in those cases where there has been extensive suppuration with separation or destruction of the soft parts, allowing the superior extremity of the bone to move about and thus seek, as it were, a new position. The upward displacement is, undoubtedly, the most frequent, but even this is extremely rare. In one of'my cases, the end of the thigh- bone projected above the acetabulum, where it had formed for itself a super- ficial socket in the iliac bone, admitting of very slight motion. The real cause, then, of shortening in the third stage of tuberculosis of the ileo-femoral articulation is not dislocation, as has been so often asserted, but the destruc- tion, partial or complete, of the head and neck of the thigh-bone, along with a certain degree of elevation of the corresponding hip. Diagnosis.—Although the symptoms of this disease are usually well-marked, especially after the lapse of some time, my observation satisfies me that it is extremely liable to be diagnosticated erroneously. The inexperienced prac- titioner, misled by the seat of the pain, too often contents himself with a most superficial examination, aud, taking this as the basis of his therapeutic indi- cations, is very apt to make a wrong application of his remedies, addressing them, perhaps, solely to the knee, which is only sympathetically involved, when they ought to be directed exclusively to the hip, the actual seat of the morbid action. Numerous cases, illustrative of the truth of this remark, have fallen under my observation, and there are few surgeons in extensive practice who have not, like myself, had occasion to lament the great mischief that has thus been entailed. In a malady so grave as this an error of diag- nosis may be fraught with the worst consequences both to the part and sys- tem, eventuating, as it necessarily must, in the loss of precious time; for it but too often happens that, when the true nature of the disease is discovered, all our efforts to arrest its progress are unavailing. The affections with which this disease is most liable to be confounded, or which may, at least for a time, obscure its diagnosis, are sprains and rheu- matism of the ileo-femoral articulation, psoas abscess, purulent collections in the vicinity of the hip and in the upper part of the thigh, and inflammation of the periosteum of the great trochanter. A sprain, twist, or contusion of the hip-joint is not an infrequent occur- rence, and may, if followed by considerable inflammation, give rise to severe pain and stiffness, seriously weakening the part, if not completely disqualifying it for the performance of.its functions. The consequence is that the patient, in attempting to walk, raises the hip of the affected side and relaxes the corresponding limb, by bending the knee and retracting the heel, very much TO DISEASES AND INJURIES OF THE JOINTS. - as in the earlier stages of tuberculosis. The muscles, also, by degrees become flabby and attenuated, and there is a sensible diminution of the temperature of the cutaneous surface. The gluteo-femoral crease is in time effaced, and even the general health may suffer. The signs of distinction are, the history of the case, the absence of pain in the knee, the greater latitude of motion, the absence, in general, of constitutional disturbance, and, lastly, the fact that the foot, although everted, is usually easily rotated on its axis, whereas, in strumous disease of the hip-joint, it is commonly pretty firmly fixed. Rheumatism of the hip-joint, chronic and subacute, is generally caused by cold, or by the sudden suppression of the cutaneous perspiration. It is seated principally in the ligamentous and synovial structures, the cartilaginous and osseous being seldom involved, except in very severe and protracted cases. The pain, which runs down the front of the thigh, is dull, heavy, or aching; the gait is limping; the pelvis is higher on the affected side than on the sound, and the limb exhibits, in the main, the same attitude as in lameness from sprains and contusions, with this peculiarity that the foot is always strongly everted, while in the former case it is generally inclined inwards. The patient in the morning complains of stiffness in the hip, which usually diminishes very sensibly after exercise, but is sure to return in the evening if there has been much exertion or fatigue. The muscles of the thigh are attenuated, but more firm than in tuberculosis, while those of the leg often retain their normal bulk ; the gluteo-femoral fold is effaced ; the limb, owing to the obliquity of the pelvis, appears shorter, often from one to two inches, than natural; the great trochanter is uncommonly indistinct; and a creaking noise is generally heard if the head of the thigh-bone be moved forcibly upon the acetabulum. Now, although these phenomena bear a very close resem- blance to those of strumous disease of this articulation, yet the absence of severe suffering at night, and at all times at the knee, the marked relief afforded by gentle exercise, the trifling annoyance from pressure, percussion, and motion, even when rudely performed, and the rare existence of rheuma- tism in children, together with the frequent co-existence of this disease in other parts of the body, will generally be sufficient to prove that the affection is not tubercular. It is not often that psoas abscess can be mistaken for tubercular disease of the hip-joint; for, although the matter which is poured out in its latter stages, occasionally points at the outside of the groin, or at the upper and inner part of the thigh, there is always the most marked difference in the character of the two swellings, to say nothing of other symptoms. In psoas abscess the tumor is usually situated above Poupart's ligament, while in hip-joint disease it is commonly below; in the former it always sensibly diminishes and sometimes even entirely disappears under pressure, or when the patient lies down, but quickly reappears when the pressure is removed, or when the patient raises himself up ; in the latter, on the contrary, it never changes its position, or, if it do, it is in consequence solely of the force of ulceration, absorption,and gravitation; in psoas abscess the swelling receives a distinct impulse on coflghing, laughing, and crying, which is not the case in tuberculosis of the hip-joint. Again, in psoas abscess, the principal pain is in the loins; it is fixed there, and is always greatly increased by the erect posture, as well as by every attempt to extend the corresponding limb. In hip-joint disease, the pain is most severe in the knee, or in the knee and hip. Iu psoas abscess there is at no period any change in the position of the great trochanter nor any alteration in the length of the limb; in hip-joint disease, on the contrary, especially in its more advanced stages, these are prominent symptoms. Finally, psoas abscess occurs nearly always after puberty, whereas the other affection is most common in early childhood. TUBERCULOSIS OF THE HIP-JOINT. U Sometimes large deposits of pus take place in the cellular tissue of the nates, or beneath the gluteal muscles, and, forming a prominent tumor in the direction of the ileo-femoral articulation, may thus simulate abscess of the hip-joint from tuberculosis. These accumulations are commonly the result of external injury, or of a phlegmonous, rheumatic, or erysipelatous state of the system, and are, therefore, in general easily distinguished by their history, by the rapidity of their progress, by the severity of the local distress, and by the comparatively prompt recovery of the parts after the evacuation of their contents. Cold abscesses of the nates, besides being exceedingly infrequent, exhibit none of the diagnostic signs of articular disease, especially such as pain in the knee, or pain in the hip-joint upon rotating the thigh, so charac- teristic of the latter malady. It is only when they depend upon caries of the innominate bone that the distinction would be likely to be attended with difficulty, and in this case a thorough exploration with the probe would pro- bably furnish the requisite light. Finally, diagnostic embarrassment, to an annoying extent, occasionally arises from periostitis of the great trochanter in persons of a rheumatic or gouty habit of body. The fibrous membrane of this portion of the femur becomes exquisitely painful and tender to the touch, under the slightest mo- tion and percussion, and the disease, extending above the neck of the bone and capsular ligament of the joint, causes distress and difficulty in walking, with elevation of the corresponding side of the pelvis, similar to what is seen in coxalgia. The soft parts around are swollen and puffy, giving the hip an increased breadth and thickness; by and by suppuration takes place, sinuses form, and small portions of the.bone separate and come away. Unless the case be well managed the joint becomes stiff, and the patient does not regain his health for a long time. The signs of distinction are the persistence of the gluteo-femoral crease, the coexistence of rheumatism or gout in other regions, and the fact that the disease usually occurs later in life than coxalgia. But it is chiefly in the very early stages of this affection that erroneous views of its diagnosis are liable to be formed; when it is fully established, the phenomena are generally too well marked to be mistaken. It has been seen that the very first symptom, in every case, is pain in the knee; so uniform and constant, indeed, is this occurrence that it must be regarded as pathognomonic, and yet, as was previously stated, it rarely happens that it is referred to its true source. Instead of being considered as an expression of disease of the hip-joint, it is too often regarded merely as an effect of neu- ralgia, rheumatism, or injury of the knee, to which, accordingly, the treatment is exclusively directed. Its great value, as a diagnostic, is totally overlooked, and thus the disease is allowed to progress, at the only time almost when it admits fof prompt and radical cure. In order to avoid this serious and too common mistake, a most thorough examination should be made in every case presenting the slightest suspicion of the existence of tuberculosis of the hip-joint. The very fact that there is pain iu the knee, severe in degree, and of frequent recurrence, should of itself excite the alarm of the surgeon ; but especially should he be on his guard if, added to this, there is a limping in the gait, an increase of suffering after slight exercise, and disturbed sleep at night. If the diagnosis is obscure, the examination must be repeated, again and again, until it is perfectly cleared up. To conduct the investigation properly the patient must be completely stripped, and viewed both behind and in front, as he stands on the floor. If there be any flattening of the nates, unusual prominence of the trochanter, or change in the gluteo-femoral fold, it will be sure to be detected, and so, also, if there be any alteration in the attitude, size, or length of the corresponding limb. If the patient be now requested to walk, the amount of Ijmping will be discovered, as well as the manner in which he raises and moves the leg 12 DISEASES AND INJURIES OF THE JOINTS. and foot. To complete the investigation, the patient is now stretched out on the floor, or on a hard lounge, with a view of ascertaining the amount of suffering produced by rotating the head of the thigh-bone upon the aceta- bulum, and also by bringing these parts forcibly into contact with each other by percussing the knee, the leg being flexed, or the sole of the foot opposite the ankle, the foot being bent ou the leg. The patient being next turned upon his abdomen, the hip is thoroughly examined, first, with reference to the condition of its soft parts, and, secondly, as to the amount of sensibility of the component structures of the joint; finally, if there be any obliquity of the pelvis it may easily be observed both in the erect and in the recumbent posture; and any change in the length of the affected limb may be determined by extending a piece of tape, or other suitable band, from the anterior supe- rior spine of the ilium to the inner side of the lower extremity of the patella. The difference in the length of the measure on the two sides will give the difference in the length of the thighs, or the distance between the hip and knee-joints. The use of chloroform will often be of great service in conduct- ing the movements of the limb while the patient Prognosis—So mortuary statistics of this affection have yet been furnished and it is, therefore, impossible to state, with any degree of precision, the mean • TUBERCULOSIS OF THE HIP-JOINT. 73 duration of fatal cases, or the relative proportion of deaths to recoveries. My opinion, founded upon numerous observations, is, that the mortality from the disease is slight in almost any event, even when there has been palpable neglect in regard to treatment, medical, surgical, and hygienic. In this view, I believe, most writers fully concur. When death does take place, it rarely happens before the eighteenth month, and very often not until after the second year. Fig. 15. Changes wrought fn the acetabulum and head of the femur, in coxalgia. # Treatment.—Although the treatment of coxalgia involves the same prin- ciples as that of tuberculosis of the joints in general, there are certain points to which it is necessary to direct special attention, growing out of the pecu- liar structure and situation of the articulation, the frequency with which it is assailed by this disease, and the tender age of those who are most ob- noxious to its attacks. < Rest of the affected joint, as well as of the whole body, is here of primary importance, and no time should therefore be lost in securing it to the greatest possible advantage. The restraint must not be limited to a few days or 74 DISEASES AND INJURIES OF THE JOINTS. weeks, but be continued as long as there is the slightest evidence of active disease. In order to render the patient as comfortable as possible, and enable him to endure his protracted confinement without detriment or inconvenience, he must be furnished with a suitable bed provided with slats and a firm but elastic mattress. A common trundle-bed, about four feet in width, will answer every purpose, and is in every respect preferable to the common bed, especially if the patient is a child, as he will thus be less liable, if he should roll out, to hurt himself. The sheet should be well secured at the sides that it may not become rumpled, and the pillow should be of medium size, so that, while it affords adequate support to the head and shoulders, no undue weight may be thrown upon the trunk and pelvis. The confinement, if rigidly insisted upon, will not prove irksome ; with the aid of toys and other sources of amusement the little patient will €oon—often, indeed, in a few days—become reconciled to his new mode of life. With strict attention to this point, the disease, if in its incipiency, may, in general, be easily arrested without any formal treatment, excepting, perhaps, the occasional exhibition of a laxative and a proper regulation of the diet. If the joint be stiff and painful on pressure, a few leeches may be applied, or the skin may be thoroughly painted once a day with the dilute tincture of •iodine, or a small blister may be raised, and the raw surface sprinkled with morphia. A diaphoretic and anodyne draught may be administered at bed- time if fever exist. The best laxatives, in this stage of the disease, will be from two to three grains of calomel with double that quantity of jalap. The diet must be very plain and simple, especially if the patient be, in other re- spects, well conditioned. General bleeding will seldom be required, unless the suffering is unusually severe and the blood decidedly thick and abundant, when the loss of a few ounces cannot fail to be highly beneficial. To control the spasmodic action of the muscles of the limb, and thus afford more perfect repose to the diseased.joint, recourse may be had to a splint,' extending from near the crest of Fig. 16. Fig. 17. Dr. -Davis's apparatus for extension of the thigh and leg in coxalgia. • The same for exten- sion of the femur only. the ilium to within a short dis- tance of the ankle, so constructed as to cover-in nearly the whole of the affected -buttock. The most suitable materials are gutta per- cha, undressed sole-leather, or trunk-maker's board, soaked in hot water, carefully moulded to the hip, thigh, and leg, and kept in place with adhesive plaster and a common roller. When dry, these substances form an ad- mirable case, which, if properly padded, will effectually ward off pressure and prevent excoriation. Within the last six years, the attention of surgeons has been prominently directed by Dr. H. G. Davis, of New York, to the importance of treating this dis- ease by what he calls "continued, elastic extension," with a view of removing, as he alleges, pressure from the acetabulum and head of the thigh-bone. For the purpose of effec tually securing this object, he has contrived an ingenious apparatus, com- TUBERCULOSIS OF THE HIP-JOINT. 75 posed of a splint, two bands, a roller, and several strips of adhesive plaster, together with a cord, pulley, and weight, to be used when the patient is con- fined to bed. The splint is about one inch and a half wide*, very light, and long enough to extend from near the crest of the ilium to within a short distance of the ankle. It consists, as seen in fig. 16, of two portions; an upper made of corrugated cast-steel, and a lower, which is simply a ratchet bar, worked by a key, and so constructed as to slide within the other. To the upper end of the splint is attached, by means of a cat-gut, a perineal band, composed of two parts, one being elastic, the other inelastic. Wheu applied, the elastic lies inside of the other, and the amount of elastic extension is regulated by the dif- Fig. 18. ference in their length. The inelastic, being made slightly tense, prevents the limb from receding when the weight of the body is thrown upon it. Near the inferior extremity of the splint is a buckle in- tended to receive a band stitched to the bottom of the adhesive strips. By this arrangement the splint may be made to take a firm hold both of the thigh and leg. The apparatus represented in fig. 17 is intended for the thigh only. The splint is attached to a steel frame which encircles the limb, to which it is firmly secured by adhesive strips, aided, if necessary, by the roller. The leg being thus left free, the patient en- joys the unrestrained use of the knee-joint. With the aid of a crutch, he may, with either of these con- trivances, exercise during the day in the open air, while at night, as he lies in bed, the requisite degree of extension may readily be effected by means of a pulley, cord, and weight. The apparatus of Dr. Davis has been variously modified by different surgeons, among others by Dr. Sayre and Dr. Taylor, without, however, any essential change of principle. The apparatus of the former of these gentlemen, and its mode of application, are depicted in the annexed sketch, fig. 18. He employs a perineal belt of thick India rubber tubing, but this, unless great care is taken, is extremely apt to chafe. It is difficult to conceive how an apparatus of this, or, indeed, any other kind, could act so as to keep apart the inflamed surfaces of the joint. It is ques- tionable whether any amount of extension, however great or protracted, could produce such an effect, and I am, therefore, myself inclined to ascribe all the good which it does, and this is no doubt very consi- derable, to the perfect quietude which it secures. In the second stage of the malady, the great topi- cal remedy is an issue made with the actual cautery, ^^i^^b^^- applied to the most prominent part of the swelling, ^ or as near as possible to the focUS of the morbid Dr. Sayre's apparatus applied. action. The eschar, which should be from half an inch to an inch in diameter, usually drops off in from four to six days, and, besides furnishing an ample supply*of thick pus, affords an excellent surface for the endermic use of morphia, now so necessary for allaying the violent 76 DISEASES AND INJURIES OF THE JOINTS. pains and spasmodic twitchings of the muscles. If the discharge flag, U can easily be re-excited with some stimulating unguent. It should be maintained in full force unttl the severity of the disease has completely subsided. The quantity of morphia necessary to compose the parts, will vary, according to the age and other circumstances of the patient, from half a grain to a grain and a half being sprinkled upon the surface of the issue once or twice a day. Should the general health suffer from the want of exercise, the limb may be put up in a suitable apparatus, and the child sent into the open air. In the third stage of the disease, when abscesses exist in and around the joint, accompanied with hectic irritation, the indications plainly are to evacu- ate the matter and to support the system. The knife should be introduced in such a manner as to make a valvular incision, as in an ordinary strumous collection, the opening being immediately closed with adhesive plaster, and the operation repeated at intervals of six, eight, or ten days, until all tend- ency to reaccumulation has disappeared. The object should be to permit as little air to penetrate the joint as possible, and at the same time to afford free vent to the pent-up fluid. In any event, however, no matter what precau- tions may be used, more or less hectic irritation will be sure to follow, and should claim the special attention of the surgeon. In general, the most ap-. propriate means for relieving it will be opium and quinine, with brandy, cod- liver oil and elixir of vitriol. If the joint contain dead bone, the incision should be free and direct, so as to afford an opportunity of getting rid of it, for, so long as it remains, it must necessarily be productive of mischief. When the pus has been evacuated, the affected parts should be supported with some sorbefacient and slightly stimulating plaster, as the soap, galbanum, or ammoniac and mercurial, the latter being the best. The sinuses about the joint may be injected with a weak solution Of iodine, iodide of iron, nitrate of silver, bichloride of mercury, or chlorinated soda. If numerous, and not too deep, they may often be advantageously laid open, but in per- forming such an operation care must be taken to guard against pain and loss of blood. As soon as the patient is able, he should have the benefit of ex- ercise in the open air, and a suitable opportunity should be sought for the institution of passive motion of the affected joint. When the parts in and around the joint are so much diseased as to render recovery by the ordinary means entirely hopeless, recourse should be had to excision. The operation, the statistics of which will be given in the chapter on excision of the joints, may be conveniently performed by making a curved incision, from five to six inches in length, perpendicularly over the joint, in a line with the great trochanter, separating the parts, and cutting off the diseased structures with the saw or pliers. If more room be required, the incision may be crucial, or in the form of a T or V. The flaps are after- wards approximated with stitches and plasters, and the immobility of the limb is secured by appropriate splints, pads, and bandages, as in fracture of the thigh-bone. When the patient has been exhausted by protracted suffering, and life is fast ebbing away, it has been proposed, as a dernier resort, to amputate at the hip-joint; and the records of surgery contain several examples, among others, one by Dr. Duffie, of this city, in which the operation has been fol- lowed by the most gratifying results. Notwithstanding this, however, I should hesitate before undertaking so grave a procedure, the more especially as the same end may generally be more readily attained by the more simple and less dangerous operation of excision. CHRONIC RHEUMATIC ARTHRITIS. 77 SECT. VII.—CHRONIC RHEUMATIC ARTHRITIS. The joints are liable to a peculiar form of disease, known under the name of chronic articular rheumatism, or chronic rheumatic arthritis, and first sys- tematically described by Dr. R. W. Smith and Dr. R. Adams, of Dublin, the latter of whom has published an able and elaborate treatise upon it.' It is observed chiefly in elderly and middle-aged subjects among the laboring- classes, though occasionally it also occurs in the higher orders of society, in particular among the indolent and habitually intemperate in eating and drinking. Both sexes are obnoxious to its attacks, but whether with equal frequency or otherwise has not been determined. The joints which are most liable to suffer are those of the hip, elbow, wrist, and fingers; one of which only may be affected, or a number may be implicated simultaneously, or in more or less rapid succession. Sometimes the disease leaves one articula- tion, and fastens itself upon 'another; but, in general, when it has once effected a firm lodgment it holds on to it pertinaciously, now and then remit- ting, but seldom entirely intermitting, at least not for any length of time. Ill-fed and ill-clothed persons, living in moist, underground apartments, or in damp, confined alleys, are particularly prone to attacks of this kind. A gouty, rheumatic predisposition probably favors its outbreak. The immediate cause of this disease is generally a suppression of the cuta- neous perspiration from exposure to cold, or from long-continued immersion of the feet in water, as often happens in the laboring classes. Occasionally its origin is traceable to external injury, as a blow, sprain, or concussion. In the female, it is sometimes apparently'dependent upon irregularity of the menses; and in both sexes it is frequently connected with disorder of the digestive apparatus, as dyspepsia, constipation, or derangement of the biliary secretion. The disease often, if not ordinarily, approaches in a slow and stealthy manner, the first symptoms being usually merely a sense of soreness and stiff- ness of the affected joint, with slight derangement of the general health. As it progresses, the local distress assumes a more marked and open- character ; what was before only a feeling of uneasiness now becomes a source of real pain and distress. The joint, gradually growing rigid, moves with great difficulty, and a careful examination seldom fails to detect fluctuation, de- pendent upon the presence of synovial fluid, an early product, and generally the principal one, of the inflammation in its milder forms. When the effusion is considerable it will necessarily seriously change the contour of the affected joint, the synovial membrane bagging across the ligaments, as is so apt to happen when the disease is seated in the knee, wrist, or elbow. It is seldom that pus forms in' any case, even if unusually severe and protracted ; but plastic matter is often poured out in large quantity, and it is the presence of this substance that causes the remarkable rigidity which so constantly attends the complaint in its more severe grades. Spasmodic twitchings of the muscles in the neighborhood of the affected joints commonly set in at an early period of the inflammation, and constitute a source of great distress, effectually interrupting sleep, and requiring large doses of anodynes for their subjugation. The pain in chronic rheumatic arthritis is often excessive; it is always increased by motion and pressure, and is usually materially aggravated at night. It is of a dull, heavy, aching character, and frequently extends in different directions, but especially along the course of the larger nerves, which it sometimes follows to their very extremities. The general health suffers severely ; the patient is feverish, and deprived of appetite and sleep ; T8 DISEASES AND INJURIES OF THE JOINTS. the bowels are constipated; and the skin is hot and arid. The urine, how- ever, although commonly scanty and high colored, does not deposit any lithic acid, a circumstance which remarkably distinguishes this disease from gout and rheumatism, properly so called. In old cases of this disease, or in the strictly chronic form of it, the general health, although perhaps somewhat impaired, is comparatively good, and the patient may even grow fleshy and ruddy. His locomotive powers, however, are greatly deranged, and he is, in consequence, often obliged to use crutches. The affected joints are habitually tender, sore, and distorted, perhaps fre- quently presenting an appearance of being partially dislocated. Such a change is particularly liable to occur in the fingers, but is also occasionally noticed in the hip, shoulder, and other large articulations. Exostoses some- times spring from the sides of the affected joints and serve to add to the deformity, already sufficiently great. The synovial burses are also apt to suffer, becoming inflamed, enlarged, and distended with fluid. The muscles, in consequence of their perpetual inactivity, become atrophied and powerless. What strikes the observer as very peculiar, amidst these changes, is the entire absence of cretaceous deposits in and around the disabled joints. Chronic rheumatic arthritis is essentially an inflammatory malady. If the affected structures be examined in the earlier stages of the disease, they will be found to exhibit indubitable evidence of vascular injection of the synovial membrane, and of the presence of synovial fluid, with here and there, perhaps, a patch of lymph, or more or less of this substance intermingled with the other secretion. Pus, as already stated, is seldom seen in any case. When the disease is permitted to go on unchecked, great structural changes gradu- ally take place, consisting in the removal, either partial or entire, of the syno- vial membrane and articular cartilages, and the conversion of the extremities of the bones into a hard, ivory, or porcelaneous substance, totally destitute of its normal qualities. In many cases the ends of the bones have a beautiful polished aspect, being perfectly smooth and. glistening; while in others they are remarkably rough and tuberculated, or beset with exostosic incrustations. The inter-articular fibro-cartilages are generally completely destroyed, and the funicular ligaments often undergo partial absorption, while the capsular are liable to become 'stretched and relaxed, thus allowing the bones to slip away from each other, and produce an appearance of being partially dislo- cated. Finally, fibroid, fibrocartilaginous, and osseous growths of various shapes and sizes, are extremely prone to form in the interior of joints thus affected, but as these have already been described in a preceding section, no further mention of them need be made here. The changes wrought in this disease are beautifully illustrated in the annexed cuts, from Druitt. Fig. 19 represents the head of the thigh-bone, and fig. 20, the corresponding acetabulum, in an advanced state of rheumatic arthritis. What is the pathology of this disease? That it is of an inflammatory nature is unquestionable ; but how it is produced, or what the peculiar con- dition of the system is which predisposes to its development, or which keeps the affection in play after it has been fairly established, are circumstances in its history of which we are totally ignorant. The diagnosis of the affection is, in general, sufficiently easy, especially in its more chronic forms. The history of the case, the excessive obstinacy of the disease, and the gradual failure of the functions of the affected joint, together with its distorted appearance, and the absence of cretaceous deposits in the structures around the articulation, and of lithic acid in the urine always readily distinguish it from ordinary gout and rheumatism, the only maladies with which it is at all liable to be confounded. The prognosis of chronic rheumatic arthritis is generally most unfavorable In the milder forms of the disease, and in its earlier stages, a cure is certainly CHRONIC RHEUMATIC ARTHRITIS. 79 occasionally practicable, but under opposite circumstances the patient almost invariably remains a cripple for life, it being impossible by any mode of treat- ment at present known to effect restoration of the disorganized structures of the affected joints. Fig. 19. Changes of the acetabulum in chronic rheumatic Appearances of the head of the femur in chro- arthritis. nic rheumatic arthritis. Treatment.—In the treatment of this affection, everything depends upon the efficiency with which the case is met in its earliest stages ; for after the morbid action has made serious inroads, all that can, in general, be expected from our remedial interference is a mitigation of suffering, but seldom any- thing like a complete, permanent cure. Unfortunately it but too often hap- pens that the disease has occasioned great disorganization of the affected structures, before the practitioner is afforded an opportunity of taking it in hand. Considering its inflammatory character, the course of treatment to be adopted is indisputably the antiphlogistic, directed not to the part merely, but also, and in an especial manner, to the state of the general system, which, whatever may be the real pathology of the disorder, is always more or less extensively implicated. In this country there are few cases of chronic rheu- matic arthritis which will not, in their earlier stages, bear active depletion by the lancet, purgatives, diaphoretics, and antimonials. The quantity of blood taken from the arm must of course depend strictly upon the condition of the constitution, as to the existence or absence of plethora, anorexia, and other evidence of vascular disturbance. Mercurial purgatives, administered in efficient doses, in union with jalap or rhubarb, and compound extract of colocynth, are among the most efficieut means that can be employed for ar- resting the morbid action ; and it would be difficult to conceive of any case in which they can altogether be dispensed with. At the same time, how- ever, they must be used with caution. The improvement of the secretions always forms an important indication, and there is no class of remedies so likely to do this promptly and effectually as purgatives. • After the violence of the disease has been moderated by these means, the most efficient prescrip- tion, according to ray observation, is a combination of morphia, antimony, Fig. 20. 80 DISEASES AND INJURIES OF T"HE JOINTS. and veratrum, given in full and sustained doses, until it makes its specific impression upon the heart and nervous system. One grain of morphia, with one-sixth of a grain of tartar emetic, and ten drops of tincture of veratrum, is a fair average dose for an adult, to be repeated once or twice in the twenty-four hours, according to the severity of the suffering, or the effects of the remedy, which should, of course, always be carefully watched. Administered in this way, it is sure promptly to subdue pain, produce perspiration, and reduce vascular excitement. When this result has been brought about, the medi- cines are given in smaller or less frequently repeated doses, until the necessity for their exhibition entirely ceases. Colchicum is seldom of any material benefit in this disease in any of its stages ; for, although the disorder unquestionably generally partakes of a rheumatic or gouty nature, yet, as already stated,' there is rarely any lithic acid deposit in the urine, or cretaceous formation within the joints, and this is probably one, if not the principal, reason of the inefficiency of the medicine. Dover's powder, so highly extolled by some practitioners in the treatment of chronic rheumatic arthritis, is both bulky and nauseous, and in every respect inferior to the articles mentioned in the preceding paragraph. Among the more important topical remedies are leeches and fomentations, medicated with acetate of lead, opium, and aconite. Local steam baths are sometimes highly beneficial, the vapor being conducted by means of a tube directly to the inflamed parts. Cold applications are rarely admissible in any case, from their tendency to shock the system, and cause metastasis. As the disease declines, recourse should be had to the dilute tincture of iodine and to steady compression with the bandage. At a still later period, passive motion must be instituted, and the parts around the joint must be well douched and shampooed twice a day, in order to promote the absorption of effused fluids and the restoration of impaired function. In the more advanced chronic forms of the affection the main reliance of the practitioner must be upon a proper regulation of the diet, which must be chiefly of a mild, farinaceous character, with a little white meat or fish at dinner; the preservation of the secretions by the occasional exhibition of a few grains of blue mass, or calomel; the steady, persistent use of iodide of iron, either alone or in union with iodide of potassium, in doses of from three to six grains, three times a day; and a residence in a dry, genial climate, exempt from sudden and severe vicissitudes. A sojourn of from three to six months at the Hot Springs in Arkansas, with the daily use of the warm baths obtainable at that place, will often prove serviceable. If the general health is much broken, cod-liver oil with iron and quinine may be required. In all cases the body should be incased in flannel, and gentle exercise should be frequently taken in the open air; a precaution of paramount importance in regard to the prevention of anchylosis, which is always so much favored by inactivity in all articular affections, whatever may be their character. SECT. VIII.—ANCHYLOSIS. By this expression is meant the stiffness of a joint, the effect of disease of some of its component elements, its etymology havino- reference to the an- gular deformity which so generally characterizes the affection. Several varie- ties of the complaint are met with, of which those commonly recognized are the complete and incomplete; all motion in the former being annihilated, while in the latter motion still exists, although in a very limited degree. There is another form of stiffness, in which the structures of the joint retain their normal characters, but are prevented from being exercised by disease in the neighboring tissues; and this circumstance has induced the division ANCHYLOSIS. 81 of anchylosis into true and false, or into intra-articular and extra-articular. This classification is not only more philosophical than the other, but is of paramount importance in a practical point of view, as it leads to a just ap- preciation of the etiology of the disorder, and also, as a necessary conse- quence, to proper therapeutic indications. The terms complete and incom- plete refer, in fact, merely to different degrees of the same complaint, and might be very well replaced by the words fibrous and osseous, as more ex- pressive of the true nature of the anchylosis. 1. Intra-articular Anchylosis.—Intra-articular anchylosis may be produced by whatever has a tendency to excite inflammation in the synovial membrane of the joints, with deposits of plastic matter upon its free surface. Hence it may arise from all kinds of external injury, as wounds, sprains, blows, and contusions; the presence *>f inter-articular bodies; luxations, especially neglected ones; and fractures which involve the joints, or are situated in their immediate neighborhood. Gout, rheumatism, syphilis and struma also act as exciting causes; but of all these causes, as well as others that might be referred to, there are none which, according to my experience, so fre- quently occasion anchylosis, permanent and irremediable, as fractures and dislocations. Long disuse is another circumstance which powerfully disposes tothe occurrence of stiffness of certain articulations, especially those of the fingers, wrist, and elbow. I am aware that the force of this influence has been denied, but certainly not upon just grounds ; for modern experience has shown, and my own observation has repeatedly verified the fact, that this cause alone is often capable of producing anchylosis of a very obstinate and intractable character. Such an event need not surprise us if we remember that motion is the appropriate stimulus of an articulation, and that more or less of this is just as necessary to its healthy action as food is to the stomach, light to the eye, or sound to the ear. When motion is suspended for any length of time, the synovial membrane becomes dry and stiff, and, eventually taking on inflammation, it pours out plastic matter, which effectually oblit- erates its cavity and so induces permanent anchylosis, on" the principle that when the function of a part is destroyed its structure is also destroyed, or, at all events, essentially changed in its chaTacter. All joints are liable to this variety of anchylosis, but it takes place much more easily in the ginglymoid than in the orbicular, and among the former it is more frequently witnessed in the knee, elbow, and wrist,-than in any others. Several joints are sometimes involved in the occurrence, especially when it happens in consequence of gout, rheumatism, or syphilis, and instances have been noticed in which nearly every articulation in the body was com- pletely anchylosed, the skeleton forming almost one rigid piece. In every case of intra-articular anchylosis a series of changes is obliged to take place before the loss of function can be said to be complete. Hence if we examine a joint which is about to become thus affected, it will be found that the first step consists in the effusion and organization of plastic matter, and the second in the gradual conversion of this matter, first, into fibrous, or cellulo-fibrous tissue, then into cartilage, and finally into bone, the latter forming the ultimate link in the morbid chain. ' A fibrous or fibro-cellular anchylosis generally terminates, and that at no distant period, in osseous anchylosis, the change from one to the other being regularly progressive until the process is completed, this being the method which nature adopts to effect a cure when any serious accident befalls a movable articulation. These adhesions and transformations vary in extent, not less than in structure and consistence. Sometimes they are very limited, a considerable portion of the synovial membrane remaining sound, or being only slightly affected by disease, and, under such circumstances, the connection between the opposing surfaces is generally easily»broken, so that ultimately the joint 82 DISEASES AND INJURIES OF THE JOINTS. may regain its original functions. In a second series of cases, again, the • fibrous or fibro-ligamentous bands are more numerous, extending from different points of one articular cartilage to the other, and thus effectually obliterating the synovial cavity, or, at all events, completely destroying its usefulness. Finally, in a third series of cases, the new tissue becomes the seat of osseous deposits, which, going on gradually increasing, in time usurp the place of the synovial membrane and cartilage, and, bringing the extremi- ties of the two bones in contact, fuse them firmly together; so that if a section be made of what was once the F. 21 joint, their areolar and solid structures will be found to be inseparably blend- ed, their junction being no longer in- dicated bj» the thin layer of compact substance which originally invested their heads. These changes are well seen in fig. 21, representing osseous anchylosis of the knee, from a speci- men in my cabinet. The femur and tibia-are firmly soldered to each other, and the patella to both, the three forming one piece. The treatment of this variety of anchylosis must vary according to the nature and extent of the tissues upon ■ which it depends, and also, in no in- considerable degree, upon the cha- racter of the articulation. When the case is of recent standing, when the adhesions are weak and of limited extent, and when the joint is not too complicated in its structure, a reason- able hope may be entertained that the Osseous anchylosis of the knee-joint. . nevy tjssues may De broken Up, and brought fully uuder the action of the absorbents, so that, in due time, and with proper diligence, the functions of the joint may be measurably, if not completely, re-established. Under oppo- site circumstances, however, a cure will not only be difficult, but generally impracticable. Much may be done in most cases of intra-articular anchylosis, in the way of prevention, by the steady and persisteut use of sorbefacients and passive motion, as advised in the chapters on fractures and dislocations. The attend- ant inflammation having been divested of its violence, the plastic deposits must be disposed of before they have an opportunity of becoming firmly organized, and the only way in which this can be effected is by frictions with stimulating lotions, aided by the cold or hot douche, and by rubbing the articular surfaces gently against each other, at first once every forty-eight hours, and then once or twice a day, until all the matter has been absorbed, and the synovial membrane has regained its primitive characters. Much more skill and attention are required in these cases than the surgeon is usually willing to bestow, and it unfortunately too frequently happens that their entire management is confided to persons who are wholly ignorant of the manner in which it should be conducted. The consequence is that a great deal of harm is commonly done, which it is impossible subsequently to rectify by any mode of treatment, however carefully carried out. For the most part, indeed, the time for successful interposition has gone by when the case falls into judicious hands. ANCHYLOSIS. 83 When, through neglect, mismanagement, or unavoidable circumstances, the movements of the joint have become greatly impaired, or when the case has already attained a certain degree of chronicity, instead of abandoning the patient to his fate, an attempt should be made to break up the adhesions by forcible means, not forgetting, however, that they must, nevertheless, be con- ducted with a certain degree of gentleness in order to prevent mischief. The patient being placed under the influence of chloroform, the distal portion of the limb is moved with one hand, while the proximal, or that nearest the trunk, is firmly steadied with the other, at the same time that it rests upon a smooth, solid surface, so as to afford a better fulcrum for the other part to move upon. Thus, when we wish to break up the adhesions in anchylosis of the knee, the thigh is firmly pressed upon the table, while the leg, drawn away from its edge, is alternately flexed and extended to as great a degree as may be compatible with safety. In operating on the elbow a similar pro- cedure is adopted, the arm being the fixed, and the forearm the movable point. Much muscular power is frequently required to conduct these move- ments, and yet the greatest care must be taken so to distribute this power as not to produce any mischief. Not long ago, in one of my cases at the Jeffer- son College Clinic, I was so unfortunate, in attempting to remedy an anchy- losed elbow, as to fracture the humerus just above the joint, the accident being announced by a loud snap, very different from the crackling noise which attends the severance of fibrous, or cellulo-fibrous bands. The patient was an old female, aged sixty-five, who had dislocated her elbow nearly three months previously, and it is highly probable lhat the bone had become soft- ened and brittle from an extension of the inflammation. Such an occurrence is not always avoidable; for I am quite sure that in the case in question I did not use near as much force as I had often employed before on similar occa- sions without any such mishap. The amount'of force and the length of time during which it should be continued must vary according to the circumstances of each individual case, especially the strength and extent of the adhesions. The efforts should always be very gentle at first, and be gradually increased as the parts are foudfi to yield. If the joint be tender when the case coraes under treament, it may be necessary to spend a few days in preliminary treatment, dieting, purging, and perhaps even bleeding the patient, to prepare him for the ap- proaching ordeal. The subsequent management must be of a strictly anti- phlogistic character, and the repetition of the operation must depend upon the effects of the first trial; at all events, it should now be conducted with great gentleness, and rather with a view to a passive than an active result. In many cases it will be found advantageous after the first efforts to extend the joint by an angular splint, worked by a screw, and worn steadily until the object is attained, the degree of tension being regulated at will by the patient. Apparatuses for fulfilling these indications are delineated in the accompanying Bketches. Fig. 22 represents Kolbe's contrivance for straightening the knee; and fig. 23 that of Stromeyer, modified by Mutter, for rectifying anchylosis of the elbow. These attempts at curing anchylosis may not only eventuate in fracture of the bones, either of the joint itself, or of those in their immediate vicinity, but they may give rise to consequences still more disastrous, as violent in- flammation, erysipelas, gangrene, and loss of life. It will be perceived, then, how cautiously all such procedures should be conducted, although they are unquestionably always less hazardous when conducted with the hands than when made with the^aid of machinery. Finally, when it is found that there is no possible chance of effecting.a cure, but that anchylosis is inevitable, every effort, compatible with safety, should be made to place the affected limb in a situation most conducive to its 84 DISEASES AND INJURIES OF THE JOINTS. future usefulness. Thus, the wrist should be straight; the elbow bent at a right angle with the arin; and the arm be brought close to the side of the Fig. 22. Fig. 23. body, and as far forwards as possible, to enable the patient to put his hand to the mouth. In anchylosis of the hip, the thigh is flexed a little upon the pelvis; when the knee is concerned, the leg is inclined somewhat backwards; and in anchylosis of the ankle, the foot is placed at a right angle to the leg; the parts being found to be most serviceable when held in these several positions. * Bony anchylosis is incurable, except by an operation, which consists in cutting out a V-shaped portion of bone, as originally proposed and success- fully executed by Dr. John Rhea Barton, in 1826. His patient was a sailor, twenty-one years of age, who had lost the use of his hip-joint, in conseqnfnce of an injury from a severe fall on shipboard. The thigh was drawn up nearly at a right angle with the axis of the pelvis, the knee projecting inwards across the sound limb, and the foot presenting forwards. All attempts at correcting the malposition having failed, a crucial incision was made through the integu- ments, over the most prominent part of the great trochanter, and, raising the flaps thus defined, the operator next detached the muscles connected with this portion of the bone, making a passage both in front and behind the femur for the easy introduction of the finger. With a saw constructed for the purpose, he now divided the bone through the great trochanter and a part of its neck in a transverse direction. The wound being lightly dressed, the limb was placed in Desault's fracture-apparatus, as modified by Pbysick, and the case managed, upon strictly antiphlogistic principles. Twenty days after the operation the limb was gently and cautiously moved, in different directions, but neither so long, nor so violently as t<5 produce severe irritation. At first, the motion was repeated only every other day, but afterwards every twenty-four hours, for four months, at which time the artificial joint had acquired such a degree of freedom as to enable the patient to walk about with the aid merely of a cane. The wound had healed, and he could not only rotate the foot, but abduct it twenty inches, and carry it forwards and backwards to a still greater extent. Th» case is reported in full,.with an illustrative plate, in the third volume of the North American Medical and Surgical Journal. ANCHYLOSIS. 85 The operation of Dr. Barton, or, more correctly speaking, an operation conduct^ upon similar principles, is particularly applicable to the relief of deformity of the lower extremity, dependent upon anchylosis of the knee- joint. The proceeding was first executed by Professor Gibson, in 1838, in the case of a boy, seventeen years of age, who made an excellent recovery, the limb being only half an inch shorter than the sound one. It is divided into four distinct stages. In the first, a triangular flap is made of the soft parts in front of the limb, consisting of the integuments and the extensor muscles, by making two horizontal incisions, one just above the superior bor- der of the patella, and the other two inches and a half higher up, down to the bone. This flap, which has a broad base on the inside of the thigh, is then dissected up, and held out of the way. The next step is to remove a V-shaped portion of the femur, which is easily done with a narrow saw, care being taken not to divide the bone completely, for fear of injuring the pop- liteal artery. In the third stage the bone is fractured, by gently flexing the limb; and, lastly, the flap is replaced and secured by suture. The dressing is completed by putting the limb on a double inclined plane, where it is re- tained for the next ten days, or until the ends of the broken bone have become enveloped in plastic matter, when it is placed in the straight position, in a suitable apparatus for insuring quietude. The patient is usualjy able to rise, and walk about on crutches, in six weeks. The sawing of the bone constitutes one of the leading objects of interest in this operation ; if the wedge-shaped piece is too large, there is a possibi- lity of non-union,-whereas, if it is too small.it maybe impracticable to straighten the limb sufficiently. In order to avoid these contingencies, all that is necessary is to measure the angle of deformity, and then to saw out a portion of bone equal to the complement of that angle. The adjoining cut, fig. 24, will afford a better idea of the nature of the operation than any de- scription of it, however elaborate. Dr. J. Kearney Rodgers modified this operation by connecting the ends of the bone with silver wire, on the supposition that the proceeding would Fig. 24. tend to expedite their reunion: Such a measure, however, is hardly required if proper care be taken to keep the limb well secured during the after- treatment. Of 10 cases of this operation, qf which the results have transpired, 8 recovered and 2 perished, death in one having been caused by an attack of intercurrent pneumonia from accidental' exposure. The success would thus seem to be eminently flattering. When Barton's operation. the operation is done at the knee, the risk is always greater when the joint retains a portion of its natural struc- tures than when these structures are completely annihilated. The amount*of shortening after this operation is variable. In general, it ranges from half an inch to an inch and a quarter. In a case by Dr. Buck, of New York, in which the excision was performed through the patella, the patient recovered with a shortening of four inches. An operation for the relief of bony anchylosis of the knee, based upon the same principles as that of Dr. Barton, but differing from it in some essen- tial particulars, was performed by Professor Pancoast at the Clinic of the Jef- ferson Medical College in the winter of 1859, the patient being a youth on whom extension had previously been tried in vain. It consisted in perfor-at- t 86 DISEASES AND INJURIES OF THE JOINTS. ing with a stout gimlet the femur subcutaneously, through a single opening, at half a dozen points, just above the knee, and then forcibly broking the bone. The limb was placed in appropriate apparatus, the upper end of the inferior fragment forming an angle with the apex projecting into the ham. A large abscess formed at the seat of fracture, but, with this exception, the case progressed favorably, and the boy made a good recovery, the foot com- ing down well, and the limb being nearly as straight as could be desired in such a condition, of the knee-joint. An operation similar to the above was performed by Professor Brainard, in 1860, upon a man twenty-three years of age ; but in this case the femur was divided through its condyles by means of the peculiar perforator of that surgeon, the use of which is less liable to be followed by severe inflammation than that of the gimlet. The patieut recovered with a good limb. In an- other case of anchylosis of the knee, the patella was detached subcutaneously from the femur and tibia, and excellent motion of the joint obtained. 2. Extraarticular Anchylosis.—In extra-articular anchylosis, the spurious anchylosis of some authors, the articular structures retain, at least for a time, their normal characters, but their functions are impaired or suspended, by the diseased condition of the surrounding parts. Several distinct causes may induce such a result, of which muscular contraction, vicious cicatrices, osseous deposits, and the pressure of new growths, or aneurismal tumors, and paralysis of the articular muscles, are the most common and efficient. a. Of the several causes here enumerated, "as capable of producing rigid- ity of a joint, permanent contraction of the muscles and tendons, which naturally influence and control i£s movements, is the most frequent. We meet constantly with examples of this in gout, rheumatism, fractures, and dislocations, where, from an extension of the inflammation, which attends these diseases and accidents, motion is greatly impeded, if not completely destroyed, by this occurrence. The influence exerted by permanent contrac- tion of the muscles is well illustrated in club-foot and analogous distortions, where the joints are not only crippled in their functions, but greatly changed in their form and relations, giving the limb that peculiar aspect, from the resemblance to which it derives its name. Similar effects may be caused by the contraction of the aponeuroses, as is witnessed in the affection just men- tioned, as well as in several others. b. Secondly, a joint may become stiff in consequence of the existence of a vicious cicatrice, as thpt, for instance, caused by a burn or scald. The tendency of the new substance, called by the French pathologists the modu- lar tissue, is to go on contracting until it produces hideous deformity, stretch- ing the soft parts to their utmost capacity, and drawing the neighboring articular surfaces completely out of their natural position. The morbid adhesions formed after ulcerative mercurial ptyalism generally give rise to distressing and often irremediable anchylosis of the temporo-maxillary arti- culation. c. In gout, rheumatism, and other affections, as well as in certain accidents, the motions of the joints are occasionally destroyed by the formation of osse- < ous bridges, extending across the articulation, from one bone to the other. Such an occurrence is most frequently met with in the sacro-iliac symphyses, and in the joints of the vertebrae; it sometimes occurs also in the more per- fect joints, especially the ginglymoid. In fractures, followed by exuberant callus, the muscles and tendons, in the vicinity of the neighboring joint may be so completely imprisoned by the new matter, as to cause anchylosis of the worst kind. J d. Anchylosis may be produced, in greater or less degree by the develop- ment of various kinds of tumors, or morbid growths, in the neighborhood of' an articulation, or in direct contact with it, interfering with its functions and * NEURALGIA. •87 ultimately, if not removed, perhaps annihilating them. Thus, an aneurism of the popliteal region may cause stiffness of the knee, and an osteo-sarcoma of the jaw, partial anchylosis of the temporo-maxillary joint. e. Finally, paralysis of the muscles of a joint may induce a certain degree of anchylosis; we constantly observe cases where, from long disuse of an articulation from this cause, its functions are permanently lost. The shoulder- joint frequently becomes stiff and useless, from palsy of the deltoid interfer- ing with its natural movements. It is extremely probable that the most of the causes here enumerated may, if long continued, induce permanent anchylosis, in consequence of the opera- tion of the general pathological law, that, when a part ceases to perform its functions, it gradually degenerates, and is ultimately completely deprived of its characteristic attributes. Nature abhors everything that is useless, and when a joint is once rendered passive, the synovial membrane, losing its secreting faculty, becomes dry, and is at length converted into fibrous, or fibro-cellular ttssue. The treatment of extra-articular anchylosis must be regulated by our know- ledge of the nature of the exciting cause, which should, therefore, always be clearly ascertained before we attempt to interpose any curative agents. Thus, if it be found to depend upon contraction of the muscles, tendons, or aponeu- roses, whether singly, or unitedly, the only remedy, in confirmed cases, is their subcutaneous division, an operation which will be fully considered in the chapter on club-foot; whereas, in recent cases, it may often be relieved by a course of friction, douching, and passive motion, aided by gentle exercise on the part of the patient. Vicious cicatrices must.be cut out, and, .if possible, replaced by new substance; such a procedure, however, is not always practi- cable, and hence most cases of this description go on from bad to worse until they are rendered wholly irremediable. Osseous bridges, circles, or bands may occasionally be removed with the saw and pliers; morbid growths are exsected, or, as in aneurism, the artery leading to it is tied4; and paralysis of the muscles is relieved by stimulating frictions, the cold douche, shampoo- ing, and electricity, the general health being at "the same time improved by tonics, alterants, and exercise in the open air. SECT. IX.—NEURALGIA. The joints are occasionally the seat of neuralgia, although much less fre- quently than is generally supposed, especialfy if it be regarded as an inde- pendent lesion. As a complication of coxalgia and other articular affections it is not uncommon. During my long residence in the Southwest, where neuralgia is exceedingly frequent, in every form, I witnessed comparatively few cases of it in the joints, although I met with it constantly in other parts of the body ; and, from what I can learn, it is also unusual in the northern and eastern States. In our more southern latitudes, too, it is 'seldom observed. It is not improbable, moreover, that in many, of the cases in which it is sup- posed to attack the joints it is in reality situated altogether exterior to them, in the structures immediately around, and not in those concerned in their composition. Any of the articulations may suffer from this disease, but it is by far more frequently met with in those of the knee and hip than in any others. Neuralgia, considered as an independent affection, is most frequent in young, delicate, nervous females, soon after the appearance of the menses, of the derangement of which it is occasionally an exponent. No period of life, temperament, habit, or occupation, however, is exempt- from it. The attacks are sometimes strictly periodical, precisely like those of an intermit- tent fever, coming and going regularly once a day, or every forty-eight hours; 88 DISEASES AND INJURIES OF THE JOINTS. but more frequently they are irregular, the patient being tormented nearly constantly, the pain being now slight, now severe, and then perhaps again entirely absent, though never very long at one time. The paroxysms are frequently coincident with neuralgia in other parts of the body, alternating with it, usurping its place, or going on with it simultaneously. The pain is either of a dull, heavy, aching character, or sharp, lancinating, and darting, flying about in fits and starts, in different directions, almost with the rapidity of lightning. It is usually attended with more or less soreness and tender- ness on pressure, motion, and percussion, and sometimes with a slight degree of tumefaction or puffiness of the parts around the affected joint," which often entirely disappears in the intervals of the attacks. Motion also is usually somewhat impeded. In the more aggravated cases the whole limb may be swollen, tender, and disabled, and under such circumstances there is commonly also a sense of numbness, extending to the very extremity of the member. The general health is not always appreciably affected ; often, however, there is marked disorder of the digestive organs, with a sallow state of the skft, headache, and derangement of the renal secretion. In the female the symp- toms are often of a hysterical character, and are liable to frequent exacerba- tions in consequence of the peculiar state of the mind, which is generally morbidly sensitive, and absorbed in* selfishness and disagreeable forebodings. It is of great moment to discriminate carefully between neuralgic and other affections of the joints, inasmuch as a wrong diagnosis may lead to serious errors in practice, inducing perhaps the employment of harsh measures where gentle ones alone are required ; or, on the other hand, allowing the patient to move about and exercise the joint when he ought to observe the most per- fect quietude. In general, the history of the case, the peculiar nature of the pain, the suddenness of the attack, the absence of constitutional disturbance, and the perfect freedom of motion of the affected joint, when the surgeon takes hold of the limb and attempts to carry it about in different directions, will serve to distinguish it from those organic diseases to which the articula- tions are liable. Where, however, there is any doubt respecting the. real nature of the complaint, the'examination should be repeated again and again, and varied in every possible manner, so as to elicit the true state of the case. In many instances the best diagnostic is the success or failure of anti-neuralgic remedies. In the treatment of this affection the first thing to be done is to ascertain, if possible, the nature of the exciting cause, and then to direct our remedies accordingly. Attention to the diet, bowels, and secretions should, in every case, receive prompt consideration, and should be kept prominently in view throughout. The malady very often has its origin in a vitiated state of the alimentary canal, or in the suppression of some important habitual discharge, by correcting or restoring which the symptoms frequently disappear without any further treatment. In general, however, anti-neuralgic remedies, properly so called, will be needed, and of these the best, according to my experience, are quinine, strychnine, and arsenious acid, in doses varying from three to five grains of the first, with the twenty-fifth of a grain of the second, and the tenth of a grain of the last, three times in the twenty-four hours. When there is marked evidence of anemia, iron may be advantageously combined with these remedies. If, on the other hand, the patient is plethoric I usually add to each dose about the sixth or eighth of a grain of tartar-emetic with a view to its relaxing and diaphoretic effects. Morphia also forms a valuable adjuvant, and can rarely be dispensed with in any case. Colchicum often proves very serviceable, and I have known it to afford prompt relief when everything else failed. It is particularly valuable when the disease partakes of a rheumatic or gouty character. In the hysterical form of the affection DISLOCATIONS. 89 assafoetida and valerian may prove beneficial, but even here they are, as a general rule, far inferior to the articles just pointed out. As topical remedies the most valuable are the soap liniment, with a liberal addition of laudanum and chloroform, kept constantly upon the part with a piece of flannel; and the steam of hot water, conveyed to the joint from a tube connected with a boiler near the bed. Leeches may be employed when the articulation exhibits evidence of being inflamed, but, as a general rule, they will be found to afford only very transient relief. ' ' • SECT. X.—DISLOCATIONS. 1. GENERAL CONSIDERATIONS. A dislocation, or luxation, is the sudden and forcible removal of one arti- cular surface from another, generally caused by external violence, and attended with more or less laceration of the connecting ligaments. The accident being of frequent occurrence, and liable, when neglected or injudiciously managed, to be followed by.permanent deformity and lamefless, should claim the serious attention of every practitioner, since his reputation for tact and skill will greatly depend upon the manner in which he acquits himself when he is required to take charge of such an injury. An unreduced dislocation, like a badly treated fracture, is often a standing monument of the surgeon's igno- rance and incapacity; nay, what is worse than all, it sometimes involves him in-ruinous law suits and in entire loss of character. As all joints are necessarily composed of at least two bones, the question naturally arises, which should be considered as the luxated one? Upon this subject all surgical authorities are, so far as I am acquainted with their writ- ings, agreed. In all accidents of this description the bone nearest the trunk is regarded as the fixed bone, and the one articulated with it as the dislocated one. Thus, in luxation of the shoulder-joint, the scapula retains its normal position, either actually or supposititiously, while the humerus is thrown off the glenoid cavity, at one time in this direction, and at another in that. In dislocation of the elbow, the ulna and radius are forced away from the hume- rus, the latter serving as the fixed point. The same rule obtains in regard to all the articulations of the inferior extremity, except that of the ankle, in which, by a singular perversion of the manner of considering the subject, the foot is looked upon as the fixed point, and the tibia as the movable one. Dislocations are divisible into simple and complicated, complete and in- complete, primitive and consecutive, recent and old, single and double. To these varieties may be added another, which, as it occurs during intra-uterine life, and probably depends upon imperfect development of the«tructures of the joints, has obtained the appropriate name of congenital. This form of luxation is of sufficiently frequent occurrence and importance to receive sepa- rate consideration. A luxation is said to be simple when it is unaccompanied by anything more than a slight rupture of the ligaments, or oLthe ligaments and muscles. Although such an accident is usually produce* by external force, as a blow or fall, yet it occasionally arises purely from muscular action, especially when the displacement is favored by preternatural laxity of the ligaments, disease of the articular surfaces, or a weakened and wasted condition of the muscles which surround and support the joint. A complicated dislocation, on the contrary, is one where, in addition to the loss of relation between the two contiguous surfaces, there is some serious lesion of the soft parts, as, for example, a wound communicating with the dis- placed bone, or opening directly into the articulation, laceration of important 90 DISEASES AND* INJURIES OF THE JOINTS. vessels or nerves, contusion of the integuments and muscles, or fracture of the luxated bone. When the wound penetrates the affected joint, the accident is usually called a compound dislocation. All complicated luxations are necessarily the immediate and direct result of external injury. A complete luxation is one in which the head of a bone, being totally re- moved from its corresponding articular surface, effects a lodgment in a new situation ; as, for instance, when the head of the humerus is forced down into the axilla, resting against the border of the scapula, below the glenoid cavity. In an incomplete luxation, on the contrary, the articular surfaces, although they have lost their relative position, remain still partially in contact with each other. Displacement of the head of the humerus against the coracoid process affords a good illustration of this variety of accident. In primitive dislocation, the displaced bone continues in the position into which it was originally forced ; in consecutive, it abandons its original situa- tion, and becomes fixed in another. Such an accident, however, can only happen, as a general rule, when the luxation depends upon some organic dis- ease of the articular surfaces, allowing them gradually to separate fro'm each other, either by the mere weight of the corresponding limb, or by the action of the neighboring and astociated muscles. In the traumatic form of the injury such an event must be exceedingly rare, although we must admit its possibility, the dislocating agent forcing the bone at once to the greatest verge of its displacement; or, as not unfrequently occurs, its farther progress is effectually arrested by some opposing osseous prominence or some tensely strung soft part, as a tendon, muscle, or fibrous membrane. Luxation of the knee-joint from caries of the articular surfaces furnishes a characteristic ex- emplification of these two kinds of displacement. In this accident, of which I have seen several cases, the head of the tibia gradually forsakes the con- dyles of the femur, slipping back into the popliteal region, from whence, in time, it is drawn up against the posterior surface of the bone by the flexor muscles, thus suffering secondary luxation. A similar occurrence, although exceedingly uncommon, may, nevertheless, happen in a very robust subject in traumatic dislocation of the hip, shoulder, or lower jaw, where the force is barely sufficient to lift the head of the boue out of its socket upon, but not over, its rim, from which it is afterwards removed either by mere muscular contraction or by the conjoint influence of this and the weight of the part connected with the displaced bone. • The terms recent and old refer merely to the duration of the injury, and might seem, at first view, to require no particular explanation. The pro- priety of this, however, will be rendered at once obvious if the question be asked, when does a dislocation become old ? does it become old in a few days, or weeks, or months ? As far as mere time is concerned, no lesion of this kind ca* be regarded as old unless'it has existed for at least from six to twelve months ; but if we look at the subject in a practical point of view, or, what is the same thing, in reference to our ability to restore the affected joint to its natural relations, it will be found that, while one dislocation may not be old at the end of several months, another may become so within the first few weeks. Thus, a luxated^houlder may frequently be successfully reduced after a lapse of two months, 6t even considerably later, whereas if we attempt to restore a dislocated elbow at the end of one-third or even one-fourth of that time, we shall generally signally fail. The import of these two terms, then, is one of much greater importance than has generally been admitted, having, practically considered, a positive value and significance. A single dislocation is one id which one joint only is involved • in the double form of the accident, on the contrary, the corresponding joint is like- wise affected. The lower jaw suffers more frequently in the latter way than any other piece of the skeleton, but a similar displacement is also occasionally DISLOCATIONS. 91 witnessed in the humerus, ulna, radius, clavicle, iliam, and fibula. Double dislocation may be complete or incomplete, simple Or complicated. In relation to its seat, it may be observed that nearly all the joinis in the body are liable to dislocation ; nevertheless, experience.has shown, what a knowledge of the structure and functions of these parts might have led us to anticipate, that those which admit of varied and extensive motion are much more prone to this injnry than such as enjoy only a very limited motion. Hence what are called the ball and socket joints, of which those of the hip and shoulder are the best representatives, are a great deal oftener affected than the ginglymoid, as those of the elbow and knee. The tables of Mons. Malgaigne have established the -interesting fact that dislocations of the shoulder-joint are more frequent than those of all the other movable articu- lations together, 321 cases out of 481 having occurred here. Comparing the relative proportion of cases in the two extremities, the same distinguished observer finds that thgy are seven times more numerous in the superior than in the inferior. These differences*in the relative frequency of this lesion in different joints are, as already stated, clearly referable to the differences in their structure and functions. Of all the large articulations in the body, that of the shoulder is the most insecurely constructed ; the glenoid cavity is re- markably shallow; the capsular ligament is long and loose, and the joint, admitting of every variety of motion, is under the direct influence of nume- rous powerful muscles, and exposed to numerous accidents. Why, then, should we be surprised that it is so often the seat of dislocation ? The hip- joint, on the contrary, is the most admirably contrived joint of which we can possibly form any conception ; as a piece of mechanism it is perfect; the acetabulum is an immense socket, in which the whole head of the femur is literally buried, and to which it is still further secured by two powerful liga- ments, the round and the capsular; and, in addition to all this, it is sur- rounded by numerous large muscles, which serve to support and protect it from injury. Thus constituted, this articulation is comparatively seldom the seat of dislocation, hardly, as compared with that of the shoulder-joint, in the proporyon of 1 to 9£. The clavicle, which enjoys only a very limited degree of motion, is not unfrequently luxated, its exposed situation and its buttress- like office rendering it peculiarly prone to the accident, occupying, in this respect, nearly the same rank, according to Malgaigne's statistics, as the hip.- joint. . « Thus, recapitulating what has been said above, we may conclude that the most powerful predisposing causes of dislocation are, varied and extensive motion of the joints, want of firmness between the articulating surfaces, aris- ing either from their shallowness or the structure and arrangement of their ligaments, and the exposed situation and peculiar functions of the bones entering into their composition. The direction in which dislocations occur is subject to much diversity, de- pending upon the nature of the joint, and the direction in which the force is applied at the time of the accident. In the ginglymoid articulatious the bones may be displaced backwards, forwards, or to either side ; in the orbicular, as, for example, that of the shoulder, downwards, forwards, upwards, or back- wards. Although dislocations may occur at any period of life, yet experience has shown that such accidents are much more frequent in mjddle-aged and elderly persons than in children and youths. Of 643 cases of dislocation, analyzed by Malgaigne, only one occurred being tfider the fifth year, and none after the ninetieth; the period of the greatest frequency being between the thirtieth and sixty-fifth year. The reason of these differences is to be. found in the circumstance that the bones of young subjects, being comparatively soft and pliant, and not yet everywhere completely solidified, yield most easily at their 92 DISEASES AND INJURIES OF THE JOINTS. • epiphyses and even at their shafts, while those of very old and decrepit peo- ple are generally so brittle that it requires much less force to break than to luxate tJiem. It is seldom that we have an opportunity of seeing a disloca- tion of the hip-joint after the age of sixty, while it is sufficiently common to meet with fracture of the neck of the femur within the capsular ligament. This statement, however, must be received with some degree of restriction, for it is obviously not applicable to all the articulations. The shoulder-joint, for instance, forms a striking exception, its dislocation in old age being much more frequent than fracture of the superior extremity of the humerus. Causes.—The efficient causes of dislocation are two, external injury, and muscular contraction, being, in fact, the same as those of fracture. Most cases are due to the former, acting either directly upon the joint, or indirectly through some bone articulated with it. Dislocation of the shoulder, conse- quent upon a blow or fall upon its top, affords a good illustration of the man- ner in which injury acts when applied directly to an,articulation. In this case the force is spent upon the superior Extremity of the humerus, propelling the head of the bone down into the axilla, beyond the glenoid cavity of the .scapula. The femur may be luxated in a similar manner, by a heavy body falling on the hip, while the thigh is in a state of abduction.. Lateral dislo- cation of the patella is another instance of displacement occasioned by direct violence. Sometimes a severe wrench is necessary to.produce the accident, especially when the bones are connected by short and strong ligaments, re- quiring great force to separate them. A more common mode of causing this accident is by the indirect application of force; indeed, there are few cases which are not produced in this way, whatever may be the nature of the articulation. Nearly all the dislocations of *he upper extremity, and many also of the lower, are the result of violence, transmitted from the distal portion of the limb, and concentrated upon some particular bone, which thus loses its connection with the opposing surface. It is in this manner that falls upon the hand generally may luxate the wrist, the elbow, or even the shoulder, according to the point upon which the vio- lence is exploded. Dislocation of the clavicle is usually induced by fajls upon the shoulder, in which this bone is acted upon by two forces coming in oppo- site directions, the one being caused by the weight of the body, and the other by the object struck. ^ Of the ability of the muscles to induce this accident, experience has fur- nished ample proof. My own practice has afforded me several well-marked cases of it; two having occurred in the shoulder, and the others in the lower jaw. Of the former, one was occasioned during an attack of epilepsy, and the other merely by raising the hand above the level of the head. Yawning is a common cause of dislocation of the temporo-maxillary articulation. Several cases have been recorded of displacement of the thigh-bone by mus- cular contraction. In the ginglymoid joints such occurrences must, for ob- vious reasons, be much less frequent than in the orbicular. Some persons possess the power of dislocating certain joints by their own unaided efforts, simply by voluntary muscular action. I have seen several individuals who possessed this faculty, but I have always noticed that, how- ever strongly they exerted their will, they could not produce anything like a complete displacement of the articular surfaces, and I presume that most of the cases that have been reported have been of this description. Dr. Haynes, of Saratoga, New York, has recently published the particulars of the case of a lad, aged seven years, who is said to be able to dislocate, and also to re- duce, the joints of the knee, elbow, wrist, thumb and fingers with perfect ease, by muscular contraction. In all cases of dislocation, whether the result of direct or indirect injury, or of muscular contraction, the accident is materially favored by a partial SIMPLE DISLOCATIONS. 93 separation of the articular surfaces. The lower jaw-cannot suffer displace- ment so long as it is closed, but if the chin be struck while the body is de- pressed, and the condyle drawn forward upon the anterior convex part of the temporal fossa, the slightest blow will suffice to throw the bone down over the root of the zygomatic process. Dislocation of the humerus into the axilla is greatly promoted by abduction and elevation of the arm. The femur is generally luxated upwards and backwards against the dorsal surface of the Fig. 25. Dislocation of the knee from disease. ilium, by falls upon the hip, and the occurrence is always facilitated by the circumstance of the person having a heavy load on the' back. A twisted or contorted state of the limb is generally highly conducive to the accident. Organic disease of a joint may become a cause of dislocation, as seen in fig. 25, from a'patient of Professor T. G. Richardson. The man, who was about middle life, had labored for a long time under an arthritic affection of the knee, which was gradually followed by permanent displacement of the head of the tibia backwards behind the condyles of the femur. There was no external disease of any kiud. The head of the bone could easily be re- duced, but could not be kept in position, owing, apparently, to the complete destruction of the ligaments of the joint. 2. SIMPLE DISLOCATIONS. Dislocations are characterized by a certain train of symptoms, by which they may, in*general, be easily distinguished from other accidents. Of these symptoms, the most constant and prominent are, loss of function of the affected articulation, lodgment of the displaced bone in an unnatural situation, de- formity of the joint, «and change in the mobility, length, and axis of the corresponding limb. To these may be added, as subordinate phenomena, the noise which is occasionally heard by the patient at the moment of the accident, numbness of the parts from pressure of the luxated bone upon the nerye's, contusion and discoloration of the integuments, together with pain, swelling, and crepitation as effects of the resulting inflammation. The im- portance of the subject will require that each of these symptoms should be considered somewhat in detail. Immediate and, generally, entire, loss of function of the affected joint is a necessary consequence of dislocation, however induced. Thus, in luxation of the temporo-maxillary articulation, the lower jaw is widely separated from the upper, and all the efforts that the patient can make are insufficient to shut his mouth. When the principal joints of the upper extremity are 94 DISEASES AND INJURIES OF THE JOINTS. affected, the person is nnable, without assistance, to carry his hand to the head, or to execute the motions of flexion, extension, circumduction, pro- nation, and supination; the whole limb feels heavy and numb, and requires to be supported by the sound one. In dislocation of the foot, leg, and thigh, progression is not only impracticable, but every attempt of the kind is attended with so much distress as to cause at once its discontinuance. The loss of function necessarily persists so long as the joint remains unreduced, although, in time, it is often partially regained. Impairment of the motion of the corresponding limb is an important symptom of this lesion. The patient, in general, not only loses allvoluntary control over the member, but the surgeon, upon taking hold of it, and at- tempting to carry it about in different directions, finds it impossible to effect his object. Motion, it,is true, is not always completely abolished, but there is no case in which it is not considerably, if not greatly, restricted. In some of the articulations, as, for example, in that of the elbow, the displaced bones are so thoroughly interlocked, or hooked together, as to render it difficult, even by the most adroit and persevering efforts at extension and counter- extension,, to disengage them from each other, and restore them to their natural situation. Immobility, therefore, is one of the most valuable symp- toms of dislocation. Its causes are threefold, muscular contraction, opposing osseous prominences,»and constricting ligamentous bands, or all these united. A knowledge of these obstacles is of great practical moment, as it involves important therapeutic considerations, which should be well understood by every surgeon. . In most cases of this accident the surgeon is able to feel the displaced bone in its new situation, beyond the limits of the corresponding articular surface. Sometimes, indeed, it may even be readily detected with the eye, in consequence of the prominence which it form.s by raising up the muscles and integuments beneath which it lies. In order to ascertain the precise position of the bone, a careful examination will generally be required, espe- cially when there is much tumefaction obscuring the symptoms. For this purpose one hand is placed upon the injured joint, while the other is employed in moving the corresponding limb ; when greater accuracy is necessary,- this office is confided to an assistant, in order that both hands may be used for conducting the investigation. If the manipulation is productive of severe pain, it should be desisted from until the system has been brought fully under the influence of anaesthesia. The distance to which the head of the displaced bone is thrown varies, in different cases, from a few lines to several inches, depending upon the size and shape of the joint, and the amount of force em- ployed in producing the accident;*as a general rule, it is greater in the orbi- cular than in the ginglymoid articulations. Deformity of the joint is another symptom of dislocation, and generally one of the most reliable. This usually manifests itself in a marked flattening of the articulation, as in dislocation of the humerus into the axilla, where there is always a loss of rotundity of the cushion of the shoulder from the manner in which the deltoid muscle is spread out; or in great increase of the width of the joint, as in lateral luxation of the elbow and knee. Sometimes the joint has a singularly contorted, angular, or twisted appearance. . A change in the length and axis of the limb articulated with the displaced bone is generally a prominent symptom. It is seldom that the limb retains entirely its normal length ; most commonly this is either increased or dimi- nished, the extent varying according to the structure of the joint and the degree of force employed to produce the accident. Shortening is much more frequent than elongation. Thus in the various forms of luxation of the shoulder and hip there is only one in each in which the limb is increased in length, while in all the.rest it is considerably, if not greatly, shortened, SIMPLE DISLOCATIONS. 95 amounting in some of them to several inches. No material difference exists in regard to this symptom in the dislocations of the orbicular and ginglymoid articulations. Dislocation not only changes the length of the affected limb, but also, in most cases, its axis, giving it a peculiarly contorted or twisted appearance. ' This appearance is nowhere more striking or conspicuous than in the dis- placements" of the elbow-joint, in some of which it is almost diagnostic. Another excellent illustration of this occurrence is afforded in luxation of the head of the humerus into the axilla, where this trait is often so well marked as at once t« convince the practised eye of the nature of the accident. In most of the displacements of the orbicular joints the limb stands off at a con- siderable distance from the body, in a constrained and twisted state. Of the subordinate symptoms there is not one which is of any real value; nevertheless, they are deserving of some consideration, if it be for no otter reason than that of completing the history of this accident. It is highly probable that most dislocations, at least those of the larger joints, are attended with some degree of noise at the moment of their occur- rence ; but that this noise is not often heard by the patient may be assumed from the fact that he is so seldom conscious of it when interrogated respecting it. The reason of this no doubt is that the confused state of his mind conse- quent upon the sudden and unexpected nature ofthe.accident prevented him from perceiving it. Sometimes, however, it is so loud that he is compelled to hear it, as it were, in spite of himself. Its character cannot be easily de- scribed, but it may perhaps be said to bear a closer resemblance to a crack- ing noise than anything else to which it can be compared. It appears to be caused by the sudden and forcible separation of the articular surfaces, aided, probably, by the laceration of the connecting ligaments, and is generally most distinct in luxations of the orbicular joints. A good deal of numbness is occasionally present in the parts immediately around the affected joint, or even in the whole of the corresponding limb. It evidently depends upon the compression of the nerves by the displaced bone. This symptom is always remarkably conspicuous in dislocation of the hume- rus into the axilla from the head of this bone pressing upon the brachial plexus, the tingling sensation often extending to the very tips of the fingers. A certain amount of contusion and discoloration is often present in this lesion, but the occurrence is by no means constant; a circumstance which is almost to be regretted because it serves to indicate, in some degree, the seat of the injury. The contusion is sometimes accompanied by scratches of the skin, or even considerable wounds, which thus complicate the case. The dis- coloration varies from the slightest change of the normal hue to deep purple, depending upon the size and number of the vessels whose laceration is the occasion of it. Large quantities*of blood are sometimes effused, but chiefly among the tissues in the immediate vicinity of the joint concerned, or among them and within the joint. Tlie pain which follows dislocations varies not a little in different indivi- duals, depending, perhaps, often quite as much upon their idiosyncrasy as upon the severity of the injury. Its immediate cause, of course, is the rup- ture of the ligaments and other structures in and around the affected joint, and may, on the one hand, be so excessive as to induce fainting and other distressing effects, or, on the other, so insignificant as hardly to attract atten- tion. It is always increased by manipulation and motion, as well as upon the supervention of the inflammatory process, and frequently continues for days and weeks, depriving the patient of appetite and sleep. In nervous, irritable subjects it occasionally assumes a neuralgic character. When the displaced bone compresses an important nerve, it is generally attended with a feeling of numbness and tingling. 96 DISEASES AND INJURIES OF THE JOINTS. More or less su-ellhg always succeeds to dislocations; sometimes almost instantly, but generally not under several hours ; at one time slight, at an- other exceedingly severe. When it appears suddenly, within a few minutes after the accident, it is always due to effusion of blood, and is then either •attended or soon followed by discoloration of the integuments. Coming on more slowly, there will be reason to conclude that it is the result purely of inflammatory deposits, especially serum and lymph, or of these deposits and of blood combined. When the incited action runs very high, the swelling will generally be proportionately great, the part beirig hard, stiff, glossy, painful, and intolerant of manipulation. • Much has been said and written concerning the friction-sound which occa- sionally attends recent unreduced dislocations, different authorities having ascribed it to different causes'. By-some, as J. L. Petit, ft has been supposed to depend upon a dryness of the articular cartilages ; others consider that it is due to the presence of a superabundance of synovial fluid; Sir Astley Cooper was of opinion that it proceeded from a deposit of fibrin within the joint and in the neighboring burses; lastly, Malgaigne thinks that it is occa- sioned by the rubbing of the head of the luxated bone against an osseous surface denuded of its periosteum. I have alluded to these various theories rather because they represent the views of distinguished authors, than on account of any intrinsic, value which they may possess. The question of the real cause of this sound is still an open one, and more careful observation and dissection than have yet been made will be required before it can be finally settled. Meanwhile, I am strongly inclined to the belief of the Eng- lish surgeon that it is mainly, if not wholly, due to plastic effusion into and around "the articulation, and this idea is strengthened by the fact that it can- not be elicited until after the occurrence of inflammation. If it were caused by dryness of the articular cartilages, or denudation of the bone, it ought, as a natural consequence, to be perceptible immediately after the infliction of the injury, which, however, it never is. The term friction perhaps expresses the nature of this sound better than any other that can be employed; it is entirely different from the grating noise and sensation caused by rubbing together the two ends of a broken bone; it is more like the sound occasioned by rubbing over each other two pieces of sole-leather; it is a soft, creaking, or crackling noise, not a grating one. Diagnosis.—The accident with which dislocation is most liable to be' confounded is undoubtedly fracture, especially fracture in the vicinity of the articulations, an occurrence not-only quite frequent, but generally exceedingly embarrassing, on account of the difficulty of its diagnosis. The most con- stant and reliable symptoms of dislocation, as already stated, are, deformity, both of the affected joint and limb, loss of function, impaired motion, and difficulty of restoring the displaced bone toMts natural situation. In fracture the most important characters are, distortion, preternatural mobility, and cre- pitation, with facility of reduction. If we compare these symptoms with each pther, we shall find that, although there is some resemblance between some of them, yet that, in the main, they are strikingly dissimilar, and, therefore, in so far, diagnostic of the accidents which they serve to characterize. Deformity is common to both dislocation and fracture, and js therefore of little, if any, value as a point of distinction between them. The same is true of the loss of function, which is often, per- haps generally, quite as great in the one as in the Other. If a man with a luxated hip may occasionally support the weight of his body upon the affected limb, or even walk slightly upon it, he can sometimes do as much, and even more, when he has an impacted fracture of the femur, or a fracture of the neck of that bone temporarily unattended with a separation of the fragments. A dislocated jaw is quite as helpless as a broken one ; in neither case can it SIMPLE DISLOCATIONS. 97 perform the office of mastication. Both these symptoms, then, are without the slightest value in a diagnostic sense. But it is very different with the others above enumerated. Mobility, for example, is a differential sign of great value. In dislocation, mobility is either entirely lost, or, at all events, very much impaired; the displaced bone is more or less firmly fixed in its new situation, and can only be restored to its natural position by powerful efforts, often long and anxiously continued. In fracture, on the contrary, there is always an increase of motion, or, more properly speaking, there is preternatural mobility, the limb allowing itself to be bent, extended, and even rotated upon' its axis. Moreover, by extension and counter-extension the member may be readily restored to its natural length and shape, but the moment these efforts are discontinued there is a reproduction of all the pre- vious symptoms. Such an event never happens in dislocation; when the bone is once reduced it remains reduced, unless accident should again lift it out of its socket. Lastly, in luxation the replacement is usually attended with a peculiar noise or snap, caused by the forcible contact of the opposing surfaces; in fracture such a noise is never distinguishable. Crepitation is another valuable diagnostic in these accidents. In dislocation the only sound ever perceived is a kind of friction-sound, and this is never present until after the supervention of inflammation; in fracture, on the contrary, crepitation is oue of the most important symptoms; indeed it is the characteristic sign of the lesion. It may be detected immediately after the accident, and during all stages of the after-treatment up to the time of incipient union. Deformity and preternatural mobility may both be absent, and yet if there be crepita- tion, or a rough grating noise and feel upon rubbing together the ends of the broken bone, there can be no doubt respecting the real nature of the case. It is a fracture, and nothing else. So, on the other hand, if there be deformity and loss of motion, with absence of crepitation, the rational infer- ence is that the case is one of luxation, or, at all events, not one of fracture. Another valuable sign in this accident, but one which has only a general application, is the difference in the position of the affected limbs in the two classes of injuries. In dislocation the limbs often stand off at a considerable distance from the body, in a constrained and unseemly attitude ; in fracture, on the contrary, they always hang close by the side of the body. Most of the displacements of the hip and shoulder-joints exhibit this peculiarity, and I consider it as of no little value as a means of discriminating between these lesions and fractures of the superior extremities of the femur and humerus. Contusion, discoloration, pain, and swelling being common to both dislo- cation and fracture, are worthless in a diagnostic point of view. Instead of being of advantage in this respect, they only, in general, serve to embarrass the attempts at discrimination. Numbness, however, possesses a certain value, especially in some of the luxations of the shoulder and hip, where it occasionally constitutes a prominent and distressing symptom, which is never the case in fracture, except under very rare circumstances, when the ends of the broken bone pierce or compress a large nerve. Important aid may sometimes be derived, in our investigations, from a knowledge of the position which the dislocated bone is most liable to occupy. Thus in displacement of the shoulder, the head of the humerus is usually thrown into the axilla, or forwards against the chest, seldom upwards or backwards; the most common luxations of the femur are those upon the dorsal surface of the ilium and into the sciatic notch. -In the ginglymoid joints, especially those of the knee and elbow, posterior displacement is most common. After all, however, no matter what may be the character or prominence of the symptoms, a correct and reliable diagnosis can only be arrived at, in any case, by a thorough examination of the condition of the parts concerned. vol. n.—1 98 DISEASES AND INJURIES OF THE JOINTS. Without the light which such an investigation is capable of furnishing, no surgeon, however skilful or experienced, can always be certain whether the accident is one really of dislocation or of fracture, or whether these lesions do not co-exist. In conducting the examination, the same general rules are applicable as in fracture. The sooner, of course, it is made the less likely will it be to occasion severe suffering to the patient, or annoying embarrass- ment to the practitioner. When the parts have become tumid and infiltrated, the nature of the accident is usually very much obscured, and the manipula- tion only aggravates the already existing mischief. Besides, they will then be so painful as to render it impossible to touch them without putting the patient under the influence of an anaesthetic. It is unnecessary to say that when a joint is in this condition, it must be handled with the greatest care and gentleness; yet at the same time the exploration should be thorough, otherwise it cannot be satisfactory, and, if one trial is not sufficient, another should be made soon after the first, means being used, meanwhile, to allay pain and inflammation, in order to render the parts more tolerant of mani- pulation. A careful measurement of the affected limb, or, rather, of the portion of the limb between the affected joint and the next one below, will often throw considerable light upon the diagnosis. Thus, if, in injury of the shoulder- joint, the distance between the acromion process and the elbow be found to be considerably greater than on the sound side, it would be a legitimate inference that the case was one of dislocation into the axilla, and not of frac- ture of the head or neck of the humerus. In luxation of the elbow backwards, the forearm is always sensibly shortened, only, however, in front, for behind it must necessarily retain its normal length. The measurement must be taken with a piece of tape, which, in order to insure greater accuracy, should, if possible, be graduated, the ends being applied against two fixed points, and the same operation being performed upon the sound limb. When, notwithstanding all these examinations and precautions, the case remains one of doubt, the surgeon should not hesitate to adopt the suggestion of Malgaigne, of inserting a long and slender needle into the joint, and also, if necessary, into the parts immediately around, with a view of ascertaining their precise condition. Should a hollow be found where there is naturally a projection, or a projection where there ought to be merely a cavity, the presumption will be strong that the case is one of dislocation, and the con- jecture will be converted into positive certainty if there be an absence of cre- pitation and preternatural mobility. There can be no possible objection to such an exploration, if it be conducted with proper care in regard to the avoidance of the larger vessels and nerves, and if the instrument be sufficiently slender to make only a small puncture, and so well tempered as not to break. It is surprising when we consider the facility and safety of this operation, and the undoubted light which it is capable of affording in obscure cases of this accident, that it should not have attracted more attention, or been more frequently employed. Finally, dislocations are sometimes painfully simulated by sprains, so much so, indeed, as to puzzle and perplex the most sagacious observer. Under such circumstances, nothing short of the most.patient and accurate examina- tions and measurements, repeated again and again, in the recumbent and in the erect position, will be likely to prevent mistake. Morbid Anatomy.—On dissecting a joint that- has been recently luxated, the head of the bone will be found to be more or less removed from its socket, the distance to which it has been thrown ranging from a few lines to several inches, according to the structure of the parts involved, and the degree of force concerned in producing the accident. In the incomplete form of the lesion the articular surfaces still partially retain their apposition while in the SIMPLE DISLOCATIONS. 99 complete all connection is lost. The displaced head rests either upon some muscle, tendon, or bone, or upon all these structures, and the socket is gene- rally occupied with blood, either fluid, or partly fluid and partly coagulated. The ligaments are lacerated, elongated, and relaxed, the extent of the rent varying from a mere fissure, barely large enough to admit the escape of the bone, to almost, complete separation from their osseous attachments. The capsular ligaments are usually more extensively torn than the band-like, and, in both cases, shreds of the injured structure are occasionally interposed be- tween the bone and the parts upon which it rests. In dislocations from muscular contraction, as ki those of the jaw and shoulder, slight laceration of the ligaments is generally conjoined with marked elongation, and dissection has rendered it probable that cases of this kind occasionally occur even with- out any rupture whatever. The muscles in the immediate vicinity of the injured articulation usually participate, at least to some extent, in the mis- chief sustained by the ligaments; being, like them, more or less stretched, contused, or even lacerated, though the latter occurrence is commonly neither frequent nor extensive. The nervous trunks around the joint may be com- pressed and displaced by the luxated bone, but are rarely, if ever, torn, or seriously hurt in any way. The same is true of the larger vessels, both arte- rial and venous, the hemorrhage which follows the accident, and which is usually quite small, proceeding from the smaller ligamentous, cellular, and muscular branches. If the patient has survived the accident several days, so that the parts have had time to become inflamed, more or less plastic matter will be found, both in the socket and in the neighboring tissues, matting and gluing them together. Prognosis.—The prognosis of simple dislocations must be considered with reference to two circumstances, the restoration of the displaced bone, and the severity of the injury sustained by the accident. If attended to early, they may commonly be easily reduced, and are seldom dangerous either to life or limb. If, however, they be neglected, or improperly managed, more or less deformity and loss of motion must ensue, and the resulting inflammation may be so great as to cause serious constitutional disorder. Luxations of the orbicular joints are generally less hazardous than those of the ginglymoid, but they are nearly always more difficult of reduction, on account of the adja- cent muscles being more numerous and powerful, and, consequently, more resisting. On the other hand, however, the displacements of the orbicular articulations retain their reducibility much longer than the ginglymoid; thus, a luxated shoulder, may often be restored at the end of several months, whereas a luxated elbow generally becomes irreducible within as many weeks. In children, old persons, and females, the restoration is generally more easily accomplished than in adults, or in strong, robust individuals, whose muscles are more developed, and, therefore, less easily subdued. This difference obtains, in the same relative degree, even when anaesthetics are used. Treatment.—The leading indications in the treatment of simple luxations are, first, to return the articular surfaces as soon as possible to their natural situation ; secondly, to keep the affected joint at rest until the lacerated liga- ments and other structures have become repaired; thirdly, to limit and sub- due inflammation; and, fourthly, to restore the functions of the parts. The nature of these indications, and the mode of fulfilling them, should be kept clearly and prominently before the eye of the practitioner in every case of dislocation that may happen to fall under his observation and treatment; for unless he has accurate and definite conceptions upon the subject, he must often fail in accomplishing his object in a satisfactory and creditable manner. In entering upon the consideration of the treatment of this class of acci- dents', the first question that arises is', what are the causes which oppose the reduction of dislocations, or, in other words, why is it that dislocations do 100 " DISEASES AND INJURIES OF THE JOINTS. not disappear of theirown accord ? Until recently it was generally supposed that the principal barrier to the reduction was the resistance offered by the muscles connected with the displaced bone, contracting at first spasmodically, and then permanently, so as to hold the part firmly in its new position. To overcome this action of the muscles in the vicinity of the affected joint has, therefore, always been a leading indication in the attempts at reduction; and yet hpw signally these attempts frequently fail, after the most thorough relax- ation, not only of these muscles, but of the whole system, by the lancet, tartar- emetic, and the warm bath, is well known. This fact of itself, then, is suffi- cient to prove that, although muscular contraction is one of the main agents which oppose the reduction, yet it is not by any means the only, nor always even the principal, one. If the difficulty depended merely upon the resist- ance of the muscles, whether spasmodically acting or temporarily shortened, the use of depressants and anaesthetics, aided by steady, persevering exten- sion and counter-extension, ought to enable the surgeon to reduce, promptly and effectually, every dislocation whatever that may come under his notice. But this is not the case; the patient, in former clays, used to he bled to syn- cope, nauseated to the utmost with tartar-emetic, and literally parboiled, and yet, half dead as he was, restoration was frequently impossible, and so it is still in these days of chloroform and ether. This, then, being the fact, we must seek for other opponents, capable at least of aiding the muscles in their resistance, or of themselves sufficient to offer a serious, if not insuperable, barrier to the reduction. Such obstacles are found in the bones and liga- ments, and but for these it would be difficult to conceive of any case of dis- location that could resist, more than a few minutes, any well directed efforts at restoration. In truth, almost every dislocation would reduce itself. Why is it that the surgeon frequently experiences so much trouble in replacing a luxated thumb ? Is it not because of the resistance offered by the promi- nences and ligaments of the affected joint ? The muscles of the thumb can certainly not exert any serious influence in preventing the reduction, for cases have occurred where the luxated phalanx has been literally torn away in unsuccessful attempts of this kind. In. dislocation of the jaw, the principal obstacle to the reduction is th£ zygomatic process of the temporal bone; and, although the temporal, pterygoid, and other muscles usually contract with great power, yet this would rather tend to favor the reduction than to pre- vent it if the condyle of the bone were not firmly locked in the fossa below. The obstacle which bony prominences offer to replacement is well shown in the luxations of the shoulder and hjp, the former being always comparatively. easy of reduction, on account of the smooth and shallow state of the margin of the glenoid cavity, while the latter, in consequence of the opposite state of the rim of the acetabulum, are generally comparatively difficult. This resistance, however, is always, other things being equal, most striking in the ginglymoid articulations, owing to the greater complexity of their structure, and their larger size, but more especially to the greater number and bulk of the neighboring prominences and depressions, thus permitting the displaced bone to become more readily interlocked with the fixed one. A serious barrier to reduction is often afforded by the ligaments, caused by the small size or the peculiar shape of the rent made at the time of the accident, the bone passing readily through it, but being unable to return on account of the manner in which it is girt by the edges of the aperture; the membrane or cord being drawn over its neck like a purse with its string tightened. That this frequently happens in the capsular ligaments, in luxa- tions of the orbicular joints, may readily be imagined when we take into consideration the difficulty of effecting reduction, however thoroughly the system may be relaxed, while, in regard to the funicular ligaments, or those SIMPLE DISLOCATIONS. 101 of the ginglymoid articulations, the fact is abundantly attested by daily experience. Finally, it is extremely probable that the reduction of certain dislocations is materially impeded, if not at times prevented, by the head of the displaced bone becoming entangled among the neighboring muscles or tendons, pro- ducing an effect similar to that occasioned by the ligaments and bones. The means which are usually employed for surmounting these several obstacles,*consist of certain manipulations or manoeuvres, as extension and counter-extension, aided, if necessary, by pressure and thorough relaxation of the system. Occasionally mere pressure, if properly directed, is sufficient to effect reduc- tion, especially when the dislocation is seated in a joint with loose ligaments, or when the ligaments are extensively lacerated and the neighboring muscles are in a passive, crippled, or paralyzed condition. In general, however, more or less extension and counter-extension will be required, and the mode of applying and conducting these becomes therefore a matter of paramount consequence. Upon these subjects much' diversity of sentiment has existed among writers, some contending for one mode of practice, and others for another, as though it were possible to lay down any specific rules upon points of treatment which must necessarily vary according, to the exigencies of every particular case. My own experience is that it is generally best to apply the extending power to the bone which is articulated with the luxated one, or, in other words, as far as possible from the site of injury. Many highly re- spectable authorities, however, select the distal portion of the displaced bone, under the supposition that it affords a more direct and influential leverage. In not a few instances, indeed, we are obliged to adopt this course from necessity, the nature of the case not admitting of any choice ; as, for example, in dislocations of the wrist and elbow, and in the corresponding ones of the inferior extremity. Extension and counter-extension may be made by the hands of intelligent assistants, aided, if requisite, by lacs, napkins, or sheets, or by means of pul- leys. As a general rule, the resisting power, or the counter-extending means, should be fully equal to the extending, and both should be applied in such a manner as to create as little inconvenience and pain as possible; they should be exerted slowly and gradually, and at the same time continuously, the object being not to fret the muscles which oppose the reduction, but to fatigue and exhaust them. Hence any sudden and violent movements would only be followed by mischief. With regard to the extension, it should always be first made in the direction of the luxated bone, but in proportion as the resistance is overcome the limb should gradually be brought back to its natural position. During the reduction the patient may sit up or lie down, as may be most convenient, or as the exigencies of the case may seem to demand. Whenever chloroform is administered, recumbency is indispensable, for the reasons already several times mentioned. As a general rule, the patient should lie upon a bed or table during the reduction of nearly all the dislocations of the principal articulations, especially those of the shoulder, hip, and knee; in those of the elbow, hand, ankle, clavicle, and jaw, on the contrary, it will be found most convenient for the surgeon to have him sit up. The number of assistants must vary from one to three, four, or five, according to the nature of the case, and it will be of great benefit if their duties are always accurately .defined before the operation is entered upon, otherwise delay, annoyance, and embarrassment will be sure to be the result. The counter-extending band, which generally consists of a folded sheet, a jack-towel, or, what is better, of a long stout piece of.muslin, should be fastened round the trunk or limb so 102 DISEASES AND INJURIES OF THE JOINTS. as to diffuse its pressure over a considerable space, without the risk of injur- ing the soft parts, exciting the muscles in the neighborhood of the dislocation, or interfering mechanically with the return of the luxated bone. The extend- ing band must also be secured with great care. The best plan is to envelop the surface of the limb to which it is to be applied with a soft wet napkin, folded, and passed round at least twice. . This answers the double purpose of protecting the skin and of preventing the noose or lac from slipping, which seldom fails to happen if we use a dry cloth. The lac should be of sufficient strength not to break, and should be fastened round the napkin by means of the clove-hitch, or sailor's knot, the proper method of making which will be readily understood by a reference to the accompanying sketches, fig. 26 and fig. 27. Or, instead of this, we may use the French knot, which is equally efficient, and which is executed by placing the band across the limb so as to form a loop on each side, each end being then passed under the limb through the opposite loop. In the more simple forms of dislocation, the requisite extension and counter-extension may be made with the hands, or by the pres- sure of the heel, knee, or fist. Fig. 26. Fig. 27. Compound pulleys. French knot. Pulleys, fig. 28, are rarely required in the present improved mode of reduc- ing dislocations/the use of anaesthetics and the "manual method," as it is termed, having well nigh rendered their application unnecessary in all recent ^cases of the accident. I have myself not had occasion to employ them for 'several years, and there is reason to believe that, as the profession becomes better acquainted with the nature of the subject, they will ultimately be almost entirely dispensed with. There is no doubt that they .have done immense mischief, even in the hands of otherwise judicious surgeons, and that they as often impede as favor reduction. A formal description of this instrument will be unnecessary here, as its appearance«and office, known to every one will be SIMPLE DISLOCATIONS. ' 103 readily understood from the annexed representation, fig. 29. During its ap- plication the patient should be recumbent, one hook being fastened to a Fig. 29. Pulleys applied. « staple, fig. 30, in the floor or wall, and the other to the noose in the lac en- circling the limb. The cord should then be tightened, either by the surgeon himself, or by a trustworthy assistant, the operation being per- formed with all possible care and gentleness, so as not to en- Fig. 30. danger fretting of the muscles, fracture of the bones, or rup- ture of any of the soft parts. A very ingenious contrivance, serving as a ready and effi- cient substitute for the pulleys, was suggested, some years ago, by Professor Gilbert. It consists in the use of a thin but strong rope, from four to eight strands of which are passed under the extending band, and doubled upon themselves. The free extremities are then drawn tightly, ajid secured to a staple in the wall. A stick is next carried across the centre of the strands, and revolved upon its axis as a double lever. In this manner a single assistant may furnish any amount of power that may be necessary, gradually and steadily overcoming mus- cular action,.while the surgeon himself attends to the dislo- cated bone. The annexed cut, fig. 31, affords an illustration staple. of the apparatus as applied to the subject. * Fig. 31. Dr. Gilbert's mode of extension and counter-extension. 104 DISEASES AND INJURIES OF THE JOINTS. Another instrument of great power is the dislocation tourniquet devised by Mr. Bloxam, of London, represented in fig. 32, and which, although it acts upon the same principles as the multiplying pulleys, is a more convenient as well as a safer con- trivance, capable of affording real aid in drawing the bone into its natural position in cases of unu- sual muscular resistance. Of the surgical adjuster, invent- ed by Dr. Jarvis, I have but little to say; I have never employed it in recent dislocations, and in the repeated trials which I have made with it in those of somewhat long standing it has not been my for- tune to meet with any success. It is an instrument of extraordinary power, and should therefore be used with great care and discre- tion. In the hands of its ingeni- ous inventor it has doubtless been productive of benefit. Fig. 33 represents the adjuster as applied for the reduction of a dislocation of the hip-joint. As the resistance of the mus- cles is one of the chief barriers to the reduction of dislocations, means, to which the term auxili- ary is applied, are generally at once resorted to with a view to its counteraction. These means are both local and constitutional, and are particularly necessary in strong, robust individuals. The most efficient remedies of this class, for- merly at the disposal of the surgeon, were copious bloodletting, usually car- ried to syncope, nauseating doses of tartar-emetic, the warm bath, and full doses of anodynes. Sometimes the disgusting practice of intoxication by alcoholic liquor was pursued; and Dr. Physick occasionally advised the smok- ing of tobacco to bring about the desired relaxation. Since.the introduction of chloroform and ethel much of this practice has become obsolete, these articles having very properly taken its place. Even bleeding is now seldom necessary, except occasionally where, from the excessive muscularity of the patient, unusual difficulty is expected, or where, from the injury sustained by the soft parts, it is important to employ at once active measures for pre- venting excessive inflammation. Tartar-emetic, the warm bath, and tobacco have justly been proscribed. The patient is anaesthetized in the usual manner, and all manipulative action is withheld until the system is completely Relaxed and the mind rendered unconscious, when the operation is to be at once proceeded with, the action of the remedy being gently*maintained until the object is accomplished. I have employed this practice in every case of dis- location that has fallen under my notice during the last ten years, and have good reason to be satisfied with the result, never having failed in a single instance. When a surgeon is called to a case of dislocation immediately after it has Bloxam's dislocation tourniquet. SIMPLE DISLOCATIONS. 105 happened, he may occasionally succeed in effecting his purpose by taking advantage of the faint and relaxed state in which he finds the patient in con- Fig. 33. Jarvis's adjuster, applied for the reduction of a dislocation of the hip-joint. sequence of the shock he has sustained. At other times, again, he may suc- ceed by diverting the patient's attention, either by engaging him in conver- sation, or by a sudden expression of surprise, while he makes a forcible attempt at reduction. • The mere idea qf pain is generally sufficient to excite the muscles to spasmodic action, so as to oppose the efforts of the surgeon at restoration. It was therefore formerly a matter of great consequence to prevent this by a playful remark, an impertinent question, or an angry reply, calculated to distract the attention of the sufferer, and throw the muscles off their guard. Dupuytren is reported, upon one occasion, to have employed a similar, though.less polite, expedient Having been called to a lady of rank on account of a dislocation of the shoulder, he was for a long time foiled in his efforts; the assistants pulled, he pushed and pressed, and the patient shrieked and offered every possible resistance. His temper became ruffled; he tried in vain to distract her attention. At last, said he, "Ma- dam, I have repeatedly asked you how this accident has happened, and you have as constantly deceived me; you have not informed me that you had been drunk." The woman, shocked at the remark, indignantly asked, " Who has told you so ?" "Your son, madam." The poor patient was stupefied, all the muscles became instantly relaxed, and iu a moment the luxation was reduced. As soon as the system is properly relaxed the surgeon proceeds to the reduction, trusting either to his own personal efforts, or employing such aids as he may consider the exigencies of the case to require. When the extension and counter-extension have been kept up for some time, bringing thus the head of the displaced bone gradually nearer and nearer to its^ocket, he should grasp the part firmly with his hands, and thus assist in lifting it into its natural position. Or he may accomplish this by means of a band or fillet thrown across his neck and shoulder, while he makes strong and steady pressure against the head of the bone,-pushing it back in the direction of the luxation, 106 DISEASES AND INJURIES OF THE JOINTS. or towards its fellow. In many cases the reduction will be facilitated if, at the moment the bone approaches its socket, the limb be rotated upon its a.xis, carried towards the body, or drawn over the opposite limb. AY hen the re- placement threatens to be unusually troublesome, the ingenious surgeon will not fail to employ all kinds of expedients and stratagems to accomplish his object, rather than abandon the patient to his fate with a useless limb. • From the great amount of facts published within the last few years, it is obvious that most recent simple dislocations of every joint in the body may be thoroughly and expeditiously reduced by manipulation alone, especially if the patient be at the time completely chloroformized. Dislocations of the ileo-femoral articulation have already, in numberless instances, been success- fully managed in this manner, and no expert surgeon at the present day thinks of employing any other method. The treatment which Dr. Reid so happily effected for this joint, and which in all simple cases of these accidents, has superseded every other, has recently been extended by Dr. Henry H. Smith, to luxations of the shoulder-joint, with a result which leaves no doubt that simple manipulation,'if properly applied, is, in almost every instance, fully adequate to the accomplishment of the object. Difficulty will be likely to occur only, or chiefly, in those cases of displacement in which the head of the bone has slipped through a very narrow opening in the connecting ligament, grasping the bone with extraordinary firmness, and so impeding its return to its proper position. Further remarks upon this subject will appear in the sections on dislocations of the shoulder and hip-joints... The return of the head of the dislocated bone to its natural situation is indicated by the restoration of the shape and motion of the joint; by a snap or noise heard at the moment of the reduction, but which is always very faint when the patient has been anaesthetized; and by a great and sudden diminu- tion of pain. Finally, it is always extremely desirable, as soon as the nature of the accident has been clearly ascertained, to effect the reduction as speedily as possible, even although there should pe considerable inflammation and swell- ing, and, consequently, a probability of inflicting severe pain; for it is much better, I conceive, to pursue this course than to subject the patient to the risk of having, by the delay, an irreducible dislocation, of which there must always be some apprehension, especially when the injury involves a gingly- moid articulation. In making these reirfarks I do not, of course, mean to he understood as saying that there ought to be no exceptions to this procedure; I should certainly be very loth to attempt replacement if the parts were very tumid and painful; in such a case I should wait a few days, but only a few days; in the hope of being able, by leeches, saturnine and anodyne lotions; antimonials, and other means, to reduce the inflammation to such an extent as to render the parts more tolerant of the approaching ordeal. In obstinate cases of dislocation, rendered so by the manner in which the bones are»interlocked with each other, and in which the muscles passing over them are stretched like tense cords, the reduction is sometimes greatly facili- tated by a resort to tenotomy, performed of course subcutaneously. The expedient is particularly valuable in dislocation of the tarsal joints, but it may also be advantageously employed in displacement of the larger articula- tions, especially in those of long-standing. The operation has recently been successfully-performed in a number of instances, and I am not aware that it has been followed in any by bad results.. After-treatment.—When the reduction is completed, measures must be adopted, first, to prevent a recurrence of the accident, and next to limit in- flammation, more or less of which must necessarily take place after every injury of this kind, however simple. The former of these objects is accom- plished by appropriate bandages, or bandages and splints, with rest in the COMPLICATED DISLOCATIONS. 107 recumbent position, especially if the injury be seated in the lower limbs ; in dislocations, on the contrary, of the upper extremity, the arm should be sus- pended in a sling, and the patient, after a few days, may walk about in the open air. Inflammatory accession is met by the usual antiphlogistic reme- dies.'.both constitutional and topical, among the latter of which evaporating lotions, .as spirits and water, and solutions of acetate of lead, along with laudanum, are the best, and they will generally be found most agreeable and •beneficial, at least during the first forty-eight hours, if they be applied warm. Whenever the joint is so situated as to admit of the application of the roller, this is on no account to be omitted, as it serves both to support the parts and prevent swelling. Its effects, however, must be most carefully watched ; and the first wrapping must always be very light, lest undue constriction be the result. Pain is subdued by full doses of morphia. Finally, another object, one, indeed, of paramount importance, is to prevent anchylosis. Hence, as soon as the inflammatory symptoms are abated, pas- sive motion must be instituted, and repeated, steadily and perseveringly, at first, once a day, and afterwards twice or even thrice, until the functions of the joint are perfectly re-established ; an object which can seldom be attained, in any case, under several months, and in some, indeed, not under six, ten, or twelve, depending upon the nature of the joint, the extent of the injury, the character of the treatment, and, above all, the co-operation or want of co-operation of the patient, whose conduct has often much more to do with the production of a stiff and useless joint than his surgeon. After the more prominent inflammatory symptoms have disappeared, the absorption of effused fluids should be promoted by soap liniment, or moderately stimulating embro- cations, followed, in due time, by the cold douche, dry frictions, and sham- pooing. • 3. COMPLICATED DISLOCATIONS. A complicated luxation, as stated elsewhere, is one where the displacement is accompanied .by a fracture, the rupture of an important vessel or nerve, a violent contusion, or a wound communicating'with the cavity of the articula- tion, or extending deeply among the tissues in its neighborhood. Not un- frequently, several of these lesions coexist, thus materially increasing the gravity of the case, and the difficulty of managing it. A complicated dislocation may, of course, occur in any of the articulations, but it is by far more frequently met with in those of the elbow, wrist, knee, and ankle than in any other, for the reason, probably, that the heads of the bones are less protected there by muscles, and also that they are more sharp or angular, than in the orbicular joints. Hence, when the injuryis unusually violent, the articular extremities, losing their ligamentous connections, are apt to be impelled with so much force against the soft parts, as t*> lacerate them from within outwards, dividing muscles, tendons, fasciae, vessels, nerves, and integument, and perhaps protruding several inches beyond the external wound ; or, the vulnerating body, impinging forcibly against the external surface, may commit the mischief from without inwards, the bones being comparatively passive until the moment they are struck, when they, in their turn, may inflict additional injury upon the structures beyond where the pro- jectile does not penetrate. In the great majority of instances, at least in civil life, the lesion is caused by falls, blows, or kicks; in military practice numerous cases of complicated dislocations occur from gunshot injury. Compound dislocations, as they are commonly called, appear to be very rare in comparison with simple. Thus, in 94 cases of dislocations, reported by Dr. Norris, as having occurred in the Pennsylvania Hospital, only 2 were compound ; and of 166 cases collected by Professor Hamilton, only 8 wene of this description. * 108 DISEASES AND INJURIES OF THE JOINTS. Symptoms.—The symptoms of complicated dislocations are usually suffi. ciently characteristic, and do not, therefore, require any formal description. In general, there will be more or less distortion of the joint, inability of mo- tion, discharge of synovial fluid, and shortening of the corresponding limb, with contusion, discoloration, and ecchymoses of the soft parts. When there is a wound, the end of the bone not unfrequently protrudes at the external opening; sometimes fo the distance of an inch or two. Crepitus will of course be present when the dislocation is complicated witji fracture. Great" numbness and partial paralysis will indicate the division of an important nerve; while coldness of the extremity, with absence of pulsation in its distal portion, and copious extravasation of blood, will be denotive of serious in- jury of the principal artery. t Prognosis.—A complicated luxation, as the name implies, is always-a serious injury, liable to be followed by the most dreadful consequences, jeo- parding the safety both of limb and life. The resulting inflammation is generally extremely violent, and is peculiarly prone to lead to abscess, ery- sipelas, and .pyemia, especially in persons of intemperate habits, or of a dilapidated system. Under such circumstances, and sometimes even when the person was in the most perfect health just before the accident, the con- stitutional disturbance is generally very great, delirium sets in early, and the parts are soon seized with gangrene. The danger of mortification will neces- sarily always be proportionately great when there has been a division of an important vessel or nerve, interrupting circulation and innervation ; pyemia will be most likely to happen when there has been excessive shock, and necrosis when the protruded or exposed bone has been stripped of perios- teum, broken in pieces, or covered with dirt. But the danger to limb and life is not limited to the primary effects of the injury ; often, after an attempt has been made .to save the parts, the surgeon is chagrined to find that all his efforts have been unavailing, that the patient is gradually worn out by hectic irritation and profuse discharge, and that amputation, now performed as a dernier resort, hardly holds out a single prospect of cure. A guarded prog- nosis, then, is becoming in every case of complicated dislocation, however simple, if such a term be applicable to such a subject. Much of our success in these accidents will depend upon the promptness and efficiency of our treatment, or the manner in which the parts are managed during and after the reduction, which should always be effected as speedily as possible, and with as much care and gentleness as the case will -admit of, the patient being fully anaesthetized. If there be any wound, the edges must be brought accurately together with strips of adhesive plaster, aided, if neces- sary, by suture, and smeared over with collodion, to exclude the air. Any loose splinters of bone that may be present are to be removed, care being taken no% to interfere with any that are sufficiently adherent to render it probable that, if left behind, they will reunite. The fingers and forceps will be the best instruments for performing the operation. If the end of the bone protrude at the wound, it must at once be restored to its natural position, any dirt that may cover it having been previously picked away, or removed with the syringe. Should it be girt by the integuments, so as'to render the reduction impracticable, a circumstance, however, which must be extremely rare, the opening must be carefully enlarged with the probe-pointed bistoury; and a similar practice should be followed when the wound is too small to admit of the easy extraction of loose fragments. If the end of the bone is very sharp, angular, or denuded of periosteum, it should be cut off with' the saw or pliers, but such a step should only be taken after the most thorough conviction of its imperative necessity, for the same rule applies here as in the soft parts to save all we can, and sacrifice nothing improperly. I can hardly conceive of a case where it would be necessary to remove the end of a dis- COM PLICATED. DISLOCATIONS. 109 located bone simply because it protruded at a wound. If the patient be completely relaxed by chloroform, extension and counter-extension, with judicious coaptative pressure; could not fail to effect restoration, even when the bone is pretty tightly girt. Finally, when luxation is complicated with'fracture, the rule is to reduce the former before the latter is set, for the reason that if the restoration of the joint be postponed until the broken bone is repaired, it will often be impos- sible to effect it. Under such circumstances, the reduction of. the luxation is often greatly facilitated by putting up the fracture firmly in splints, as we thus secure a longer and better leverage. After-treatment.—The reduction having been effected, the joint and corre- sponding limb are to be enveloped in a bandage, that of Scultetus being passed round the wounded part, and placed securely in splints, or, what is preferable, in a tin case, or wooden box, in order to keep it perfectly at rest, and in as" easy a position as possible. Pain and inflammation are relieved by the usual remedies; and it is here that anodynes will be likely to display their happiest effects, both in allaying suffering' and in preventing serious constitutional disturbance. Antiphlogistics must be employed cautiously, with due reference to the effects of shock, long confinement, and copious drainage. In a word, the patient must not be purged and bled simply be- cause he has a compound dislocation: on the contrary, such measures, if employed at all, must be used with the greatest possible caution. The diet must be rigidly adapted fo the exigencies of the case ; as in all other severe injuries it should be nutritious rather than otherwise, and cases will often arise where it should be decidedly so from the very commencement of the treatment. The enfeebled patient will often be immensely benefited by the addition of milk-punch, whiskey, ale, or porter, especially if he have been accustomed to any of these articles previously to the accident. In the event of suppuration or erysipelas, quinine will materially aid recovery, and must not be omitted. The affected-parts must be handled as little and as gently as possible ; all officious interference must be refrained from; the secretions are to be removed from time to time with the sponge, and fetor must be allayed with the chlo- rides. In case of wound, or much discharge, the limb should be placed in bran, which will answer the threefold purpose of maintaining equable pres- sure, absorbing the secretions, and affording a comfortable bed for the parts to rest upon, with the additional advantage, in hot weather, of preventing the formation of maggots. Amputation and Resection.—Concerning the propriety of amputation, the same general rules are applicable as in complicated fractures, a subject which has been duly discussed under that head. The following summary, however, will not be out of place here respecting the operation. The reasons for immediate amputation are, first, the excessive contusion and laceration of the soft parts; secondly, the rupture of the principal artery or nerve of the limb, attended with other serious injury; thirdly, an extremely shattered state of the bones; fourthly, free exposure of a large joint; and, lastly, the advanced age, depraved habits, or ill health of the patient. Secondary.am- putation may be required, when, after an attempt has been made to save the limb, gangrene has taken place, or life is assailed by exhausting suppuration consequent upon extensive disease of the soft parts, the joint, or bones, or of all these parts together. Very great and irremediable deformity of the limb, standing in the way of its usefulness, is also a just cause for amputation. _ Instead of amputation in some of the above cases, resection may occa- sionally be advantageously employed, either primarily or secondarily. The primary operation is particularly indicated in dislocations complicated with a shattered and comminuted condition of the bead of the displaced boue, 110 DISEASES AND INJURIES OF THE JOINTS. and has been so often performed successfully that it may now be regarded as one of the established proceedings in surgery. 'Its greatest success has been obtained in compound luxations of the shoulder-joint. Even when there is no fracture of the head of the dislocated bone, but simply extensive laceration of the ligaments, completely detaching the parts from each other, it is questionable whether, in many cases, resection would not be the most expedient practice. For some highly judicious remarks upon this subject, fortified by a .reference to numerous authorities, both ancient and modern, the reader may profitably consult a paper by Professor Hamilton in the American Journal of the Medical Sciences for October, 1857, and also the able treatise of this gentleman on fractures and disloca- tions, published in 1860. Secondary resection may be employed in caries, or caries and necrosis, of the ends of the bone, coming on after a fruitless attempt to save the parts. 4. CHRONIC, OLD, OR NEGLECTED DISLOCATIONS. The subject of old, chronic, or neglected luxations has not received the attention which its. importance merits. The morbid anatomy of these acci- dents is still imperfectly understood, no connected body of facts illustrative of it having yet been published, and" it is to be feared that their treatment is seldom guided by sound scientific principles. They constitute a class of cases which almost every surgeon approaches with' doubts and misgivings, being anxious to do something for the patient's relief, and yet afraid lest that something shall produce serious, if not irreparable, mischief. I candidly confess that I have always shared these feelings, and that I have never had charge of an old or neglected dislocation without a strong secret wish that it had fallen into other hands, such has usually been my disappointment, and the anxiety attendant upon my efforts at reduction. The risk of rupturing an important vessel, perhaps the main artery of a. limb, of breaking a bone, or of exciting extensive suppurative action in the parts arouiid the affected joint, with the more remote chance of inducing pyemia, is well calculated to cause the practitioner to hesitate before he enters upon an enterprise so fraught with unpleasant consequences. The blood that is effused in dislocations, unless unusually abundant, is generally very soon absorbed, just as it is after other accidents involving sub- cutaneous hemorrhage. Hence it is very seldom that we have an opportunity of meeting with ajiy in chronic cases; it is only now and then that a small clot or stratum, decolorized, and.partially organized, is seen, and even this is almost always eventually carried off. The inflammation consequent upon the lesion is constantly followed by a deposit of plastic matter, both in and around the joint, filling up the socket of the bone, and infiltrating the cellular tissue, muscles, and other structures in the neighborhood. More or less of this substance is also effused around the displaced head, becoming gradually organized ; it renders the parts firm a*nd rigid, thus seriously interfering with their functions. That which is poured out around the bone is at length con- verted into an adventitious capsule, of a» pale grayish aspect, and dense fibroid texture, not unlike the pre-existing capsule, with which it generally ' communicates by one or more openings, and which, by degrees, becomes wasted and attenuated from want of use. The muscles, in great measure de- prived of their functions, are transformed into pale, rigid, aud contracted bands, which, in time, often undergo- the fatty degeneration. The perios- teum, near the joint, is usually somewhat thickened, and occasionally studded with osseous stalactites. The articular.cartilage lining the affected socket is generally partially absorbed, or more or less changed in its appearance, tex- ture, and consistence, while that which invests the h'ead of the bone exhibits CHRONIC, OLD, OR NEGLECTED DISLOCATIONS. Ill a rough, scabrous aspect, being thickened at one point and atrophied at another, the osseous substance itself often becoming hard and sometimes even eburnized. Few opportunities have occurred of observing the condition of the vessels and nerves in ancient dislocations; in the cases in which this has been noticed, the former were found to be preternaturally flexuous-, to accom- modate them, as it were, to the displaced bone, and the latter somewhat attenuated, but'otherwise sound. In those cases in which the displaced head enjoys, a good deal of freedom, it generally forms for itself a sort of socket, as in fig. 34, most commonly in a neighboring bone, but sometimes in the sub- Fig. 34. stance of a muscle, or partly in the one, and partly in the other. This socket, however, although it may admit of consider- able motion, is a very im- perfect type of the origi- nal, as is also the new ligament by which it is surrounded. In t addition to the changes now described, and which, it will be per- ceived, relate exclusively to the articular structures and to the parts imme- diately around, Changes Old dislocation of the hip, a new acetabulum being formed, Which are USUally the more while the Original one is but little changed. conspicuous in proportion to the duration of the dislocation, it will be found that the whole limb below the seat of true injury, and sometimes even for some distance above it, has a shrunken and withered appearance, its muscles being thin, flabby, and wasted, and its temperature materially diminished. In man7 cases it is affected with rheumatic or neuralgic pains, subject to aggravation with every change of the weather and with every disorder of the general health. The motion of the new joint is necessarily much restricted, and is often performed with a peculiar grtting noise and sensation, caused by the roughened state of the contiguous surfaces, and the entire absence of synovial fluid. When all motion is lost the joint gradually undergoes complete bony anchylosis. It has long been a question with surgeons at what period after the occur- rence of a dislocation it should be considered as impracticable to effect reduction. The question, as might have been expected, has been differently answered by different observers, and by the same observers for different joints. Thus, Sir Astley Cooper, who has always been regarded as the leading authority upon the subject, thought that three months for the shoulder, and eight weeks for the hip, might be set down as the limit, beyond which any efforts of this kind, except in persons of very lax fibre or advanced age, would be highly imprudent; an opinion which accords so well with general expe- rience as, in my judgment, to entitle it to be considered as a law.- It cannot be denied that this law has exceptions, but this only serves the more fully to establish its validity. Thus, in relation to at least one of the joints in ques- tion, that of the shoulder, quite a number of cases have been reported of reduction at from four to seven months after the receipt of the injury. In- deed, the late Dr. Nathan Smith, of New Haven, met with one in which he succeeded completely nearly one year after the accident. Examples of reduc- 112 DISEASES AND INJURIES OF THE JOINTS. tion of dislocations of the hip-joint of from three to six months' standing have also occurred, although it will be found, upon careful inquiry, that their number is exceedingly small. ■ For the ginglymoid articulations the period is still more limited, although, in this respect, it varies a good deal among themselves. In relation to the elbow-joint, which is the best type of the ginglymoid class, I have found, in quite a considerable number of cases, that any attempts at reduction, however perseveringly or judiciously continued, will generally prove completely abor- tive after the third week. On the contrary, the wrist-joint may generally be rectified at a considerably later period. These differences in the reducibility of dislocations of different articulations are due altogether to peculiarities of structure and the amount of inflammation consequent upon the injury. The surfaces of the orbicular joints are comparatively smooth and simple, and their displacements are seldom followed by much inflammation ; the reverse in both particulars being true in regard to the ginglymoid joints. Evidently, then, every luxation must rest, so to speak, upon its own merits, as far as the question of its restoration is concerned ; for, as has just been stated, while one joint becomes irreducible in a fortnight or a month, another, differently constructed, may remain reducible eight weeks, or even a much longer period. \A much better rule by which to decide this question is to judge by the extent of motion of the affected bones, the previous attempts at replacement, and the degree of inflammation consequent upon the injury. If the joint is very stiff and tender, if the luxated head has contracted firm adhe- sions, involving, perhaps, a large artery, or some other important structure, and if, in addition to this, there is reason to believe that the socket is filled up with new matter, any attempt at reduction would not only prove abortive, but might be followed by very serious accidents, jeoparding limb and life. Cases in which severe injury and even death have been the consequence of long-continued and violent attempts at reduction have happened to surgeons of great experience and eminence, and should serve as warnings to the young practitioner against the employment of undue force or protracted efforts where the prospect of success is at all doubtful. The conduct to be observed in the reduction of chronic dislocations resolves itself into a few simple rules.. In the first place, it is necessary, a3 an im- portant preliminary, to prepare the part, as well as the constitution, for the operation, by the systematic movement of the joint, and by light diet and purgatives, aided, if the person be at all strong and plethoric, by at least one large bleeding. The object of this depletion is not merely to weaken the muscles, hut to lessen the risk of severe inflammation and the formation of abscesses. The motion of the joint is intended to break up any abnormal adhesions that the bone may have contracted with the surrounding tissues, and should be conducted with great care and gentleness, the corresponding limb being carried about in different directions, flexed, extended, depressed, elevated, adducted, abducted, rotated, and circumducted; the operation should not be performed, at first, oftener than once a day, but by degrees it may be repeated every twelve hours, and it should be steadily continued for at least a fortnight, free use being made all along of evaporating and sorbe- facient lotions, with minute doses of mercury, administered to the extent of slight ptyalism. It does not seem to me that attention enough is usually given to this pre- liminary treatment. All writers speak of the importance of breaking up the morbid adhesions of the joint before the commencement of the reductive efforts, but none, so far as I know, say anything of the manner of conducting the operation and of the necessity of conjoining with it the use of sorbefacient remedies, for the purpose of promoting the absorption of the plastic material, upon which so much of the difficulty generally depends. If this point were CONGENITAL DISLOCATIONS. 113 more closely attended to, it is easy to perceive that the operation would be both more safe and more likely to be successful. The preliminary treatment having been gone through with, and the patient being thoroughly anaesthetized, the extension and counter-extension are to be conducted in the usual manner, only with more care and patience, and with an additional number of assistants. The object is, not as in i-ecent luxations, to fatigue the muscles, but to extend and stretch their fibres, shortened, hard and tense in consequence of long disease and inflammatory irritation. Under no circumstances should the surgeon employ violent or forcible measures, because such a procedure would not only tend to increase the resistance, and, as a necessary result, the difficulties of the reduction, but would be very likely to cause dangerous laceration of the soft parts, and secondary mischief. Should the operation fail, it must not be too soon repeated, but some time must elapse before another attempt is made, special attention being meanwhile paid to the suffering joint in the way of support and fomentation. The rupture of an important artery, as, for example, the axillary in dislocation of the shoulder, will be denoted by a rapid effusion of blood into the connecting cellular tissue, attended with discoloration of the integuments, and the cessation of pulsation in the distal portion of the limb. The proper remedy, in such an event, is immediate ligation of the affected vessel, and the avoidance, of course, of further interference. Should fracture occur, the operation must also at once be suspended, and the case be treated upon general principles. In order to facilitate the reduction of old dislocations, resisting the ordi- nary efforts, Dieffenbach, of Berlin, many years ago, proposed the subcutaneous division of the muscles concerned in opposing the replacement of the bone, and such an operation has been repeatedly performed, though not always with the advantage that had been anticipated. I have myself occasionally employed it, but in no instance, so far as I now recollect, with any benefit. The great objection to the procedure, is the danger of dividing important structures, especially large vessels and nerves, which are very often greatly displaced, and which, if injured, might occasion serious consequences. No one, therefore, should undertake such an operation unless he has the clearest possible conceptions of the anatomy of the parts, and is fully prepared to meet any emergency that his knife may produce. 5. CONGENITAL DISLOCATIONS. ■ There are certain dislocations which- exist at birth, and which are hence denominated congenital. Their occasional occurrence, recognized at an early period of tjje profession, has been satisfactorily established by a number of modern observers, especially by Chaussier^ Paletta, Dupuytren, Breschet, Pravaz, R. W. Smith, Guerin, and Dr. Carnochan. Different joints are liable to this variety of luxation, but its occurrence is by far most common in those of the hip, wrist, and shoulder. The lesion is generally single, that is, limited to one side, but in some cases it is double, taking-place simultaneously in the two opposite articulations. Occasionally it occurs in different joints in the same subject, as, for instance, in the shoul- der and wrist, or in one of these joints and in that of the hip. Both sexes are liable to it, but by no means in an equal degree, observation having shown that females suffer much more frequently than males, in the proportion, as nearly as can be ascertained, of at least three to one. This is a very curi- ous fact, too constant to be altogether dependent upon chance. Of twenty- six cases of congenital dislocation of the hip, noticed by Dupuytren, not above four occurred in males. Congenital luxation is sometimes hereditary. There are several instances VOL. n.—8 114 DISEASES AND INJURIES OF THE JOINTS. upon record in which it appeared in a number of successive generations, and also in several members of the same family. Causes.—The causes of congenital dislocations have elicited much atten- tion, as well as a great deal of controversy; but, notwithstanding this, the question, so far as its final settlement is concerned, stands precisely where it did at the commencement of the inquiry. The various theories that have been advanced in explanation of this vexed subject, may be arranged under the fqllowing heads : 1st, external violence inflicted upon the fat us; 2dly, disease of the articulations ; 3dly, arrest of development. A brief examina- tion of these views will suffice for my purpose. 1st. There can be no doubt that undue force exerted upon the foetus, whe- ther from without, as when the mother receives a fall or blow upon the ab- domen, or from inordinate contraction of the uterus, is capable of inducing partial dislocation of the joints, or, at all events, such a state of the articu- lating surfaces as to predispose them strongly to displacement. It is well ascertained that external violence is capable of producing fracture of the fcetal bones; I have myself seen one unmistakable instance of the kind, and Cha«ssier has recorded a case in which numerous fractures co-existed with congenital dislocations of the hip and shoulder joints. It is extremely pro- bable that a deficiency of the amniotic liquor may predispose to this occur- rence, by enabling the womb to exert its contractile force more readily and fully upon the foetus, thus forcing the articulating surfaces away from each other at a time when they are too imperfectly developed to resist such pres- sure, especially if frequently repeated. A theory of the formation of club- foot, which is probably nothing originally but a partial displacement of the tarsal joints, has, as is well known, been founded upon this supposed con- tractile power of the uterus, and of its injurious influence upon the foetus. Finally, there is reason to believe that what is termed congenital luxation is occasionally produced by violence inflicted upon certain joints during delivery, in rude and forcible attempts to bring away the extremities. 2d. The second theory rests upon the idea that this affection may depend upon disease of the joints, awakened prior to the child's birth. It is ex- tremely plausible ; at all events, it is impossible not to be impressed with the conviction that it may occasionally be followed by such a result, if not directly, at any rate by inducing relaxation of the ligaments, and so favoring the ac- tion of the muscles in separating the articular surfaces. Children in the womb are, it is well known, liable to numerous affections, some of them of a highly inflammatory character, terminating at one time in death, and at ano- ther in serious and irremediable deformity. Of these affections, synovitis is one, and it is probable that it generally has a gouty, rheumatic, or sy- philitic origin. 3d. The theory of an arrest of development has many advocates, both in regard to the origin of this and of other affections; but what do we know of it ? Certainly nothing beyond the fact that it is expressive of the imper- fect growth of a part, and of the concomitant deformity; it affords us no clue whatever to the nature of the causes that induced it, either remote or proximate. The fault may exist in the germ, or it may be superadded to jt after conception, in consequence of some intrinsic defect, or as a result of the operation of causes acting through the mother. Morbid Anatomy.—The pathological changes accompanying this lesion are numerous and diversified, having reference to the textures both of the affected joint itself and of those in the parts around. In the first place, the displaced articular extremities are generally deprived, in part, if not entirely, of their natural shape and structure, being rounded off, and divested of sy- novial membrane and cartilage; the atrophy of the osseous tissue is gene- rally very conspicuous, and is obviously the result of disease of the joint. CONGENITAL DISLOCATIONS. 115 The deepest cavity, as, for instance, the cotyloid, often completely disappears, not by being filled up with plastic matter, as in traumatic luxation, but by the absorption of its component elements. Very frequently the displaced bone forms a new socket, generally superficial, but quite sufficient for the amount of motion to which it is restricted. The ligaments are elongated and re- laxed, thin, ribbon-shaped, partially wasted, or completely destroyed; occa- sionally, however, instead of being stretched and attenuated, they are very short, tense, and strong, obviou*sly from interstitial deposits. The surround- ing muscles are either atrophied, and partially transformed into fatty matter, or fhey are unnaturally large and stout, from the increased exercise devolved upon them by the displaced bone. ■ Symptoms.—The symptoms of congenital dislocation are characteristic. The affection, manifesting itself in various kinds of deformity, is noticed at, or soon after, birth, having commenced without any apparent violence ; it is unattended with pain, or, if pain be present, it is much less than in the trafi- matic form of dislocation; the swelling also is inconsiderable, if, indeed, there is any at all; the head of the bone can be felt in its abnormal position, and the portion of the limb connected with it is generally singularly dis- torted, being changed in its axis, flexed, extended, or twisted. Motion is either much impeded, or too free; the affected member is commonly some- what shortened, and more or less attenuated, from the wasted condition of its muscles. By extension and counter-extension the displaced surfaces may generally be easily restored to their proper position, but the moment they are discontinued they resume their former place. This is practicable, -how- ever, only in the younger class of subjects ; in old cases, reduction is always proportionately difficult, often impossible. The deformity invariably in- creases with age, and is sure to be followed by an arrest of growth of the surrounding structures. Prognosis.—The prognosis of congenital dislocation is eminently unfa- vorable. This is particularly true of the lesion when it is of long standing, as when the person has attained the age of puberty or of manhood, when no plan of treatment that has yet been devised can be of any material, if, indeed, of the slightest, avail, owing to the impossibility of effecting accurate adjustment of the articular surfaces, in consequence of the organic changes which they have undergone. Even under the most propitious circumstances, as it respects age and preservation of structure, the difficulties of effecting a permanent cure will generally be extremely great, well calculated to exhaust the patience both of the subject and the surgeon. The prognosis should, . therefore, always be very guarded. Treatment.—From what has just been stated, it must be evident that the sooner the treatment of this lesion is commenced the more likely will it be to be successful, or, if not altogether successful, productive of amelioration. The principles which should guide the practitioner do not differ essentially from those which govern him in the traumatic form of the accident. The two leading indications obviously are to effect reduction, and to prevent a recurrence of the displacement. No difficulty is generally experienced in fulfilling the former, especially in very young and tender subjects; it is the latter that causes all the trouble, that annoys the patient, and frets the sur- geon. Various kinds of apparatus, much of it of a very complicated and expensive character, have been devised for retaining the parts in contact after they have been reduced ; but it admits of doubt whether most of it could not advantageously be replaced by more simple means, such as ordinary splints, wire cases, and adhesive strips and rollers, which might be so applied, as, in most cases, to answer the purpose most perfectly. Permanent extension and counter-extension will, of course, be required when there is retraction of the dislocated bone. Long confinement, however, should always, if possible, be 116 DISEASES AND INJURIES OF THE JOINTS. avoided, as it is of paramount importance to preserve the general health. The principal local remedies, worthy of attention, are the cold douche and friction with aramoniated and other liniments, together with direct support. If the patient is feeble and anemic, benefit will accrue from the exhibition of tonics, as iron and quinine, a nutritious diet, and exercise in the open air. SECT. XI.—DISLOCATIONS OF PARTICULAR JOINTS. 1. HEAD AND TRUNK. DISLOCATIONS OF THE HYOID BONE. » The possibility of a dislocation of this bone, at one time strenuously denied, rfas of late years been attested by a number of well-authenticated examples. In 1848, Dr. Ripley, of South Carolina, read a paper upon the subject before the Medical Society of Paris, in which he described such an accident as hav- ing occurred in his own person ; and more recently, Dr. Gibb, of England, has published a communication in which he declares that he has seen not less than four cases of it, all of them in the male sex. In one of these there was an occasional displacement of the left horn of the hyoid bone, the patient perceiving a sudden click in that part of his neck, and a sensation as if some- thing were sticking in his throat. He at length died of phthisis, when it was ascertained that the thyro-hyoid articulation contained, besides a considerable quantity of clear fluid, a large sesamoid bone, the whole arrangement being such as to admit of an extraordinary amount of motion. The reduction of this dislocation is effected by throwing the head back- wards as far as possible, so as to put the muscles of the neck completely on the stretch, and then relaxing the lower jaw, at the same time that gentle pressure is made upon the displaced part. The bone, in the case of Dr. Ripley, always returned with a click. DISLOCATIONS OF THE JAW. The connection between the lower maxillary and temporal bones is estab- lished by a hinge-joint, each condyle of the former moving upon an inter- articular cartilage, and being held in FiS- 35< place by two ligaments. Luxation, therefore, can occur only in one direc- • tion, that is, forwards and down- wards, the condyle slipping off the articular .eminence of the temporal bone into the zygomatic fossa, jig. 35. The displacement is usually double, affecting both sides simulta- neously, and is commonly produced by some sudden, spasmodic contrac- tion of the muscles in fits of yawn- ing, laughing, or vomiting, or during an attack of convulsions. Dorsey has recorded the case of a female who Double dislocation of the lower jaw. luxated her jaw in the act of scolding her husband. The accident has some- times happened in an attempt to extract a tooth, to bite a large apple, or to crack a nut.^ Occasionally it occurs in consequence of a blow, fall, or kick upon the chin, the mouth being widely opened at the moment, and the con- DISLOCATIONS OF THE JAW. 117 dyle advanced forward upon the articular eminence. More frequent in women than in men, syid in middle-aged and delicate subjects than in the old and robust, it is extremely rare in young children, owing to the peculiar con- formation of the body and branches of the jaw rendering the occurrence one of great difficulty. The symptoms of the lesion are generally characteristic, fig. 36. The . mouth is widely opened, and cannot possibly be closed; the chin is unusually prominent, and the lower line of teeth projects considerably beyond the upper; the saliva, increased in quantity, drib- bles off involuntarily ; deglutition and speech are performed with great diffi- culty; the cheeks and temples are flat- tened, and, as it were, elongated; the coronoid process is very distinguishable in the zygomatic fossa, especially if ex- amined through the mouth; and, instead of the natural prominence formed by the external condyle immediately in front of the ear, there is a distinct vacuity capable of receiving the end of the fin- ger, although with some degree of diffi- culty, owiug to the great tension of the integuments. When the displacement has existed for some time, the symp- toms, although less marked, will still be sufficiently characteristic to prevent mistake, provided the surgeon will take the requisite care to inform himself of tne history of the case and the present condition of the jaw and mouth. Although the diagnosis of this dislocation is generally sufficiently easy, a very ridiculous error has occasionally been committed. Thus, I recollect a case whieh happened many years ago, where a middle-aged woman, in an attack of cholera, luxated the lower jaw in the act of vomiting, and, when she recovered her senses, was unable to shut her mouth. A physician, a man of eminence, passing by soon after, was induced to consider the case as one of tetanus. The next day a surgeon was called in, who, at once detecting the nature of the lesion, restored without difficulty the parts to their natural rela- tions. An attack of apoplexy, attended with paralysis of the muscles of one side of the face, has been mistaken for a unilateral dislocation of the infe- rior jaw. When the luxation remains unreduced, the jaw gradually regains a part of its motion, the dental arches approaching each other, so that eventually the patient may even be able to masticate his food; speech and deglutition also improve; the saliva ceases to dribble; and much of the disagreeable deformity disappears. The reduction is effected by seating the patient upon the floor or upon a low stool,'his head being suppqrted upon the breast of an assistant. The surgeon, standing in front, introduces his thumbs, carefully defended with a piece of roller, into the mouth, as far back upon the large grinders as pos- sible, while he places the fingers of each hand under the chin and base of the jaw. Using now each thumb as a fulcrum, he forcibly depresses the back part of the jaw, to disengage the condyles from their position in the zygo- matic fossa, and at the same moment elevates the chin with his fingers, thus converting the bone into a lever-of the first kind. The return of the condyles Dislocation of the jaw. 118 DISEASES AND INJURIES OF THE JOINTS. to their natural situation is generally effected by an audible snap, and. the' instant it is about to occur the surgeon quickly remove^ his thumbs from the teeth, lest, in the act of closure of the jaws, they be seriously injured by the suddenness and violence of the contraction. Such is the mode of reduction usually recommended by writers; in my own practice, however, I find that the operation is greatly simplified by the use of anaesthesia, which, while it completely relaxes the muscles, obviates the necessity of removing the thumbs from the jaw as the bone is sliding noise- lessly into its place. A very simple and efficient method of reducing dislocation of the lower jaw has been recommended by Mons. Nelaton. The patient being seated upon a chair, and the mouth widely opened, the surgeon, standing behind him, applies the fore and middle fingers to the mastoid process of the tem- poral bone on each side, and then pushes the jaw forwards by pressing against the prominence formed on the cheek by the point of the coronoid process. A small amount of force generally suffices to effect the object, the condyles slipping back into their proper situation with a distinct snap. The older surgeons were in the habit of reducing luxations of the lower jaw by placing two pieces of cork or wood between the molar teeth, and, while using these as levers to depress the back part of the bone, they raised, the chin by means of a bandage. Another method, occasionally employed by them, consisted in pressing a stick against the lower grinders, so as to keep the jaws separated until the irritated and contracted muscles, overcome by fatigue, allowed the condyles to glide into their natural situation. In unilateral displacement of this bone, the chin is thrown towards the opposite side; the front teeth have lost their parallelism; the mouth is opened, but less widely than in the double luxation; speech and deglutition are somewhat impeded ; and the depression in front of the ear is perceptible on the injured side only. The reduction is effected upon the same principje as in the other form of the accident, with this difference merely that one thumb only is used. After either of these luxations, but especially the bilateral, the patient should for some time avoid opening his mouth, as the accident is extremely apt to recur from very slight causes. The safest plan, therefore, is to sup- port the jaw Vith an appropriate bandage, such a one, for example; as that used in fracture. During the first few weeks the nourishment should consist exclusively of slops and other articles not requiring mastication. In neglected cases of this dislocation the reduction will generally be found very difficult even as early as the end of the third or fourth week. Occa- sionally, however, it has been accomplished at a comparatively late period. Thus, in a case which happened to Mr. Donnovan, of Ireland, restoration was successfully effected ninety-eight days after the occurrence of the acci- dent. Where the ordinary means fail, instead of abandoning the patient to his fate, the efforts at reduction should be aided by the subcutaneous section of the external pterygoid, masseter, and temporal muscles. Sub-luxation.—There is a species of displacement occasionally met with in the lower jaw, which was first described by Sir Astley Cooper under the.name of sub-luxation, and which depends, apparently, upon an unusual laxity of the ligaments, permitting the condyle to slip qff from the inter-articular carti- lage. It is most common in weak, delicate females, and is characterized by an inability to close the mouth, with more or less pain, and a feeling of ten- sion on the injured side. The bone generally returns of its own accord, but should this not happen replacement may easily be effected by drawing the jaw slightly forwards and downwards, so as to afford the condyle an oppor- tunity of reinstating itself upon the inter-articular cartilage. When the relaxation of the joint is very great, the case should be treated by tonics, as DISLOCATIONS OF THE CLAVICLE. 119 iron and quinine, the cold shower-bath, exercise in the open air, and the ap- plication of a series of little blisters over the affected part. Congenital Dislocation.—A congenital dislocation of the lower jaw has been observed in a few cases, Mr. Robert W. Smith, of Dublin, having been the first to notice" such an accident, of which he has given, with great minute- ness, the results of the dissection. The patient, an idiot from infancy, died at the age of thirty-eight. The luxation existed on the right side, which was remarkably deformed, having a singularly hollow appearance, which strik- ingly contrasted with that of the sound one, which was unusually full and plump. The extremity of the finger could be readily pressed between the posterior margin of the jaw and the external auditory canal, owing, as was found on dissection, to the absence of the condyle of the bone, which was, in fact, greatly atrophied nearly as far forward as the symphysis. There was no inter-articular cartilage, or distinct capsular ligament; and both the mas- seter, pterygoid, and temporal muscles were much wasted. The temporal, malar, superior maxillary, and sphenoid bones were imperfectly developed, and the glenoid cavity existed merely in a rudimentary state. DISLOCATIONS OF THE CLAVICLE. Dislocation of the clavicle, compared with fracture of this bone, is extremely rare, there being probably at least ten cases of the latter to one of the former. The cause of this remarkable difference is to be found in the exposed situation of the bone, and the great shortness and strength of its ligaments which ren- der it much more liable to give way in its substance than at its articulations with the sternum and scapula. The displacement may occur at either joint, and there are several instances upon record where both we,re affected simulta- neously. 1. The sternal extremity of the clavicle may be dislocated forwards, back- wards, and upwards, the relative frequency of the accident being in the order here stated. Luxation downwards is rendered impossible on account of the resistance offered by the cartilage of the first rib. Dislocation forwards is generally produced by injury inflicted upon the top of the shoulder, or by falls upon the elbow at a moment when the arm is separated from the trunk. The clavicle, being thus impelled violently for- wards and inwards, completely ruptures the sterno-clavicular ligaments, and presents itself, along with the inter-articular cartilage, in front of the upper part of the sternum. The sterno-cleido-mastoid muscle is pushed down, and some of its inner fibres are occasionally lacerated, particularly when they take their origin unusually near the joint. The signs which denote the accident are, Fig. 37. a hard, circumscribed, incompressible tu- mor at the upper and anterior part of the sternum, a vacuity at the natural situation of the joint, unusual prominence of the inner portion of the cleido-mastoid mus- cle, depression of the shoulder, and incli- nation of the head towards the affected side. But the most reliable evidence of the nature of the case is derived from trac- ing the outline of the bone with the finger of one hand, while the shoulder is moved by grasping the elbow with the other, and by recollecting that in dislocation the bone retains its normal length, while in fracture it is materially shortened. The Dislocation of the sternal end of the clavicle. 120 DISEASES AN^ INJURIES OF THE JOINTS. head of the clavicle overlaps the sternum, and is always directed downwards (fig. 37), so as to enable the examiner readily'to distinguish the articular surface from which it has been removed. The reduction of this dislocation is effected easily enough, but unfortunately it is retained with so much difficulty that hardly an instance Recovers without some degree of deformity, despite the best directed efforts of the surgeon. Many years ago I had a case of this kind under my charge, which, notwith- standing the most vigilant care and attention, was as bad, as it respected the cure, at the end of three months, as it was on the day on which it happened. Since then I have met with several other similar examples. The articular cavity of the sternum is so shallow, and the ligaments unite with so much difficulty, that it is almost impossible to keep the parts in apposition sufficiently well or long to obtain complete consolidation. Fortunately, however, this occur- rence does not materially affect the movements of the shoulder, for experience has shown that these are very soon entirely re-established. It is a matter, therefore, simply of deformity, not of utility. To reduce this luxation, one hand should be placed, shut, in the axilla, while the other grasps the elbow, which is then to be raised in order to push up the humerus, and thus convert it into a lever, acting directly upon the clavicle and scapula. The shoulder is next carried upwards, outwards, and backwards, in a direction opposite to that of its displacement, and the fore- arm brought forwards across the chest, so that the thumb and fingers shall . rest upon the sound collar-bone. By this manoeuvre the articular surfaces generally resume their natural relations, but, should this not happen, the re- duction is to be promoted by pressing the luxated head.of the clavicle back- wards and slightly upwards. A wedge-shaped pad, with the thick end directed Upwards, being placed in the axilla, the limb is firmly secured to the side and front of the chest by the ordinary fracture-apparatus, or, what is better/the adhesive-strip dressing, a stout, square compress being applied directly over the sterno-clavicular articulation. The dressing must be frequently inspected with a view to its readjustment, and must be worn for at least three months with great constancy and regularity. Dislocation backwards is generally produced in an indirect manner by in- jury applied to the shoulder impelling the scapula and the outer extremity of the clavicle forwards. It may also be caused by a severe blow upon the inner end of the bone, by the body being crushed between two resisting ob- jects, and by violent traction upon the upper extremity when the trunk is firmly fixed and inclined backwards. The distinctive sign is that the head of the clavicle is forced backwards, and that it can be felt behind the summit of the sternum, sometimes below, at other times above, the level of that bone. A vacuity exists at the natural situation of the joint, the shoulder is directed somewhat forwards, the arm hangs uselessly by the side, and there is gene- rally considerable dyspnoea, with cerebral congestion, and difficulty of deglu- tition, from the pressure of the luxated bone upon the trachea, cervical vessels, and oesophagus. The ligaments are completely ruptured, and the cleido- mastoid muscle is partially separated from its sternal attachments. The reduction is effected upon the same principles as in the dislocation for- wards, the fist being placed in the axilla and used as a fulcrum, while the shoulder is pushed upwards, outwards, and well backwards, and retained in this position by an appropriate apparatus, of which a figure-of-8 bandage with a long, thick, square compress between the shoulders is one of the best. Whatever means, however, be employed, it will be found extremely difficult to keep the articular surfaces in apposition and prevent deformity. When the reduction is*unusually obstinate, as it sometimes is when the head of the bone is firmly wedged in behind the sternum, the knee should be placed be- tween the shoulders, the affected one of which should then be drawn forcibly DISLOCATIONS OF THE CLAVICLE. 121 backwards and outwards, the arm being at the same time extended nearly at a right angle with the trunk. This variety of dislocation is sometimes produced by deformity of the spine, allowing the shoulder to sink gradually forwards so as to push the head of the bone from the sternum. In a case of this kind which happened to Mr. Davie, of England, the clavicle compressed the oesophagus so severely as to caus"e great difficulty in swallowing, and danger to life by starvation. As reduction was impracticable, the trouble was remedied by sawing off the • sternal end of the bone, about one inch from the articulation. The patient speedily recovered, and lived six years after the operation. Luxation upwards is extremely rare; so much sc;, indeed, that many of the best surgeons formerly doubted the possibility of its occurrence. The cases, however, that have been reported within the last twenty years by Macfarlane, Baraduc, Malgaigne, and others, fully establish its claims to the distinction of a new species. The accident generally results from violence inflicted upon the shoulder, as a blow or fall, driving the saapula downwards and inwards towards the chest, thus separating the bone from its connections, and forcing it upwards above the fourchette of the sternum. The symptoms are usually very characteristic. The bony tumor can be distinctly felt and seen in front of the trachea, where it is easily impressed by moving the corresponding arm; the shoulder, sunk forwards and downwards, approaches nearer to the median line than naturally; there is a remarkable interval between the clavicle and the cartilage of the first rib, amounting to from six to twelve lines; the cleido- . mastoid muscle is put upon the stretch; and there is a vacuity in the natural^ situation of the joint, as in the other forms of the accident. The reduction is very easily effected, simply by lifting the shoulder thoroughly away from the chest, at the same time that it is slightly elevated and inclined backwards, and pressure made directly upon the luxated head. Retention is to be attempted upon the same principles as in the other sterno-clavicular luxa- tions; a pad being placed in the axilla, and the elbow and forearm being well supported by adhesive strips and bandages. The reunion is generally imperfect, but this does not materially weaken the functions of the limb. 2. The scapulo-clavicular articulation is effected by the acromion process of the scapula and the outer extremity of the clavicle, by a species of arth- rodia, the concave surface of the former being closely adapted to the con- vexity of the latter, and the union established by strong ligamentous bands. Admitting of hardly any motion, it can be dislocated only by external violence applied either directly to one or the other of the two bones, or indirectly through the arm and sternum. The accident is usually attended with severe contusion of the soft parts, and is seldom so thoroughly repaired as not to be followed by some degree of deformity, although the recovery of the motions of the limb is eventually sufficiently perfect for all useful purposes. The scapular end of the clavicle may be thrown from its natural position in three different directions; upwards, above the acromion process, down- wards and backwards, beneath this prominence, and downwards and for- wards, under the coracoid process. Of these several luxations, the first is by far the most frequent; both the others are extremely rare. In the dislocation upwards, the end Of the clavicle, breaking away from its articular connections, is thrown up by the action of the trapezius muscle, or by the impelling force, so as to overlap the acromion process, fig. 38, and form a small, hard, round tumor immediately beneath the skin, which dis- appears upon raising the arm, but is reproduced the moment that we let go our hold. The head is inclined towards the injured side, the limb hangs closely along the trunk, the shoulder looks as if it were somewhat flattened, and the patient is unable, without great pain and difficulty, to raise his hand to his mouth; in a word, the whole attitude of the body is nearly the same 122 DISEASES AND INJURIES OF THE JOINTS. as in fracture of the clavicle. The accident is usually caused by a Ulow upon the shoulder, and the circumstance of the trunk being strongly impelled for- wards promotes the luxation by increasing the strain. It may also be occasioned by a fall upon the elbow, and by a kick upon the acromion process. However induced, there is necessarily, in the complete form of the lesion, a rupture not only of the acromio- clavicular ligaments, but also of the ligaments connecting the clavicle with the coracoid pro- cess. In the incomplete luxation the latter always escape. The clavicle readily resumes its natural position by drawing the shoulders upwards and backwards, while the knee is interposed between them behind, as the patient sits upon a chair. To maintain it in this situation, the same apparatus and dressings must be used as in fracture of this bone, and in the sterno- clavicular luxations, already described. A thick pad, with the base directed upwards, is placed in the axilla, and the arm and forearm Dislocation of the scapular end of the must be well secured to. the chest. Direct clavicle. pressure by means of a stout compress and • piece of sheet lead, should be made upon the acromio-clavicular junction. Despite, however, all the precaution, care, and skill of the surgeon, he will seldom be able to procure a good cure. I have seen cases of this description treated for months with the most determined effort to succeed, and yet at the end of this time it was impossible for the patient to move his arm without causing a relapse. Dislocation downwards, appropriately named infra-acromial, is exceed- ingly uncommon, only a few cases of it having been reported. The fact is, although it was described by J. L. Petit, who believed it was more frequent than dislocation upwards, it has been almost entirely ignored by modern systematic writers. It has been alleged that the accident cannot happen without previous fracture of the coracoid process, a conjecture which has been satisfactorily* disproved by experiments made upon the dead subject. The accident, in the fe,w cases that have been carefully studied, has been the result of violence upon the shoulder, as a hemvy blow, or a kick from a horse, and it can hardly be imagined that it could be produced in any other manner. It is probably attended, in every instance, with a rupture of the coraco-clavicular ligaments. The characteristic sign is the situation of the end of the clavicle beneath the acromion process, which is at the same time remarkably prominent, and somewhat nearer to the sternum than in the natural state. The shoulder is flattened, and the arm, applied close to the side, is incapable of voluntary motion. Where the evidence is so distinct, error of diagnosis must be impossible. Should any doubt, however, arise upon the subject, it may easily be dispelled by tracing the outline of the two bones as far forwards as their articulation ; the finger, as it approaches this point, will at once.detect the extraordinary prominence of the one, and the marked depression of the other, and so reveal the true nature of the accident. The reduction is accomplished by pulling the shoulder outwards and back- wards, the knee resting against the dorsal portion of the spine, and the elbow being carried across the chest, to afford greater relaxation to the muscles, and convert the humerus into a lever for acting more efficiently upon the acromion process. Retention is effected in the usual manner, with the additional pre- Fig. 38. DISLOCATIONS OF THE CLAVICLE. 123 caution of preventing all motion of the inferior extremity of the scapula. A perfect cure may be expected in from five to eight weeks, both as it respects the absence of deformity and the recovery of the functions of the limb. Dislocations forwards and downwards, beneath the coracoid process—the infra-coracoid form of the accident—has only recently taken its position in surgical nomenclature. The lesion, like the preceding, is .infrequent. Mal- gaigne states that he is acquainted with only six cases, of which not less than five are said to have occurred in the practice of Mons. Godemer, of Mayenne. If this be true, the accident must be much more common than is supposed, which, however, I doubt. A fall upon the anterior surface of the shoulder appears to be the usual cause of the accident. p The symptoms are unmistakable. Besides the contusion and discoloration common to all these luxations, the acromion and coracoid processes are un- usually prominent; the top of the scapula is strongly inclined downwards and forwards, and there is a marked depression in the natural situation of the clavicle, which, upon being traced witb the finger, is found to be directed outwards and downwards, its extremity being actually lodged in the axilla. The arm can be moved in every direction, except upwards and inwards. The reduction is easily effected. The chest being firmly fixed with a strong napkin, an assistant seizes the arm, and, converting it into a lever, uses it for forcibly pushing the scapula outwards and backwards, while the surgeon him- self, grasping the clavicle, disengages it from its position beneath the coracoid process, and restores it to its natural situation. The retention is maintained by the usual apparatus. The cure is generally satisfactory. Seeing how difficult it is to keep these various dislocations of the clavicle reduced, I should not hesitate, if an opportunity arose, to fasten the ends of the bones with a silver wire, inserted subcutaneously, and retained until re- union Sccurs. The operation could be easily executed, and would not be likely to cause any bad effects. Double dislocation of this bone has been observed, so far as I know, only in two instances. One has been reported by Porral, and is said to have occurred under the care of Gerdy, in the St. Louis Hospital, in Paris. The accident was caused by a fall from a third-story window, upon the upper and back part of the shoulder. The symptoms were well-marked, the acromial end of the bone being luxated backwards and upwards, the sternal upwards and forwards. The treatment was by Desault's well-known, but now obsolete, apparatus, aided by large graduated compresses over the affected joints. Under this dressing, the outer extremity of the clavicle soon became firmly united, but the other continued obstinately displaced. The other case was reported by Morel-Lavellee, in 1859. His patient was forty years of age, and the dislocation was caused by the shoulder being compressed between a pile of wood and the wheel of a carriage, the sternal extremity of the bone being thrown forwards, and the scapular upwards towards the neck. The supra-clavicular and subclavicular hollows were entirely effaced. The inner displacement was easily reducible, but no effort that could be used made any impression upon the outer one. The clavicle is occasionally dislocated at one or both extremities, as a con- genital vice. I observed, some years ago, a well-marked example of this accident at the steruo-clavicular articulation, in an infant three months old, otherwise perfectly healthy and well-formed. The end of the clavicle pro- jected upwards and forwards, in a striking degree; and, although reduction could be readily effected, nothing that I could employ could keep the parts in place. 124 DISEASES AND INJURIES OF THE JOINTS. DISLOCATIONS OF THE SPINE. The vertebra? are so firmly connected to each other, and, excepting those of the neck, admit of such limited motion, that any injury directed against them is much more liable to break than to luxate them. Even in the cervi- cal region, where*the mobility is much greater than anywhere else among these bones, the accident is exceedingly uncommon, and it is fortunate that it is so, since it is almost always fatal, owing to the violence inflicted upon the spinal cord, as shown in figs. 39 and 40, causing death not unfrequently on Fig. 39. Fig. 40. Dislocation of the spine, between the fourth and fifth cervical vertebrae. The cord was torn, the paralysis being complete, and death occurred in a few days. The same, seen laterally. the spot, or, at all events, within the first few days. When the»patient sur- vives the more immediate effects of the dislocation, he is very apt to perish from inflammation of the spinal cord and its envelops, at a period varying from a few weeks to several months. Hence, whether the accident be con- sidered with reference to its primary or secondary effects, our prognosis must be equally guarded, few persons, under any circumstances, recovering. In a dislocation of the sixth and seventh cervical vertebrae, which was under the charge of Dr. Willard Parker and myself, many years ago, death occurred in less than forty hours; the patient was a young man, a circus rider, and the accident was produced while he was engaged in tumbling in the pit; it was instantly followed by paralysis of all the extremities, and he gradually fell into a state of unconsciousness, which lasted until,he expired. The neck was stiff and painful, but there was no sign of displacement. On dissection, we found the articulating processes and bodies of the sixth and seventh cer- vical vertebrae completely detached from each other on the right side, but on the left the processes were still slightly adherent, while the connection be- tween the bodies of the bones was perfect, although in q,high state of tension. The two contiguous spinous processes were completely severed. There was no fracture. The spinal cord was sensibly compressed by the partial rotation of the seventh vertebra, and there was a slight effusion of blood in the spinal canal at the seat of the injury. The above case is a good type of the effects which usually follow disloca- tions of the vertebras. When the lesion occurs above the origin of the phrenic nerve, death is often instantaneous from stoppage of the respiration ; if it be seated farther down, the patient may live for some time, and even eventually recover, although such a contingency is an extremely remote one. The ■ DISLOCATIONS OF THE SPINE. 125 diagnosis is generally very obscure, it being usually impossible to determine whether the accident is a dislocation or fracture, or a combination of both, while the treatment must,'of necessity, be altogether empirical. The prin- cipal symptoms are paralysis of the extremities, tympanitis, obstinate consti- pation, and retention of urine, which soon becomes loaded with phosphates, causing inflammation and ulceration of the bladder. If the patient survives any length of time, severe bedsores are apt to form upon the nates and other parts of the body, thus greatly increasing his suffering. As it respects the reduction of these dislocations, it is impossible to pre- scribe any regular or methodical course of procedure. Most practitioners, dreading interference on account of the danger of sudden compression of the spinal cord, and the consequent destruction of the patient, are in favor of allowing the parts to take care of themselves, hoping, with judicious manage- ment, for gradual recovery. Such a plan, it seems to me, is both wise and proper, at least in most cases, especially those .in which it is impossible to determine the diagnosis, or where the symptoms, although well marked, are not at all urgent, the patient having a tolerably good use of every part of the body, save the one immediately implicated in the mischief. Under such cir- cumstances, time and a "masterly inactivity" will often accomplish more than all the interference of the best surgeons. But there are exceptions, to every rule, and, while I would recommend that most cases of this kind should be let alone, I would strongly advise an opposite conduct where, the symptoms being well marked, and the danger urgent, there is reason to believe that the patient will, if not relieved, speedily perish. In such an event I should con- sider any attempt to save him, however desperate, justifiable and proper. If we succeed, we obtain a victory; if we fail, we can but hasten an occurrence* otherwise inevitable. A number of instances are upon record where the reduction has been performed successfully. Dr. James R. Wood, riot long ago, safely reduced, by manipulation, a partial dislocation of the cervical vertebrae in a child; and Dr. Ayres, of Brooklyn, more recently, happily succeeded in a case of complete luxation of these bones ten days after the acci- dent. The patient, a tall, muscular man, aged thirty, had been violently struck on the back of the neck, the anterior por- tion of which was found to be remarkably cpnvex from the blow, bulging forwards, and lifting up the larynx, as seen in fig. 41. The head, as the man sat in his chair, • was thrown backwards antl permanently ' fixed, the face being turned upwards. The posterior part of the neck exhibited a sharp, sudden angle at the junction of the fifth and sixth cervical vertebrae, around which the integuments lay in folds. It was difficult to reach the bottom of this angle, even with strong pressure of the fingers, and of course the regular line formed by the projecting spinous processes was abruptly lost. The patient complained of intense pain at this part; he swallowed with much difficulty, and the breathing was obstructed and some- what labored; but there was not the Slight- mi , .. n. , , , ' _ * Ayres's case of bilateral dislocation Ihe reduction was effected .by means of the 0f the fifth cervical vertebra. Fig. 41. 126 DISEASES AND INJURIES OF THE JOINTS. hands of the surgeon and of two assistants, applied to the chin and occiput, and then used to draw the head, at first, directly backwards, then upwards, and^finally forwards, counter-extension being made with two folded sheets stretched obliquely across the shoulders. The system was completely relaxed by chloroform, and the bones were distinctly felt slipping into their natural situation. No unpleasant symptoms followed, and, at the end of a week, the man had the complete use of his head and neck. A few cases of traumatic luxation of the occipito-atloid articulation have been reported, but, so far as I know, all, except one, and that was only a partial displacement, promptly proved fatal. The accident, until recently, was regarded by most writers as impossible, on account of the firm connec- tions and restricted motions between the two bones. A slow species of displacement occasionally occurs here in children and youths, in consequence of scrofulous disease of the articular surfaces and body of the atlas, or of this bone and some of the other vertebrae. Several exam- ples of it have come under my personal observation, and the subject has been well discussed by Schupke and other German writers. The severe local suf- fering produced by the malady is to be allayed by rest and recumbency, leeches, blisters, and issues, especially those made with the actual cautery, while the constitution is to be improved by tonics and alterants, as quinine and iron, and the different preparations of iodine. When all disease is arrested, the patient may exercise in the open air, the neck and head being well supported by an appropriate apparatus. The atlo-axoid articulation, enjoying a much wider range of motion than the preceding, is more liable to luxation by external violence, the most com- mon causes being blows upon the back part of the head, forcible torsion of the neck, tumbling, and standing on the head, eventuating in rupture of the ligament of the odontoid process, and the projection of this process against the spinal cord, inducing fatal compression. Lifting children up by the occiput and chin, in play, is capable of producing this accident, as is proved by the memorable case related by J. L. Petit, of a little boy, who, being thus raised up in the air, struggled so violently as to dislocate his neck, dying on the spot. The nature of the lesion may be suspected when, in consequence of a sudden twist, blow, or wrench, the head is turned to one side, and cannot be brought back- to its natural position, the cleido-mastoid muscle being relaxed, and the part exquisitely painful. Unconsciousness usually succeeds the occurrence, and the patient, if not promptly relieved, soon expires. When the symptoms are urgent, an immediate attempt should be made to reduce the dislocation by inclining the head towards the side to which it is directed in order to disengage the articular processes, a most hazardous step of the operation, and one which may instantly cause death by compression of the spinal cord. The process being liberated, the head and neck are next brought* to their natural position by rotating them gently in a direction contrary to that in which the luxation occurred. DISLOCATIONS OF THE RIBS. Dislocations of the costo-vertebral articulations from external injury must be extremely rare, if, indeed, they are not altogether impossible. That this is true any one may satisfy hhnself by inspecting the mode in which the ribs are connected to the vertebrae; the ligaments are both numerous and power- ful, and, besides, each joint is protected by a great thickness of muscle, so that these bones, instead of yielding at their junctions, will be much more apt to give way in their continuity. The possibility, however, of the acci- dent was not only admitted, but strenuously maintained, by many of the older surgeons, especially by Pare, Barbette, Pla'tner, and Heister, in whose works DISLOCATIONS OF THE PELVIS. 127 may even be found an account of what they regarded as varieties of the lesion. But modern experience is entirely opposed to such a conclusion ; in truth, there are altogether not more perhaps than half-a-dozen well authenticated cases of dislocation of the costo-vertebral articulations upon record, and in nearly every one of these the injury was associated with fracture of the ribs, or of the ribs and spine; all proved fatal, and in none was it possible to make a satisfactory diagnosis during life. Such an accident must, therefore, be entirely beyond the resources of surgical art; even if it were possible to detect the nature of the affection, still it would be impracticable to remedy it, except upon general principles, any direct interference being out of the • question. Dislocation of the ribs from their cartilages, and of the latter from each other, and from the sternum, is also a rare occurrence, though not as much so as displacement of the costo-vertebral articulations. I have myself seen several cases of the kind, one of which I attended, some years ago, along with Dr. J. R. Pirtle, the patient being a man, aged sixty, who fell from a scaffold, a distance of ten feet, upon the stone steps below, his left shoulder and chest receiving the blow. Immediately after the accident there was vio- lent dyspnoea, and the patient stated that he could both hear and feel, at every inspiration, something snap and jerk in his side, similar to the noise caused by pulling a finger-joint. Upon examination, this was found to proceed from a dislocation of the cartilages of the last three ribs from the sternum, playing to and fro during the movements of the chest. A fracture also existed in the left clavicle. In another instance the third and fourth ribs on the right side were severed from their cartilages. The remarkable case related by Charles Bell, in his surgical observations, in which all the ribs were dislocated from their cartilages by the thorax being violently compressed between a wall and the beam of a mill, is familiar to every surgeon. Occasionally the costal car- tilages are separated from each other. • Whatever form these costal dislocations may assume, their existence neces- sarily implies the infliction of severe injui-y, which cannot fail to tell badly upon the soft parts, both externally and within the chest, and to be followed, when it is not immediately fatal, by violent inflammation. Hence, besides the attention required by the local mischief, great care is demanded on ac- count of the state of the system; in the first instance, to bring about reaction, and, secondly, to moderate the resulting excitement by the interposition of appropriate antiphlogistics. The topical treatment is by bandage and com- press, as in fracture of the ribs, the patient being compelled to breathe chiefly by the aid of the diaphragm. DISLOCATIONS OF THE PELVIS. Notwithstanding the great extent of the sacro-iliac surfaces, and the vast strength of the ligaments by which they are connected together, observation has demonstrated that they may occasionally be displaced along with the pubic symphysis, by external violence. Dr. Thomas Harris, of this city, many years ago, met with a case of dislocation of these bones, in a woman, aged thirty-five, from a blow upon the sacrum inflicted by the husband's fist. In general, however, a much greater degree of force is necessary to produce such an accident; hence there must almost always be more or less contusion of the soft parts, both externally and internally,- extensive ecchymbsis, con- cussion of the spinal cord, injury of the sacral nerves, and fracture of some of the pelvic bones, thus seriously, if. not fatally, complicating the case. Even when the patient survives the immediate shock of the accident, he is very apt to perish from the subsequent inflammatory and suppurative irritation, per- haps weeks after the primary effects have passed off. * ' f 128 DISEASES AND INJURIES OF THE JOINTS. Violent kicks or blows, and compression of the body between two hard and resisting objects, as a wall and a carriage, are the usual causes of this dislocation. The displaced bone is thrown backwards and upwards, forming a distinct prominence beneath the skin, easily perceptible by sight and touch, and attended with marked crepitation. The limb of the affected side is short- ened and powerless, the crest of the ilium is raised beyond the natural level, the fold of the nates is flattened, the tuberosity of the ischium is higher than that on the sound side, and the ramus of the pubic bone lies somewhat pos- terior to the plane of its fellow. The parts are-contused and exquisitely ► painful, and the patient is unable to lie upon his back, or to void his urine. In the treatment of this luxation, the most important object, that upon which the safety of the patient mainly depends, is to prevent the ill effects of inflammation. To accomplish this, he must be kept perfectly at rest, and be subjected to.the most strict antiphlogistic course, of which leeching, ano- dyne fomentations, and blisters, form a most valuable constituent. When the inflammation has been well reduced, the parts should be covered with an ammoniac and mercurial plaster. The reduction, which is easily effected by pressure, is maintained by a compress and broad bandage, secured, if neces- sary, by thigh and shoulder straps. Great attention must be paid to cleanli- ness, as defecation will be both painful and inconvenient, and the urine must be regularly drawn off with the catheter. In a case mentioned by Hoin, the articular surfaces refused to come together until after the patient had begun to walk about, when the weight of the limb drew them gradually in place. The pubic symphysis is sometimes wrenched open by external violence, as I have witnessed in two cases in persons whose bodies had been crushed between a railroad car and the edge of the floor of a depot. The accident is generally fatal, not so much on account of the injury done to the joint and bone as in consequence of the violence sustained by the contents of the pelvic cavity. The-treatment must be conducted upon the same principles as in dislocation of the sacro-iliac symphysis. A separation of this joint occasionally occurs during utero-gestation, in consequence of softening of its fibro-cartilage, allowing the two bones to ride slightly upon each other. A case of this kind was under my observation not long ago. The woman was in her fifth pregnancy, and the dislocation, beginning about a month before her confinement, was so great that she could not walk, or turn in bed, without extreme distress. The parts were exqui- sitely tender on'pressure, and upwards of five weeks elapsed after parturition before they regained their healthy condition. Rest, recumbency, and leeches constitute the proper treatment, aided, when the patient is able to move about, by a belt with a pad on the pubes. The coccyx may be dislocated from the sacrum by external violence, as a fall, or kick, or by the pressure of the child's head in difficult parturition. The bone is usually thrown forwards or backwards. In a case recently re- ported by Dr. Roeser, it was displaced laterally, being torn away from the sacrum, and carried over towards the descending branch of the left ischium, where it formed a small but distinct tumor. The signs of the accident are preternatural fixedness of the coccyx, with.considerable shortening, difficulty in voiding the feces, tenesmus, and retention of urine. Reduction is effected by introducing the index and middle fingers of one hand into the rectum, while by the assistance of the fingers of the other, applied externally, the bone is pushed into its proper position. Rest, fomentations, and leeches will be required during the after-treatment. The bowels should not be moved for a number of days, and then only by means of saline cathartics and enemata, as all motion and straining would interfere with the reparative pro- cess, and might even reproduce displacement, ■ DISLOCATIONS OF THE HAND. 129 2. SUPERIOR EXTREMITY. DISLOCATIONS OF THE HAND. Dislocations of the thumb, especially of its metacarpo-phalangeal joint, are, in many respects, so peculiar as to require separate consideration. Displace- ment of the phalanges backwards is by far the most common, the disposition of the articular surfaces, and the ligaments by which they are connected together, rendering luxation forwards or laterally extremely difficult. Luxation of the metacarpo-phalangeal joint, although not of frequent occurrence, has attracted much attention on account of the difficulty of its reduction, the true nature of which can hardly be said to be even yet perfectly understood, notwithstanding the numerous researches that have been made to elucidate it. Much that has been written upou the subject must be con- sidered as purely speculative, but still a good deal of new light has been thrown upon it by the experiments and dissections of Pailloux, Lawrie, Yidal, and Malgaigne. In this accident the head of the first phalanx is thrown backwards, as seen in fig. 42, upon the dorsal surface of the metacarpal bone, generally in con- Fig. 42. Dislocation of the first phalanx of the thumb, backwards, on the dorsum of the metacarpus. sequence of violence applied to the palmar surface of the thumb, while the joint is immoderately extended. The metacarpal bone being thus impelled by the weight of the body, and the proximal phalanx by the object it strikes against, causes the ligaments to give way, and the articular extremities to glide past each other. It has been asserted that, when there is inordinate relaxation of the ligaments, mere muscular action is capable of producing the displacement, but the possibility of the occurrence, especially in its complete form, may well be questioned. The dislocation is attended with great deformity, which is so peculiar that it may be regarded as characteristic. A large tumor, hard and circumscribed, and formed by the head of the first phalanx, exists upon the back of the joint, while another, equally hard, but not quite so distinct, is perceptible on the palmar aspect of the thumb, representing the distal extremity of the meta- carpal bone; the thumb is sensibly shortened, and can generally neither be bent nor extended, its last phalanx, however, being usually flexed in conse- quence of the excessive tension of the tendon of the long flexor muscle. In most cases, the head of the first phalanx will be found to rest upon the poste- rior and inner part of the metacarpal bone, and not, as is commonly supposed, altogether upon its dorsal surface, and it is owing to this fact that the thumb looks as if it were rotated a good deal inwards. The shortening of the member often amounts fully to one inch, thus giving it a stumpy, character- istic appearance. If a dissection be made of the affected parts, the ligaments will be found VOL. n.—9 130 DISEASES AND INJURIES OF THE JOINTS. to be extensively ruptured, particularly the anterior; the extensor tendons are pushed backwards, and strongly stretched; and the external head of the short flexor muscle is torn in two, allowing the end of the metacarpal bone to pass completely through its fibres. The anterior ligament remains attached to the sesamoid bones and the first phalanx, the latter of which, as it is thrust backwards during the accident, carries both along with it, so as to deposit them, as it were, between its anterior surface and the contiguous surface of the metacarpal bone. In this way a partition is formed by these parts be- tween the two bones, extending back some distance, and constituting, as Mr. Lawrie justly remarks, a serious mechanical obstacle to replacement. The reduction, as just stated, is generally difficult, and the means formerly employed to effect it were often so severe as to inflict the most dreadful injury, sometimes followed by extensive erysipelas and even mortification. Instances, in fact, were not wanting, though fortunately they were few, of the thumb being dragged off during violent and long-continued efforts at restora- tion. In many cases, again, all efforts of the kind proved unavailing, and the parts were obliged to be left in the condition into which the accident had thrown them. Desault, in order to accomplish his purpose, in difficult cases, suggested the idea of making an incision behind the extremity of the dislo- cated bone, and raising it out of its position by means of a suitable lever; and Evans went so far as to propose its removal altogether by excision. Charles Bell, on the other hand, attempted to remedy the evil by the subcutaneous sec- tion of one of the lateral ligaments, an operation which has frequently been per- formed successfully both in this country and in Europe. Sir Astley Cooper advises, after a fair trial of the ordinary means, an abandonment of the case, under the idea that the patient will eventually have a useful thumb without reduction. I allude to these views simply because they serve to show the great difficulty which so often attends this dislocation, and the harsh expedi- ents that have been suggested for overcoming it. The most common method of effecting replacement is that by extension and counter-extension, employed upon the same principles as those which regulate their application in dislocations of other joints. It has always an- swered admirably in the few cases of the accident that I have had to treat. The extension should be made by means of the clove-hitch, seen in fig. 43, Fig. 43. ww: Clove-hitch knot. secured over a wet cloth, or piece of buckskin, to protect the soft parts, and the counter-extension with a stout silk handkerchief, the fold resting in the palm of the hand, while the ends, crossed behind the wrist, and brought around the front of the forearm, are held by an assistant. In this way the two forces can be applied with great effect, in a line with each other, and without the risk of unduly exciting the muscles concerned in the displace- ment. ^ After they have been in operation for a short time, the thumb should be inclined inwards, in a semicircular direction, towards the ulnar margin of the hand, at the same time that the dislocated head is urged forwards and downwards by the surgeon's own'thumb. Powerful extension may also be made by means of Dr. Levis's apparatus (p. 133) and Charriere's forceps. DISLOCATIONS OF THE HAND. 131 Although the method now described will, I am satisfied, generally suffice for the reduction, yet, if I should ever again be called to a case of the kind, I should at Fig. 44. once adopt the excellent plan first practised in 1826 by Professor Crosby, of New Hamp- shire, and since recommended by Mons. Gerdy, of Paris. It simply consists, as the adjoining cut, fig. 44, clearly exhibits, in pushing the phalanx back, until it stands perpendicularly on the metacarpal bone, when, by strong pressure directed against its base, from behind forwards, it is readily carried by flexion into its natural position. An-elab- orate account of this method will be found in the American Journal of the Medical Sciences, for April, 1858, by Dr. Cutter, of Massachusetts. The annexed Sketch, fig. 45, exhibits a plan Dr. Crosby's mode of reduction. of the dislocation of the head of the phalanx of the thumb forwards towards the palm of the hand. As already stated, it is an occurrence of great rarity. The symptoms are characteristic. Fig. 45. Forward dislocation of the thumb. Dislocation of the trapezio-metacarpal joint may occur in four different directions, the end of the metacarpal bone being thrown off from the articular surface backwards, inwards, forwards, or outwards; the first two forms of the accident, however, are by far the most common, as will be apparent from an examination of the structure of the articulation and the arrangement of the muscles stretched along its anterior and outer surface. Luxation backwards is always occasioned by external injury, as a blow or fall upon the dorsum of the thumb or the extremity of its metacarpal bone, by which the latter is suddenly and violently turned towards the palm. The signs of the accident are characteristic. A hard prominence is seen and felt upon the back of the trapezium, or at the posterior and radial surface of the hand, formed by the displaced head of the bone, and the thumb is in a forced state of flexion, without the possibility of being extended. The reduction is effected by an assistant fixing the hand, by grasping the wrist, and, while another pulls the thumb with a clove-hitch, the surgeon pushes the head of the bone forwards and downwards towards the palm, into its natural position. For some days the hand should be supported upon a broad splint, and means employed to moderate inflammation. I have occasionally seen a partial dislocation of the metacarpal bone of the thumb backwards from inordinate relaxation of the ligaments. The occurrence is most common in weak, deli- cate women, and requires tonics, with the cold douche and a series of small blisters, for its relief. In the luxation inwards, which is exceedingly infrequent, the metacarpal bone of the thumb is wedged in between the trapezium and the head of the 132 DISEASES AND INJURIES OF THE JOINTS. metacarpal bone of the index-finger, so as to extend the thumb, and cause the trapezium to form a projection at the outer and back part of the palm. In the reduction the extension and counter-extension are conducted as in the preceding case, but they have to be kept up a longer time, and, as the head of the bone approaches the trapezium, the thumb is to be inclined towards the inner side of the hand, in order to relax the flexor muscles. DISLOCATIONS OF THE FINGERS. The phalangeal joints are susceptible of luxation backwards, fig. 46, an occurrence which can be caused only by severe force, and which is always so well characterized as to render any description of its signs unnecessary. The reduction is effected by exten- Fig. 46. sion and counter-extension, ^ aided by pressure upon the £-$—-----__ MKr^\ head of the displaced bone. a^a. '^»sS!^gHp^^^\ The accident is extremely rare. '■P^^^^^^sid^^^^^K"^ ^ot 'on£ a°0' ■"■ na(^ a com" ^iM0 lgajjjl pound dislocation of the last ^Sf\ joint of the right middle finger, ^^\ in a stout, healthy man, in con- ^^ sequence of a fall from a hay- Disiocation of the finger. loft, in which he struck the end of the finger violently against the ground. The distal phalanx lay upon-the posterior surface of the middle one, a large wound existing in front. The reduction was easily effected, and the parts being well approximated by suture and collodion-plaster, I indulged the hope of a good cure. Presently, however, severe inflammation set in, terminating in necrosis of the two bones, and I was obliged to amputate the finger just behind the joint. Dislocation of the metacarpo-phalangeal joints is also very uncommon, although not so much so as of the joints of the fingers. The phalanx is usually displaced backwards, its extremity resting upon the posterior surface of the metacarpal bone. Of the luxation forwards I have seen but one case, and that was of many years' standing; the finger was considerably shortened, and stood out in an extended position, flexion being impracticable. Dislocation backwards is caused by a severe blow upon the back of the hand, or the extremity of the finger, while it is immoderately bent. The case is recognized by the existence of a hard tumor in the natural site of the knuckle of the hand, fig. 47, and by the shortened and flexed condition of the finger, the extension of which is impracticable. Fig. 47. Mode of reducing a dislocated finger. The reduction is generally not difficult. To effect it, extension is made upon the finger by means of a suitable lac, fastened with the sailor's noose, DISLOCATIONS OF THE FINGERS. 133 and counter-extension upon the hand, while firm and steady pressure is made by the surgeon upon the head of the displaced bone. Dr. Richard J. Levis, of this city, a few years ago devised an apparatus for reducing dislocations of the fingers and thumb, which may be used with admirable effect, as it is a powerful means, not only for securing a firm hold, but for controlling the movements of the fingers during the necessary mani- pulations. The adjoining cuts, figs. 48 and 49, will convey a much better idea, Fig. 48. Fig. 49. Dr. Levis's apparatus for reducing dislocations of the thumb and fingers. both of the nature of the contrivance and of its mode of application and action, than any description, however elaborate. It will be perceived, at a glance, that the piece of wood, which is about ten inches in length by a little over one inch in width, affords the surgeon, by its long leverage, an oppor- tunity of extending the luxated phalanx with great power, and of rotating it at the same time upon its axis, thus facilitating its disengagement from the rounded surface of the opposing bone. When properly applied, the appa- ratus is perfectly unyielding, and is in every respect preferable to the clove- hitch. In its construction, it is necessary to see that the tapes are strong and broad, otherwise they will be apt to break and cause severe contusion of the integuments. Each should be about two feet long. The apparatus of Dr. Levis is similar to the spatha described by Celsus for reducing dislocations of the shoulder-joint, and which was so much em- ployed by the earlier practitioners. Excepting by the bursting of a gun, or other severe violence, dislocation of the carpo-metacarpal joints must be regarded as an impossible occuiTence, owing to the intimate manner in which the four last bones of the metacarpus are connected with each other and with the bones of the second row of the carpus. Under such circumstances the injury is generally so great as to render it necessary to resort to amputation, or resection, the latter operation always taking the place of the former when it is in our power to save any portion of the hand likely to be of service to the patient. Conservative surgery may do much in these cases to prevent mutilation by a careful use of the knife and pliers immediately after the occurrence of the accident, when the parts are tolerant of manipulation, and admit of being put in proper form for speedy reunion. A man who cuts off a whole hand, when the removal of a portion will answer the purpose, has no just conceptions of the duty he owes to science and humanity. 134 DISEASES AND INJURIES OF THE JOINTS. DISLOCATION OF THE CARPAL BONES. From the firm connections and limited motions which characterize the carpal joints, it is evident that any displacement of them must be of very uncommon occurrence. Indeed, it was formerly asserted that such an acci- dent was altogether impossible; a statement which has been contradicted by modern experience, which has not only established the fact, but elucidated the pathology and treatment of the lesion. All the carpal bones, however, are not equally liable to luxation ; on the contrary, there are only three which appear to be susceptible of it—the magnum, the cuneiform, and pisiform —and then only when there has been considerable relaxation of the liga- ments, weakening their connections, and predisposing them to displacement under the application of comparatively slight force. Of the three bones above mentioned, the magnum is the most liable to dislocation ; women are supposed to be more subject to it than men, owing to the greater mobility of the carpal joints, and the weaker state of the liga- ments. The accident is caused by forced flexion of the wrist, from falls upon the back of the hand, wrenching the bone from its connections with the head of the corresponding metacarpal bone, and pushing it out behind^where it forms a hard, well-defined tumor, which increases when the wrist is bent, and diminishes when it is extended. The displacement is always incomplete, and is apt to be followed by severe tumefaction, which often temporarily obscures the diagnosis. The reduction is effected by firm pressure upon the bone made from behind forwards, or in a direction contrary to that of the displacement, the hand being at the time in an extended state, in order to insure greater relaxation of the soft parts, and increase the opening from which the bone has been ejected. The operation must be conducted with great gentleness, and the surgeon must not be disappointed if he does not succeed in his first attempt. In case there is much inflammation, leeches and fomentations will probably be required. To maintain the reduction the hand must be placed in a straight position, upon two binder's board splints, well padded, aud long enough to extend from the middle of the forearm to the ends of the fingers. If the tendency to displacement is very strong, as it usually is, it may be necessary to place a compress directly upon the luxated bone, with a view to a more direct concentration of the pressure. The apparatus must be worn for a long time, as the ligaments are very slow in reuniting, but care should be taken, after the first fortnight, to take it off occasionally for the purpose of moving the wrist-joint, to prevent anchylosis. Of dislocation of the cuneiform bone there is hardly a well authenticated case upon record; the accident can occur only when great force is applied, and must be treated upon the same general principles as the preceding. The pisiform bone has been found luxated in several cases in consequence of the action of the flexor muscle of the carpus, its connections having been previously weakened by disease of its ligaments. The occurrence is attended with some annoyan.ce, and is difficult to remedy. When the case is of suffi- cient importance to claim attention, the best plan is to place the hand in a slightly flexed position, in a tin case, extending from the middle of the fore- arm to the metacarpo-phalangeal joints, the carpal piece being so arranged as to form an obtuse angle with the other. A compress is applied to the lower and inner part of the wrist, in the situation of the displacement, and confined by adhesive strips aud a bandage. DISLOCATIONS OF THE WRIST. 135 DISLOCATIONS OF THE WRIST. The possibility of dislocation of the wrist-joint, as an independent traumatic lesion, has been alternately admitted and denied by practitioners, from an early period of the profession down to the present moment. Dupuytren, after much patient attention to the subject, and the dissection of a number of cases simulating this accident, positively asserts that he never saw an instance of it, except as a result of organic disease of the articulation. He felt persuaded that the pretended cases which had been reported by various writers were nothing but cases of fracture of the inferior extremity of the radius, an accident which, as every one now knows, is of very frequent occur- rence, and is generally attended with symptoms which closely simulate those of luxation of the wrist-joint. Observations, however, made since the time of the celebrated French surgeon, both in Europe and this country, indis- putably prove that, although the lesion is exceedingly uncommon, its occur- rence is not only possible, but that it has been repeatedly made the subject of the most satisfactory clinical study. The reason of the great infrequency of this accident is altogether of an anatomical character. From the manner in which the lower extremity of the radius is connected with the scaphoid, semilunar, and cuneiform bones, it is evident that any severe force applied to the hand, as in falls upon the palm or dorsum, must be promptly transmitted through the carpus to the radius rather than to the ulna, which can hardly be said to enter into the composi- tion of the joint at all, except in so far as it affords some degree of lateral support. The consequence is that the spongy and delicate structure of the radius, receiving the brunt of the injury, usually gives way, either at the arti- culation or in the lower sixth of its extent, instead of allowing itself to be dislocated, fracture of the brittle osseous matter being in general much easier than the laceration of a number of strong ligaments, such as are found to tie the contiguous surfaces together. The carpal bones may be displaced from the radius and ulna backwards and forwards; lateral luxation cannot occur without fracture of one of the styloid processes, and then only in an incomplete manner. In the luxation backwards, fig. 50, the carpal bones are driven up behind the ends of the two bones of the forearm, which lie Fig. 50. in front of the muscles of the thenar and hypothenar eminences; theconsequence is, that there is great de- formity of the wrist-joint, its antero-posterior diame- ter being much increased, although its breadth is nearly natural. The fore- arm is somewhat shorten- ed, the hand and fingers are forcibly flexed, and the ulna is thrown consider- ably forwards and inwards beyond the line of the car- pus. The radius and ulna retain their normal length, and the prominence on the back of the joint is characteristically hard, convex, and transversely elongated. In the dislocation forwards, fig. 51, the symptoms just described are Backward dislocation of the carpus. 136 DISEASES AND INJURIES OF THE JOINTS. reversed, the carpal bones lying in front, and the end of the radius and ulna behind. The hand and fingers are powerfully extended, the distance between the elbow and wrist is sensibly di- Fig. 51. minished, although the two bones retain their proper length, and the styloid processes can be distinctly felt behind at the lateral aspect of the hand, with the articular groove which naturally separates them, and which is now occupied by the tightly stretched extensor tendons. These two dislocations are liable to be mistaken for fracture of the lower extremity of the radius and ulna, although such an accident could hardly happen in the hands of a scientific surgeon, perfectly vigilant, and bent upon the dis- Forward dislocation of the carpus. charge of his duties. The principal points of distinction are, that, in luxation, there is much more of a tumor than in fracture, that the tendons of the hand and fingers are more evidently affected, being either violently ex- tended or flexed, that the radius and ulna retain their normal length, and that the bones are, as it were, firmly interlocked with each other. In fracture of the radius, or of the radius and ulna, on the contrary, the deformity is less marked in the antero-posterior diameter, the two bones, if both are broken, are sensibly shortened, there is much more mobility, and, upon bringing the fragments in contact with each other, and then grasping the lower part of the forearm with one hand, while the patient's hand is moved with the other, crepitation can readily be elicited. Moreover, in luxation the styloid process of the ulna generally lies upon a plane somewhat anterior to that of the radius, whereas in fracture it is behind that bone. The reduction of these two dislocations is sufficiently easy. All that is required, in order to accomplish it, is to extend the hand and counter-extend the forearm, just above its middle, while pressure is applied by means of the thumbs upon the displaced carpal bones in a direction opposite to that of the luxation. The limb, enveloped in a roller, is supported upon a light splint, stretched along its palmar aspect, and kept constantly wet with some evapo- rating lotion. In due time passive motion is instituted, to prevent anchylosis, which is so liable to occur after all injuries of this and other joints. Congenital dislocations are occasionally met with at the wrist, and have of late years attracted much attention, chiefly through the labors of Dupuytren, Cruveilbier, Guerin, and R. W. Smith. The carpal bones may be thrown forwards or backwards, forming, in either case, a well-marked, characteristic, angular prominence. The lesion is attended with atrophy of the bones, liga- ments, and muscles; the hand is generally useless, and the fingers are variously deformed, being usually wasted and crooked. I have lately seen a well-marked case of lateral displacement of the wrist in a puny female infant, three weeks old, the hand presenting towards the radius. Treatment is seldom of any avail. DISLOCATIONS OF THE RADIO-ULNAR JOINTS. 1. The inferior radio-ulnar joint is liable to displacement in two directions, the ulna being thrown backwards in the one case, and forwards in the other, beyond the line of the radius. The slightest anatomical inspection will serve DISLOCATIONS OF THE RADIO-ULNAR JOINTS. 137 to show, what experience has proved to be true, that the former luxation must be the more frequent of the two, though both are sufficiently rare as an uncomplicated lesion. As an accompaniment of fracture of the lower extre- mity of the radius, it is by no means uncommon; generally, however, only in a partial manner. The dislocation backwards is usually the result of violence applied to the hand or forearm, during strong pronation, any sudden twist or wrench of the joint predisposing to its occurrence. The signs are characteristic. The hand is in a fixed state of pronation, and inclined a little towards its inner margin ; the head of the ulna, directed obliquely across the radius, forms a distinct prominence above the level of the cuneiform bone; the fingers are slightly bent; the styloid process has lost its parallelism with the fifth metacarpal bone; and the inferior extremity of the forearm has an appearance of being unnaturally narrow, though, if some time have elapsed since the accident, this will probably be masked by the swelling. The reduction is effected by flexing the forearm at a right angle with the elbow, and then gradually but determinedly extending the hand, and rotating it outwards until it is brought into the supine position, when the bone will usually resume its natural relations. ' The lower extremity of the ulna may be displaced forwards by a fall upon the wrist, by a violent wrench of the hand while in a state of supination, or by injury applied directly to the forearm. The accident is one of uncommon occurrence. The symptoms are the reverse of those in the preceding disloca- tion ; that is, the ulna, lying across the anterior part of the radius, forms a remarkable projection just above the carpus, while the forearm and fingers, slightly bent, are powerfully supinated, and cannot be brought out of this position without restoring the joint to its normal condition. The reduction is effected in the same manner as in the luxation backwards, the limb, as the bone yields, being gradually but forcibly pronated. It will be necessary after both these luxations, as the ligaments will be a long time in reuniting, to keep the limb well bandaged, and supported by means of a padded splint, extending from near the elbow to the ends of the fingers. A firm compress is to be placed over the inner and fore part of the joint the more thoroughly to protect it against a recurrence of the ac- cident. 2. Dislocation of the superior radio-idnar joint may occur in three different directions, the head of the radius being thrown from the sigmoid cavity of the ulna forwards, backwards, and outwards, the frequency of the accident being in the order here stated, although some authorities contend that the displace- ment backwards is the most common. This I have not found to be the case in my own practice. The chief causes of dislocation forwards, fig. 52, are falls upon the palm Fig. 52. Dislocation of the head of the radius forward. of the hand, in which, the forearm being powerfully supinated, the head of the radius receives the whole force of the blow, and is thrown against the 138 DISEASES AND INJURIES OF THE JOINTS. coronoid process of the ulna and the external condyle. The accident, which is most common in young subjects, may also be produced by direct injury to the upper extremity of the bone, acting from behind forwards. The signs of this accident are quite characteristic. There is an obvious vacuity at the upper and outer part of the limb, and the head of the radius can be distinctly felt in its new situation, in front of the elbow, rolling about under the finger, upon rotating the lower extremity of the bone. The fore- arm, slightly flexed, is in a state midway between pronation and supina- tion, and every attempt to bring it in a straight line or to a right angle with the elbow is unsuccessful. When an effort is made to bend the limb suddenly, the head of the radius will be found to strike against the lower and fore part of the humerus and to refuse to advance; a circumstance which is character- istic of the nature of the accident. This dislocation is usually described as being accompanied by forced supination of the hand, but, in general, though not always, the position is as here stated. The reduction is accomplished by applying extension to the hand and counter-extension to the middle of the arm, while the forearm, being semi- flexed, in order to relax the two-headed flexor muscle, is forcibly supinated, at the same time that the surgeon pushes the head of the radius downwards and backwards, in the direction of its natural position. The most common cause of luxation backwards, fig. 53, is violence applied to the-hand when the fore- Fig. 53. arm is in a state of prona-, tion, and carried beyond the natural line of the body. In children the accident is liable to be produced by a sudden jerk of the arm, when in an over-stretched state of pronation, by the nurse in her attempts to prevent falls, the small size Dislocation of the head of the radius backward. of the sigmoid Cavity of the ulna at this period of life, and a relaxed condition of the ligaments of the joint, favoring the result. The peculiar attitude of the limb in this luxation is almost characteristic of the nature of the injury. The forearm is semi-flexed, and, together with the hand, in a fixed state of pronation ; the fingers are also somewhat bent, and there is an evident void at the upper and outer part of the forearm, just below the elbow, while a short distance beyond this, over the external con- dyle, by the side of the olecranon process, the prominence formed by the head of the displaced radius is distinctly perceptible, feeling hard and firm, and but faintly responding to any motions that may be impressed upon the lower extremity of the bone. Any attempt, short of what is requisite to effect the reduction, to supinate the limb, to bring it in a straight line, or to flex it at a right angle with the arm, is quite abortive, owing to the manner in which the radius hitches against the humerus. Reduction is effected by making extension upon the hand and counter- extension upon the lower part of the arm in the line of the displacement, while the surgeon presses the head of the radius from behind forwards, to- wards the lesser tubercle of the humerus, at the same time that the hand and forearm are gradually but forcibly supinated. When the patient has not been relaxed by chloroform, the return of the bone is always indicated by a dis- tinct snap. Dislocation of the radius outwards is not as common an accident as either of the preceding varieties of displacement. It occasionally exists, in an in- DISLOCATIONS OF THE ELBOW. 139 complete form, as a result chiefly of a relaxed condition of the annular liga- ment, in persons of a feeble and relaxed habit of body. Complete luxation outwards can happen only when there is a rupture of the upper extremity'of the interosseous ligament, and hence the lesion is apt to be complicated with fracture of the humerus, or ulna, and severe injury of the soft parts. A fall upon the palm of the hand, propelling the radius upwards and outwards, with the whole force of the leverage of this bone, is the most common cause of the accident. The symptoms are the following. The head of the radius, resting upon the epicondyle of the humerus, forms a distinct prominence at the outer part of the elbow, easily recognized by the finger; the bone is situated higher up than natural, the distance between it and the olecranon being materially in- creased ; the forearm is in a state midway between pronation and supination, the latter of which is impossible; and the movements of flexion and extension are of course much impeded. Besides these signs, there is always a cord-like prominence along the front of the radius, as well as on the inside of the dis- placed head, formed by the tension of the external radial aud long supinator muscles, which is gradually lost upon the outer and anterior surface of the limb. The reduction is effected by pushing the radius downwards and for- wards, the forearm being bent at a right angle, and extension and counter- extension made in the usual manner. The reduction of all these dislocations is generally sufficiently easy, but they are extremely apt to recur from the slightest causes, and it, therefore, becomes an object of great consequence, in the after-treatment, to guard against the accident by the use of the compress and bandage, aided by a suitable apparatus, to insure perfect quietude, until the ligamentous struc- tures have had an opportunity of reuniting. Meanwhile, passive motion must be attended to, lest anchylosis ensue. The superior radio-ulnar joint is liable to a species of subluxation, similar to what occurs in the temporo-maxillary articulation. I have seen several well-marked cases of it, in one of which it existed simultaneously on both sides; and in all it was manifestly dependent upon a relaxed condition of the annular ligament, allowing the head of the radius to move away to some dis- tance from the sigmoid cavity of the ulna. The subjects of this displacement are, for the most part, thin, weakly children of a strumous habit of body, and my experience teaches me that females are more frequently affected than males. The movements of the joint are not materially impaired by the oc- currence, unless it persists and gets worse, when the whole limb may become enfeebled in consequence. The cold douche, painting with tincture of iodine, and the application of a series of small blisters, with tonics to improve the general health, are the best remedies. DISLOCATIONS OF THE ELBOW. The dislocations of the elbow-joint form a subject of the deepest possible interest to the surgeon, not only on account of the frequency of their occur- rence, but because of their great liability to serious complications and the consequent difficulty of their diagnosis and treatment. I am satisfied, from no little observation, that there are no luxations in the whole body which are so little understood, or so unscientifically managed, as those now under consideration. The principal reason of this is the want of correct know- ledge of the structure of the elbow-joint, and of the complex arrangement of its osseous elements, with which few practitioners take the trouble to make themselves acquainted. The result is that cases of dislocation constantly occur, which are mistaken for fracture, and which, in consequence, are en- tirely neglected until it is too late to remedy them by means which, if time- 140 DISEASES AND INJURIES OF THE JOINTS. ously employed, would nearly always be sufficient to insure the reduction of the displaced bones, and the restoration of the bruised and lacerated struc- tures, with complete recovery of the functions of the articulation. I make these remarks because it has been my lot to see an unusually large number of badly-treated cases of dislocation of the elbow-joint, in almost every stage after their occurrence, from the first few hours to several months, when, in general, all hopes of benefiting the patient must be abandoned. The most common dislocation of the elbow is that in which both bones of the forearm are thrown upwards and backwards, in contact with the posterior surface of the humerus. Displacement forwards is exceedingly uncommon, and can take place only, as a general rule, when the accident is complicated with fracture of the olecranon process, whereby the ulna, is permitted to glide in front of the joint, which it must have great difficulty in doing when its superior extremity remains intact. Lateral luxation of both bones of the forearm from the condyles of the humerus is also very infrequent, and is necessarily incomplete, owing to the great extent of the articular surfaces in this direction, and the number, size, and strength of the muscles and liga- ments surrounding the joint. Of the displacements of the superior radio- ulnar articulation, I have already given an account, and need, therefore, not repeat here anything that was then said. The ulna alone is sometimes lux- ated upwards, the olecranon forsaking the sigmoid fossa of the humerus, and placing itself in contact with the posterior surface of the bone. 1. Dislocation of the Fig. 54. bones of the forearm backwards, fig. 54, or, more correctly speaking, backwards and upwards, usually occurs from falls in which the person, in- stinctively stretching out the arm to protect the body, receives the whole shock upon the palm of the hand. The two bones being thus impelled by the surface struck by the hand, and the humerus by the weight of the body coming in the opposite direction, the two forces explode at the elbow- joint, rupturing the liga- ments, and driving the olecranon and head of the radius backwards and upwards. There can be no doubt that a contorted state of the forearm at the moment of the acci- dent greatly promotes the luxation by increasing the strain. The signs of this dislo- cation are sufficiently ob- vious, presenting little variation in their charac- Fig. 55. Dislocation of the ulna and radius backward. DISLOCATIONS OF THE ELBOW. 141 ter, unless it is conjoined with other injury. The limb is in a semi-flexed state, and there is great deformity of the elbow, as seen in fig. 55. At the posterior part of the joint is the unnatural projection formed Fig. 56. by the olecranon, and, in front, the still more conspicuous one formed by the condyles of the humerus, fig. 54 and fig. 56, both usually perceptible by sight and touch, especially in lean subjects, and before the supervention of swelling. The forearm has generally a slightly twisted appearance, and OCCU- Dislocation of the bones backward, showing the manner pies a position midway between in which the muscles are put on the stretch. pronation and supination, in- clining, however, more to the latter than the former; any attempt to flex or extend it is not only very painful, but in great measure impracticable. The fingers are somewhat bent, and the distance between the elbow and wrist is sensibly diminished, generally from an inch to an inch and a half, but only in front, for behind the limb retains its normal length. The muscles in front of the joint, especially the flexor and brachial, are stretched like tense cords over the condyles of the humerus, while the tendon of the three-headed extensor is carried away from the bone behind, and stands out in bold relief, forming one of the most conspicuous signs of 4he accident. Although generally the forearm is semi-flexed, and nearly immovable, yet occasionally it is almost straight, and can be readily bent and extended, though not without great pain. Notwithstanding that the signs of this dislocation are usually character- istic, cases, nevertheless, occasionally occur where the diagnosis is painfully obscured. Two circumstances principally contribute to render it so. One is the inordinate swelling which so generally follows the accident, and which often exists in a high degree before the surgeon has an opportunity of exa- mining the parts; and the other, the existence of fracture of the bones com- posing the joint. When the humerus is broken off just above the condyles, the deformity will closely simulate that produced by dislocation backwards, the lower fragment, with the radius and ulna, being drawn in that direction, so as to give the back of the elbow a very prominent and distorted appearance, while the upper fragment will present itself quite conspicuously in front, under the flexor muscles. The points of distinction are that, in dislocation, the parts are fixed, and cannot be restored without a good deal of force, whereas, in fracture, they are easily moved and replaced, returning, however, to their unnatural situation the moment the efforts are discontinued. In dislocation, moreover, there is actual shortening of the anterior part of the forearm, but none in fracture; nor is there, in the former, any crepitation, which is so conspicuous in the latter. Fracture of the olecranon can always be distin- guished by the elevation of the upper fragment, and the wide gap which separates it from the lower, and by the facility with which the surgeon can flex and extend the forearm. In fracture of the head of the radius, there is no deformity of the posterior part of the elbow, and by grasping the bone with the thumb and finger above, as it is being rotated below, crepitation can be easily elicited, thus at once clearing up the diagnosis. The reduction of this dislocation is extremely easy, if attended to imme- diately after its occurrence, but very difficult if it be neglected even for a short time. Upon this subject, there is no difference of sentiment among practitioners, writers, and teachers. My experience in regard to it is ample, 142 DISEASES AND INJURIES OF THE JOINTS. and in perfect accordance with that of the profession generally. I have no recollection of ever being foiled in my efforts in a solitary instance of recent dislocation of the elbow-joint, while I can recall to mind a large number of cases where everything that could be done proved unavailing after the third week, and sometimes even by the end of the^econd. I am not prepared to assign any reason for this ; to say why a displacement, that is always so easily rectified, if properly managed, in its earlier stages, should so soon become utterly irreducible, resisting and defying all the best directed efforts of the surgeon. We can hardly suppose that it is owing exclusively to inflamma- tory adhesions, for it is difficult to conceive that they could become either so extensive or so firm, in so short a time, as to produce such a result; what- ever, however, the true explanation may be, the fact remains, and this is all that is really necessary for us to know. The practical rule, then, to be deduced from this experience is that all dislocations of the elbow backwards should receive the earliest possible attention, their reducibility being in an inverse ratio to their duration. But, although it is undoubtedly true that it is always extremely difficult, if not impracticable, to reduce a dislocated elbow at the end even of two or three weeks, yet I would by no means wish to be understood as opposing an attempt to accomplish this object when the case is of five, six, or even eight weeks' standing; inasmuch as there are upon record quite a number of examples illustrative of the propriety of this advice. I have myself met with at least two instances in which my efforts were rewarded, if not with com- plete, certainly with very encouraging, results, at the end of nearly two months. * ' The reduction of this dislocation may be effected by various methods. The one which I have usually found most efficient, and which, I believe, has not been practised by any one else, is to place the heel in the bend of the arm, the patient lying down, and the surgeon carrying his leg across the chest, while extension is made by pulling the hand and wrist. This procedure affords the operator an opportunity of exerting his strength to great advan- tage, and I have not seen a case of recent dislocation that could resist his efforts beyond a few minutes. As the bones yield the forearm is bent towards the chest over the fulcrum, furnished by the foot, a step which materially promotes the reduction. The force of the extension may be greatly increased by securing a stout lac round the limb, just above the wrist, and throwing the noose over the neck and shoulder. Counter-pressure may also be ad- vantageously made by an assistant placing his hands against the shoulder of the affected side. The patient should, of course, be under the influence of chloroform. Another method, which is also very advantageous, is to make a fulcrum of the knee in the bend of the arm, as seen in fig. 57, the patient being seated upon a chair, and the surgeon standing by his side in front, with his foot resting upon a high stool or upon another chair. The extension being con- ducted as in the previous case, the forearm is gradually brought over the knee so as to disengage more effectually the ulna and radius from the lower extremity of the humerus. This manoeuvre is usually very promptly suc- cessful. A third method of reduction, based upon the same principles as the pre- ceding, is to bend the limb forcibly round a bedpost, which is thus made to act as a fulcrum, while the requisite extension is made by pulling the hand and wrist. This plan, however, although efficient enough, has the disadvan- tage of being both awkward and painful. Finally, the reduction may often be readily effected by seating the patient upon a chair, and requesting two assistants to make extension aud counter- DISLOCATIONS OF THE ELBOW. 143 Fig. 57. extension, one grasping the wrist, the other the middle of the arm. The surgeon, standing behind the affected limb, then places' his thumbs firmly upon the olecranon, and thus aids in pushing this process downwards and for- wards into its natural position. When any great difficulty is expected, as when the patient is very muscular, or the joint has been luxated for some days, or several weeks, the best method, after the ordinary procedures have failed, is to use the pulleys hooked to the noose round the lower extremity of the fore- arm, and to a staple in the wall, floor, or bed. The counter-extending band is secured round the middle of the arm, and is either confided to two stout assistants, or fastened to some firm object behind the patient's head and shoulder. The patient should, of course, be recumbent, and fully anesthetized. After the ex- tending forces have been maintained for some time, the return of the bones will be promoted by steady pressure upon the olecranon. When these means fail, as they will be extremely apt to do if the case is of longer standing than three weeks, it has been proposed to insert a narrow bistoury into the joint, so as to divide the resisting structures, but the operation, besides being dangerous, on account of the proximity of the brachial artery and the several nerves of the limb, has not realized the expectations that had been formed of it by its advocates. Reduction being effected, the limb, carefully bandaged, must be supported in a light tin case, and kept constantly wet with evaporating lotions. If the inflammation run high, as it generally does after such an injury, leeches and even venesection may become necessary. In every case, however simple, the greatest vigilance must be employed to prevent anchylosis. Passive motion must, of course, receive early attention. In decidedly chronic cases of this accident, but where there is still a good deal of motion, the patient may often obtain a very fair use of the joint by breaking the olecranon process by forcible flexion of the limb. I have pur- sued this plan with excellent results in several instances, and equally en- couraging effects have attended it in the hands of Crosby, Mussey, and other surgeons. 2. Dislocation of the bones of the forearm forwards is an extremely rare event, which was formerly supposed to be altogether impossible without pre- vious fracture of the olecranon, or extensive laceration of the soft parts. Modern observation, however, has shown the fallacy of this opinion, by ad- ducing several unequivocal cases in which the displacement existed as a pure, uncomplicated affection. The manner in which the occurrence may happen is not well understood; but from some experiments performed upon the dead subject it would seem that if, while the forearm is powerfully flexed upon the arm, severe violence be applied directly to the olecranon and head of the radius, the articular surfaces of these bones may be thrown forwards from the condyles of the humerus with much greater facility than would at first sight Reduction with the knee in the bend of the elbow. 144 DISEASES AND INJURIES OF THE JOINTS. appear possible. But, whatever explanation may be offered, the fact is that the accident must necessarily be attended with extensive rupture of the liga- ments, and generally also with pretty severe contusion of the soft parts. A majority of the published cases of this accident have been observed in subjetts under fifteen years of age, in consequence of falls upon the posterior part of the elbow. The signs of the dislocation are sufficiently characteristic. When the ulna and radius are thrown completely forwards, in front of the condyles of the humerus, the forearm will necessarily be considerably shortened, whereas, when they retain their relation with the condyles, it will be elongated to the full extent of the length of the olecranon. The forearm, moreover, is slightly flexed, but by a little effort it may readily be extended, or even bent some- what backwards. The integuments and muscles in front of the joint are in a state of tension; the end of the humerus can easily be felt posteriorly, where it forms a large prominence, and there is a well-marked depression, a kind of vertical gutter, in the natural situation of the olecranon, bounded on each side by the margins of the trochlea. Two methods of reduction may be employed for this dislocation; one con- sists in flexing the forearm at a right angle with the elbow, and making ex- tension by pulling the hand and wrist, while the heel is applied as a fulcrum to the lower third of the arm, the patient being under the influence of chlo- roform. Or, instead of this, the extending and counter-extending forces may be applied to the hand and shoulder, the limb being in a straight position, and pressure made upon the ulna and radius by means of the thumbs. During the after-treatment, leeches and fomentations will probably be required, ana the limb must be supported in splints or a tin case until the parts have reunited. Passive motion must be commenced at an early period. 3. Lateral dislocation of the elbow joint, besides being extremely rare, can scarcely occur in any other than an incomplete form, and as a consequence of severe injury extensively implicating the soft parts. The most common cause of the accident is a fall upon Fig. 58. Fig. 59. the wrist or hand when the forearm is in a flexed and contorted state; and the displacement will be so much the more likely to happen if, the moment the extremity strikes the surface, the arm is forcibly im- pelled sidewardly. It may also be produced by violence acting directly upon the forearm and arm in oppo- site directions, as when the former is driven inwards and the latter out- wards. In a case mentioned by J. L. Petit the accident was occasioned by the limb becoming entangled in the spokes of a wheel. The dis- placement may be inwards or out- wards, and is often associated with partial dislocation backwards. In the dislocation inwards, fig. 58, there is great deformity at the ulnar side of the elbow, formed by the ole- cranon and head of the radius, the latter hitching against the inner Lateral dislocation condyle, while the outer condyle outward. presents an unusual prominence im- Lateral dislocation inward. DISLOCATIONS OF THE ELBOW. 145 mediately beneath the integuments at the external aspect of the joint; the forearm is partially bent, and somewhat supinated ; and the muscles of the arm, both in front and behind, are dragged inwards by the displaced bones. In the luxation outwards, fig. 59, the ulna rests upon the external condyle, while the inner condyle forms a sharp prominence on the inside of the elbow ; the forearm is slightly bent and rigidly pronated ; the motions of flexion and extension are much impeded; and.the flexor and extensor muscles are in a painful state of tension. Both in this and in the inward displacement there is a remarkable increase in the breadth of the articulation, along with consider- able flattening of its anterior surface, and a twisted condition of the forearm. These luxations are easily reduced by extension and counter-extension, performed in the usual manner, and by coaptation by pressing the bones in a direction opposite to that of their displacement. In general, the object may easily be attained by simply bending the elbow over the knee, as in the dislocation backwards. The after treatment requires great care, both to pre- vent re-displacement and anchylosis. The only instance of complete lateral dislocation of the elbow with which I am acquainted is one which occurred in the practice of Nelaton, and of which he has given an account, accompanied with a drawing, in his treatise on surgery. It was observed in a man, aged sixty, who was admitted for another disease, the accident having taken place twenty years previously, in consequence of a fall from a height of thirty feet. The elbow was much de- formed and anchylosed. 4. Dislocation of the ulna alone directly backwards is an uncommon acci- dent, and can scarcely be complete without fracture of the coronoid process. The signs are usually characteristic. The forearm and hand are slightly flexed, and inclined inwards as if th#y were twisted on their axis ; the ole- cranon forms a prominent projection at the back part of the joint, as in fig. 60; and the head of the radius, though usually somewhat displaced, may be Fig. 60. Dislocation of the ulna backward. distinctly felt in its natural situation during the movements of flexion and extension, both of which, but particularly the latter, are very much restricted and painful. The accident generally arises from severe falls upon the inner and upper part of the hand, suddenly and forcibly impelling the ulna upwards and backwards, away from the head of the radius; the coronoid process lodging in the sigmoid cavity of the humerus. Its most prominent features are the contorted state of the limb and the remarkable projection of the ole- cranon, which will always serve to distinguish it from other lesions. When the coronoid process is broken off, the posterior deformity will be unusually great, and, although it may be effaced by extension, yet the moment the arm is left to itself it returns. The reduction may generally be easily effected by bending the arm over the knee, and extending the hand and wrist. Coaptation may be aided, if necessary, by pressure upon the olecranon with the thumbs. When the ac- cident is attended with fracture of the coronoid process, special retentive VOL. n.—10 146 DISEASES AND INJURIES OF THE-JOINTS. means will be necessary, of which the best is a rectangular tin case, the limb being properly bandaged, and a compress firmly bound over the olecranon. 5. Finally, the bones of the forearm are occasionally dislocated simulta- neously in opposite directions, the ulna being thrown backwards behind the humerus, and the radius forwards upon a plane with the external condyle. The occurrence is uncommon, not more than five or six cases having yet been reported, and of these none have occurred*in my own practice. It is produced by falls from a considerable height upon the hand, impelling the two bones with great violence at a moment when the forearm is considerably flexed and forcibly twisted upon its axis. It is readily recognized by the singular form of the elbow, which is sensibly shortened transversely, but much increased in its antero-posterior diameter; by the great prominence at the back of the limb, formed by the olecranon process ; and by the remarkable inward con- tortion of the forearm and hand, which are both slightly bent. On attempt- ing to flex the limb, the head of the radius is found to hitch against the humerus, and to offer an insurmountable barrier to further progress. The reduction of the ulna is readily effected by placing the knee in the bend of the arm, and then pulling the hand and wrist; but that of the radius is more difficult, and will require, in addition, pressure upon the dislocated head out- wards and backwards. Compound dislocations of the elbow constitute a serious class of lesions, liable to be followed by the worst results, both immediate and consecutive. Such is the extent of the articulating surfaces that any considerable exposure by wound is extremely apt to cause ulceration of the cartilages and caries or necrosis of the bones, requiring their eventual removal, or, what is worse, the sacrifice of the limb. The danger is materially increased when there is fracture with displacement, the end of one of tht bones perhaps protruding in the form of a sharp spiculnm at the wound. Such cases will seldom progress favor- ably if an attempt be made to replace and save the parts in the usual manner. The patient, if young and vigorous, may, it is true, occasionally weather the storm, but the chances are that the limb will, by and by, have to come off, or that life will be brought in imminent danger by the protracted suppuration, ulceration, and hectic irritation. When, therefore, the symptoms are at all unpromising—the joint being extensively opened, the muscles torn, and the bones seriously involved—the best plan, as a general rule, will be to amputate on the spot, that is, the moment reaction has occurred; or, under more favor- able, but still trying circumstances, to excise the ends of the injured bones, placing them in such a position as to insure their speedy reunion, and, at the same time, in as good a one as possible for the future usefulness of the limb. The elbow is sometimes dislocated as a congenital defect; the accident presenting itself, however, only in a partial form. Most generally the dis- placement is limited to the head of the radius, which, forsaking the sigmoid cavity of the ulna, applies itself against the outer condyle. The movements of the elbow and forearm are restricted, but not annihilated; and, as the head of the luxated bone always becomes remarkably elongated as the patient advances in years, reduction is only practicable in infancy and early childhood. DISLOCATIONS OF THE SHOULDER. Dislocations of the shoulder-joint are of common occurrence, and, there- fore, deserving of great attention. As has been stated elsewhere, they are more frequent than all the other dislocations together, a circumstance which is easily accounted for by the shallow condition of the glenoid cavity of the scapula, and the extraordinary latitude of motion peculiar to this articula- tion. Moreover, there is in many persons, females and children especially, a remarkable tendency to relaxation of the ligaments and muscles of the DISLOCATIONS OF THE SHOULDER. 147 shoulder-joint, which thus powerfully predisposes to luxation, the slightest accident being, under such circumstances, often sufficient to produce it. Experience has shown that dislocations of the shoulder are not near so common in women as in men; simply, however, I imagine, for the reason that they are much less exposed than the other sex to the various exciting causes of these lesions. If there is any anatomical reason for the difference, it has not been pointed out. Age exerts a material influence upon the production of these luxations. The statistics of Malgaigne and others have proved that children under fif- teen years rarely suffer from them. My own practice has not afforded me a solitary example under the age of twelve. From fifteen to twenty-five, the accident is also comparatively rare, but from this period on it becomes more common, and from forty to sixty it reaches its maximum. After sixty, there is a marked decline in its frequency, and few cases are met with after seventy. The nomenclature of dislocations of the shoulder has been much encum- bered by the modern French surgeons with distinctions and refinements, which, so far from simplifying the subject, only serve, in my judgment, to embarrass it. It certainly does not facilitate the inquiries of the pupil to be told that there are ten or a dozen distinct forms of luxation, when all that is really useful and important may be comprised under less than half that number. Such minutiae never fail to retard the true interests of science, and disgust the student of surgery. There are, in truth, but three principal dislocations of the shoulder ; all the rest, concerning which so much has of late been said and written, being mere varieties, hardly entitled to separate considera- tion. These dislocations are the axillary, thoracic, and scapular. In the first, as the name implies, the head of the humerus is situated in the axilla, under the glenoid cavity; in the second, below the clavicle, on the anterior and lateral aspect of the chest; and in the third, on the scapula, beneath the spine of that bone. To these may be added, as varieties of the first two luxations, those cases in which the head of the bone has been found in the subscapular fossa, and upon the anterior part of the neck of the scapula, below the coracoid process. The nomenclature here suggested, besides in- dicating the situation of the luxated bone, is in strict conformity with that of the dislocations of the hip-joint. 1. The axillary dislocation, by far the most frequent of all, is usually oc- casioned by violence applied to the elbow or hand, the limb being elevated, and widely removed from the body. It may also be produced, when the arm is in this position, by a fall or blow upon the shoulder, acting directly upon the head of the humerus. I have seen three cases in which the accident was caused by the con- traction of the muscles, and several ex- amples of a similar kind have been com- municated to me by professional friends. In two of the cases here referred to, the luxation happened in an attack of epilepsy, and in the other in consequence simply of inadvertently raising the arm above the level of the head. However induced, the head of the humerus will, be found to be in the axilla, just beneath the glenoid cav- ity, lying upon the inferior border of the scapula, fig. 61, between the subscapular muscle and the long head of the triceps. The axillary vessels and nerves are some- Dislocation of the humerus into the aziiia. 148 DISEASES AND INJURIES OF THE JOINTS. what compressed, the capsular ligament is largely opened below, and the articular muscles are nearly always more or less lacerated, if not partially separated from their attachments. The symptoms are, inordinate prominence of the acromion, as exhibited in fig. 62, which is much more sharp and distinct than naturally, with a well- marked depression just Fig. 62. below this process; flat- tening of the shoulder, and unusual fulness of the axilla, caused by the presence of the displaced bone, which, on motion of the limb, can easily be felt rolling about be- tween the thumb and fingers, especially in lean subjects. The height of the axilla is at least an inch to an inch and a half greater than on the sound side. The elbow projects considerably from the side, in conse- quence of the tension of the deltoid muscle, the forearm is slightly bent, the arm is perceptibly lengthened, the fingers are numbed, from com- Dislocation of the humerus into the axilla. pi'ession of the axillary nerves, and the whole extremity, stiff and powerless, is generally somewhat supinated, although not necessarily so, for I have repeatedly seen it inclined in the opposite direction. Flexion of the forearm, also, is not an invariable occurrence; generally it is said to be so, but several cases have come under my observation where the patient was able to extend and bend it at pleasure. When the biceps and triceps are put considerably upon the stretch, as happens when the head of the bone is thrown unusually far inwards, the limb often presents a singularly twisted appearance. It seems hardly credible that an accident which is always so well marked as dislocation of the head of the humerus downwards into the axilla should ever be overlooked, or mistaken for any other lesion, and yet such is the fact, as daily experience abundantly attests. The most reliable diagnostic signs are the flattening of the deltoid muscle, the projection of the acromion pro- cess, the fulness and increased height of the axilla, and the separation of the elbow from the side of the body and the inability of the surgeon to approxi- mate it to the middle line without compelling the patient to depress the cor- responding shoulder. The latter symptom I regard as especially valuable, for I know no other lesion that simulates it. Another diagnostic sign, also, of great certainty, has recently been pointed out by Professor Dugas, of Augusta, Georgia. It consists in the fact that in dislocation of the scapulo- humeral articulation, in whatever form occurring, neither the patient nor the surgeon can place the fingers of the injured limb upon the sound shoulder, while the elbow touches the front of the chest. Various methods may be employed for effecting the reduction, but the one which I usually prefer is to place a fulcrum in the axilla, upon the head of DISLOCATIONS OF THE SHOULDER. 149 the luxated bone, while extension is made upon the forearm, just above the wrist. The best fulcrum for this purpose is the heel of the surgeon, divested Fig. 63. Reduction with the heel in the axilla. of its boot, he and the patient lying in opposite directions upon a bed or table; and the efficiency of the operation will be materially increased, if, after the extension has been maintained for a little while, the limb be gradually brought forwards over the body, so as to raise the bone upwards and out- wards to a level with the glenoid cavity. I sometimes find that I can reduce the dislocation more promptly and with less effort by sitting between the patient's limbs, with my own leg carried obliquely over the trunk, as this affords a much more powerful leverage than in the ordinary procedure. When unusual resistance is encountered, the extension should be aided by means of a stout fillet, secured round the forearm by the clove-hitch, and thrown across the surgeon's neck and shoulder. Finally, care should be taken not to raise the pa- Fig. 64. tient's head with a large pillow, nor yet to let it lie entirely flat, as both these positions would have a tendency to im- pede the reduction. Slight elevation only is desirable. Occasionally the reduction is readily accomplished-by making a fulcrum of the knee, as shown in fig. 64, the patient sit- ting up, and the surgeon supporting his foot upon the edge of his chair, or upon another chair standing close by. The operation is particularly applicable to dis- locations occurring in delicate females, and in old emaciated subjects. It is per- formed by inserting the knee as high as possible in the axilla, and then, the top of the shoulder being thoroughly steadied with the hand, carrying the elbow forcibly downwards and inwards towards the side of the body. This procedure is charac- terized by^reat simplicity, but wants the Eeduction with the knee in the axilla. efficiency of the preceding. Another method which may advantageously be employed is that devised by White, of Manchester, in the last century, and recently revived by Mai- 150 DISEASES AND INJURIES OF THE JOINTS. gaigne. The patient lying upon his back, the surgeon stands or sits behind him, as in fig. 65, and raising the limb perpendicularly along the side of the head, he firmly fixes the shoulder, with one hand upon the acromion, while with the other he makes the requisite extension by pulling the lower part of the arm. In this way the luxated head of the bone is drawn directly upwards into the glenoid cavity. Fig. 65. White's method of reduction. Mr. Kirby, of Dublin, was in the habit of reducing this luxation by a method somewhat more complicated than any of the preceding, but not less efficient. The patient being seated upon the floor, a stout fillet was secured round the lower part of the arm, and confided to an assistant, while another assistant, also seated upon the floor upou the opposite side, steadied the scapula by encircling the chest with his arms, his fingers being interlocked in the axilla. When the preliminaries were arranged, the assistants carried each one leg behind and the other in front of the patient, so as to rest the soles against each other. The limb being now elevated nearly to a right angle with the body, Fig. 66. the extension was made in a slow and gradual man- ner, while the head of the bone was urged upwards towards the glenoid cavity, the elbow being at the same time raised and brought towards the side. I have never had occa- sion to employ the pulleys in recent dislocations of the shoulder, and can hard- ly imagine that they could be necessary even in very stout, muscular subjects, as any surgeon may with a little patience and skill effect reduction, by the methods now pointed out with the aid of chloro- form. SliQuld a resort to Mode of making extension with the pulleys. DISLOCATIONS OF THE SHOULDER. 151 the pulleys, however, be demanded, they must be employed with great care, lest harm should befall the axillary vessels; for the very fact that restoration cannot be accomplished by manual effort is an evidence of probable complica- tion, and should be sufficient at least to put the surgeon on the alert. The operation is performed during the recumbency of the patient, or as he sits on his chair, as seen in fig. 66. The shoulder is firmly fixed by means of a long fold of muslin, the hand being passed through a hole in the centre, and its ends held by assistants, or fastened to a staple in the wall. The extending band is tied round the lower part of the arm, just above the elbow, and secured to the pulleys, which are then put in motion, the forces being applied transversely, and the head of the bone, as it approaches its socket, being lifted up by the hands in the axilla. 2. The thoracic variety of dislocation, the subclavicular of the French surgeons, is comparatively rare, and is usually caused by violence applied directly to the head of the humerus, or to the elbow, when the arm is elevated, and carried behind the central line of the body. The bone is thrust to the sternal side of the coracoid process, just below the clavicle, resting against the second and third ribs, under cover of the pectoral muscles, as seen in fig. 61. The anterior and inner parts of the capsular ligament are extensively ruptured, and there is usually considerable injury sustained by the adjoining muscles, especially the subscapular, the infra-spinate, and the small teres, which are often severed from their attachments to the head of the bone. The signs of this dislocation are usually well marked. The acromion juts out with great distinctness, the depression beneath it being much more conspicuous than in the axillary variety of the accident, in con- sequence of the manner in which the del- toid muscle is drawn over towards the chest; and the head of the humerus can generally be easily perceived just below the clavicle, forming a hard prominence which readily obeys the' movements of the limb. The elbow stands off widely from the body, in a backward direction, and the arm is commonly shortened from half an inch to an inch. The pain is less severe than in dislocation into the axilla, as there is no compression of the axillary plexus, but the impairment of the functions of the joint is greater. The most important diagnostic marks are the peculiar attitude of the limb, the extraordinary prominence of the acromion, and the position of the head of the bone just below the middle of the clavicle, where it can generally be both felt and seen. The reduction is easily accomplished by placing the heel in the axilla, so as to fix the scapula, and making the extension obliquely downwards and a little backwards, in the line of the displacement. The patient should lie upon the sound side, and as the head of the bone approaches the glenoid cavity it should be urged on by the pressure of the foot, and at the same time that the arm is brought oyer to the body, very much as in the dislocation down- wards. 3. The scapular form of dislocation of the shoulder is an uncommon occur- rence, and it is only within the last thirty years that its claim to a distinct variety has been fully recognized. One of the earliest cases of the kind with Dislo'cation of the humerus forward upon the chest. 152 DISEASES AND INJURIES OF THE JOINTS. which I am acquainted happened in the practice of Dr. Physick, in 1811. A goodly number have since been reported by different surgeons ; neverthe- less, the accident is undoubtedly a rare one. It is generally produced by a fall upon the elbow or hand, the limb being at the moment raised, and stretched out in advance of the body, a movement which has the effect of slightly depressing the head of the humerus, arid of throwing it backwards upon the posterior surface of the scapula, below the spine of that bone, as exhibited in fig. 68, and between the infra-spinate and small teres muscles. _ The inferior part of the capsular ligament is extensively opened, and the articular muscles are also generally seriously implicated in the mischief, their fibres being not only stretched, but often severely lacerated. It has been asserted that this luxation is always incom- plete; but after a careful examination of some of the reported cases, I am satisfied that this opinion is incorrect. The symptoms which characterize this luxa- tion are sufficiently prominent. The rotun- dity of the shoulder is diminished, but not completely destroyed, the acromion is abnor- mally distinct, and the head of the humerus can be both seen and felt in its new position, lying at the root of the spine of the scapula, at the posterior part of the shoulder. The arm is considerably shorter than in the natural state, and the forearm, strongly rotated in- wards, is bent obliquely across the chest. The axilla is deprived of its fulness, and upon making firm pressure there, before there is any considerable swelling, the finger can be made to sink into the glenoid cavity. Supination of the limb is wholly impossible, and indeed all attempts at motion are productive of an unusual degree of pain and distress, owing to the manner in which the head of the humerus is impacted under the outer border of the acromio-coracoid arch. The reduction is effected by making extension and counter-extension in the usual way, and urging the head of the bone from behind forwards by means of the hand, until it can be perceived in the axilla, when the restoration is to be completed by bringing the arm gently downwards and backwards into a line with the body and a little in advance of it. Reduction by Manipulation.—The different forms of dislocation now de- scribed may all be reduced by mere manipulation, especially in recent cases, although I believe that the method by the heel in the axilla is, as a rule, preferable to every other. In many instances simple torsion of the limb, particularly by rotation from without inwards, as recommended by Lacour, is quite sufficient for the purpose. The operation is performed by grasping the lower part of the forearm, and then turning the limb upon its axis, which has the effect of throwing the head of the humerus backwards and outwards, towards the glenoid cavity, when all that is necessary to induce it to slip into its proper position is to bring the limb on a line with the trunk. In this country attention was first .prominently called to this subject by Professor Henry H. Smith, to whom much credit is due for his attempts to generalize the redaction of these dislocations by simple manipulation. In a paper in the Philadelphia Medical and Surgical Reporter for February, 1861, he has given an accurate description of the process, accompanied by several drawings, and the particulars of twelve cases, successfully treated in this way by himself and others. Dislocation of the humerus backward upon the scapula. DISLOCATIONS OF THE SHOULDER. 153 The operation, which is best practised during the recumbency of the pa- tient, although it will also succeed when he is sitting up, provided the scapula is properly steadied, consists, first, in elevating the arm and flexing the fore- arm ; secondly, in rotating the head of the humerus upward, outward, and backward, as far as possible, by using the forearm as a lever; and, lastly, in rotating the head of the bone strongly upward and inward by a reverse move- , ment, while the elbow is brought to the side, the palm of the hand looking down, instead of up, as in the second stage of the proceeding. When the head of the bone is thrown forward upon the chest, it must, as a preliminary step, be forced down into the axilla, by carrying the elbow as far back as possible, and then elevating it, when, rotation being properly executed, it will readily slip into the glenoid cavity. In the posterior luxation, the same object is attained simply by raising the arm and carrying it strongly forward. The method of reducing dislocations of this joint by manipulation was warmly advocated, and rules laid down for its performance, by Sir Philip Crampton, as early as 1833, in a series of papers on the subject in the Dublin Medical Journal. In the luxation downwards he made gentle extension at the wrist to secure a long lever, and then slowly raised the limb to nearly a horizontal position, so as to relax the flexor and extensor muscles. He then suddenly pushed the arm upwards and a little forwards, towards the patient's face, or, in other words, rotated it inwards with the hand turned prone, and at the same instant forced the trunk suddenly backwards with the left hand placed below the axilla. In the luxation forwards, "the surgeon," says Crampton, "should place his left arm, extended horizontally, immediately below the walls of the axilla, between the dislocated arm and the chest, and then, grasping the wrist in his right hand, he should draw the arm forcibly across the patient's body." No anaesthetic need be administered in this mode of reducing dislocations of the shoulder, provided the manipulations are performed very slowly and gently, and the patient is not very muscular or rebellious. General Diagnosis.—Although the diagnosis of dislocations of the shoul- der-joint is usually sufficiently clear, yet cases occasionally occur where it is quite the reverse. There are several accidents with which they are liable to be confounded, from all of which it is of great importance that they should be correctly distinguished. Thus, mere contusion of the deltoid muscle, or a sprain of the articulation, sometimes simulates to a very perplexing extent the symptoms of luxation, by causing more or less obliquity of position of the arm, with inability to raise it; and the inexperienced practitioner is conse- quently liable to treat the'case with improper severity, employing, perhaps, violent extension and counter-extension, when nothing but the most simple treatment is necessary. In general, however, the diagnosis is easily enough determined by a careful inspection of the affected joint. If there be no dis- placement, the head of the bone will be found to occupy its natural position, the shoulder to preserve its rotundity, and the arm to retain its natural length. Motion, too, will be found to be perfect if the patient be examined while under the influence of chloroform. Great perplexity will be likely to arise when there is a fracture of the acro- mion, the neck of the scapula, or of the superior extremity of the humerus; hence, whenever such an occurrence is suspected, the surgeon cannot possibly be too much upon the alert. In each of these accidents there are three cir- cumstances, which, if carefully considered, will always serve to prevent mis- take. These are, preternatural mobility of the parts, crepitation, and facility of reduction, followed by an immediate recurrence of all the symptoms the moment the surgeon relinquishes his hold upon the limb. In dislocation, the head of the humerus is firmly fixed in its new situation, and is consequently 154 DISEASES AND INJURIES OF THE JOINTS moved with difficulty; there is complete absence of crepitation, or, if there be any noise and sensation of this kind, they are all very faint, being entirely different from those which are caused by rubbing together the ends of a broken bone; and, lastly, the restoration of the displaced bone can be effected only after much effort, generally not without energetic extension and counter- extension. Moreover, the reduction being once effected, the articular sur- faces usually retain their natural relations, having no disposition again to separate. In fracture of the acromion, the outer extremity of the bone is drawn down by the action of the deltoid muscle, giving the shoulder a sunken appearance, and the arm is sensibly elongated and supported by the patient's hand. Re- storation is readily effected by lifting up the elbow, but, upon abandoning our hold, there is an immediate reproduction of all the former symptoms, thus at once deciding the nature of the injury. In fracture of the neck of the scapula, a very rare accident, the acromion retains its natural position, but is uncommonly prominent; the arm is elon- gated, and crepitation is easily elicited by raising the elbow, which will also have the effect of restoring the form of the joint. The signs of fracture of the head and neck of the humerus are generally characteristic. The extremity of the bone, constituting the upper fragment, remains in the natural position, while the rough, angular end of the shaft projects upwards and inwards into the axilla, being drawn hither by the pec- toral and dorsal muscles. There is no displacement of the acromion, the shoulder is less flattened than in luxation, and the arm, instead of being elon- gated or of the natural length, is materially shortened. Complicated Dislocations.—Dislocation of the shoulder is sometimes, as just seen, complicated with fracture of the acromion, the neck of the scapula, or the superior extremity of the humerus. Whenever such a coincidence obtains, the rule is always to reduce the dislocation before we set the frac- ture, though the efforts at restoring the joint will generally be greatly pro- moted by putting up the limb temporarily in splints, as it will thus afford the surgeon a better leverage, which may be used with much effect in returning the luxated bone to its proper place. Compound dislocations of the shoulder-joint are rare in civil practice. When the head of the humerus is forced through the soft parts, no time should be lost in restoring it to its natural position, provided it has not sustained any serious detriment, in which case I am satisfied that it ought to be ex- sected, so as to afford the patient a better chance of recovery. Anomalous Dislocations.—Of the rare displacements of the shoulder there are several varieties, of which the best known is the one originally described by Sir Astley Cooper as a partial luxation of the head of the humerus, the bone lying upon the anterior part of the neck of the scapula, underneath the coracoid process, being thrown off from the glenoid cavity inwards and slightly downwards. Malgaigne has more recently given an account of it under the name of the subcoracoid dislocation. The accident is exceedingly uncommon. It is caused by a violent fall upon the hand or elbow, at a moment when the limb is carried backwards beyond the line of the body and a little way from the side. The anterior part of the capsular ligament is ruptured, but the muscles and tendons round the joint sustain comparatively little injury, as they are subjected to much less tension than in the complete luxations of the shoulder. Some diversity of opinion exists as to whether this dislocation should he considered as a partial or as a complete one; some contending that the head of the humerus does not entirely abandon the glenoid cavity, while others assert that it does. Without positively denying that the latter occurrence is impossible, I am strongly inclined to believe that tire displacement can seldom DISLOCATIONS OF THE SHOULDER. 155 be complete, on account of the check offered by the coracoid process to the progress of the bone as it is being impelled downwards and inwards. In the case described by Sir Astley Cooper, which was one of long standing, and the only one, I believe, that has ever been examined after death, a new articu- lar cavity was formed in the subscapular fossa, but not completely outside of the glenoid cavity, showing that the latter had not been wholly abandoned by the head of the humerus. The symptoms of this dislocation are not so well marked as in the complete varieties. It is only in very thin subjects that the head of the humerus can be very distinctly perceived in its new situation, or felt rolling about upon rotating the limb. The deltoid is less flattened than in ordinary cases, and the hollow below the acromion is also much less, the extremity of the process not .standing out so conspicuously. The elbow is carried backwards and slightly away from the side, and all attempts to elevate it are found to be abortive, in consequence of the head of the humerus hitching against the coracoid process. The limb is generally represented as being a little short- ened ; but, if this be so, the change must be very slight, and can be of no diagnostic value. The reduction is effected upon the same principles as in the other forms of displacement; but in this case it is necessary to make the extension, at first, more in the line of the luxation, in order to disengage the head of the hu- merus from the neck of the scapula. Professor Willard Parker, in 1852, described a case of luxation of the shoulder-joint, in which the head of the humerus was thrown into the sub- scapular fossa. The accident happened while the patient, a young man aged twenty, was at work in a woollen factory, his right arm being caught between the belt and drum, while the machinery was in rapid motion, and violently rotated outwards. When the limb was liberated, it was found lying diagonally across the body, in a state of strong, fixed pronation ; the rotundity of the shoulder was lost; and the head of the bone could be distinctly felt beneath the scapula. The reduction was effected by carrying the arm out- wardly at a right angle with the body, and then pulling the hand and wrist, so as to force the head of the humerus into the axilla, whence it was after- wards easily raised into its proper situation. Larrey has described a preparation which he observed in the medical museum at Vienna, in which the head of the humerus had penetrated the chest, through the third rib, so as to form a tumor within its cavity. The accident had been produced by a fall upon the elbow, which was at the mo- ment separated from the side of the body. In a case reported by Laugier, the bone was turned directly forwards, resting against the outer margin of the coracoid process. The great tube- rosity corresponded to the glenoid cavity, and the limb exhibited a remark- ably twisted appearance. Double Dislocations___Finally, there is occasionally a simultaneous disloca- tion of both shoulder-joints. Such an accident, however, of which interesting cases have been reported by Dr. W. H. Van Buren, Dr. Geddings, and others, is exceedingly uncommon. The head of each bone is generally forced down into the axilla, or one occupies this situation and the other the chest beneath the pectoral muscles. The dislocation, which is sometimes complicated with fracture of the scapula and humerus, is usually caused by a fall, in which the person stretches out both hands to save himself from injury. In a case treated by Sir George Ballingall, of Edinburgh, the accident occurred during an epileptic fit; and in another, recorded by Dr. Nathan Smith, of New Haven, in an attack of puerperal convulsions. The reduction in the double dislocation is effected upon the same general principles as in the single variety. In Smith's case, just referred to, replace- 156 DISEASES AND INJURIES OF THE JOINTS. ment is said to have been effected at the end of seven months. In a case recorded by Fischer, of Prussia, the patient, a stout, athletic man, restored the parts to their proper position by his own efforts. Seating himself upon a high bench, he seized, simultaneously with both hands, a transverse beam above his head, and, throwing himself suddenly and forcibly from his seat, both bones instantly slipped into the glenoid cavities with a crackling noise. In Dr. Van Buren's case, the man died in five hours after the accident from injury of the skull and brain. The particulars of the case, with a resume of six others, observed by different surgeons, will be found in the New York Journal of Medicine and Surgery, for November, 1857. After-treatment.—The after-treatment of dislocations of the shoulder re- quires particular attention. In the first place, it is highly important to guard against a recurrence of the accident, which is so liable to happen after all injuries of this kind, especially after luxation into the axilla. Generally, all that is necessary for this purpose is to support the elbow, forearm, and hand for some time in a sling close to the side of the body; or, if the patient be restive, the arm may be secured to the trunk, over a small pad, by six or eight turns of a bandage. Full elevation, abduction, and rotation of the limb should not be permitted for .five or six weeks, or until there is reason to believe that the capsular ligament and muscles have been in great degree repaired. The resulting inflammation is treated upon general principles. Passive motion, the cold douche, and liniments will be required to prevent anchylosis. Accidents.—Dislocations of 4the shoulder are sometimes followed by para- lysis of the arm, or, rather, of the deltoid muscle, produced by injury done to the axillary plexus, or circumflex nerve by the head of the humerus. In the event of its being slight, the affection may get well spontaneously, or with the aid of stimulating liniments, veratria ointment, and counter-irritation, especially vesication ; but in its more severe forms, as when it depends upon contusion and partial disorganization of the nerves, it often proves very re- fractory, and may even be incurable. Another unpleasant effect which now and then succeeds dislocations of the shoulder, is oedema of the corresponding extremity, arising from the pressure of the head of the humerus upon the axillary veins and lymphatics; this, how- ever, rarely lasts beyond a few days, and generally disappears spontaneously or-under very simple means. A sudden development of emphysema, first noticed by Desault, and since by several other observers, is sometimes met with after this accident, and is well calculated to create unpleasant apprehensions in the mind of the attendant. Its cause has not been satisfactorily accounted for, but it is not reasonable to suppose that it can be anything else than a slight wound of the chest, from fracture of a rib, penetrating the pleura and lungs. This idea is countenanced by the circumstance that the starting-point of the emphysema is always under the pectoral muscles, from which it rapidly spreads to the axilla, the whole extent of which it soon occupies. It may readily be distinguished from an extravasation of blood, consequent upon rupture of the axillary artery, by its elasticity; by the continuance of the pulse at the wrist, by the natural ap- pearance of the skin, and by the production of a crackling noise when the part is pressed with the finger. Astringent lotions and gentle compression are the proper remedies. Finally, the accident is sometimes attended with a rupture of the axillary artery, leading to copious infiltration of blood, or, when the lesion affects only the inner tunics of the vessel, to the formation of an aneurism. I" either case, of the latter of which a remarkable one was observed by Nelaton, the proper treatment, after the reduction of the luxation, would be the liga- tion of the subclavian. DISLOCATIONS OF THE SHOULDER. 157 Clironic Dislocations.—Chronic dislocations of the shoulder are often brought under the notice of the surgeon, and the question therefore arises, at what period after their occurrence should he refrain from an attempt at reduction ? Upon this subject I do not think it possible to lay down any definite rules. I have myself been foiled at the end of the sixth week, and I have known the same thing to happen to several practitioners of great skill and experience. On the other hand, I have succeeded, in one case, at the seventy-second day, and in another at the expiration of the third month. Physick succeeded in a number of instances after two and three months; and examples of from four to seven months' standing have been reported by McKenzie and Jameson, of Baltimore, Dorsey and Gibson, of this city, and by other American surgeons. The late Dr. Nathan Smith effected reduction, in one case, nearly one year after the occurrence of the accident; and Dr. Keppell, of England, is said to have succeeded at the end of fourteen months. These instances are certainly very encouraging, but they should, nevertheless, be received with great caution, especially when it becomes necessary to view them as examples for our imitation. It should not be forgotten, as stated elsewhere, that the greatest possible differences prevail in regard to this subject; that in one case a dislocation may become irreducible in several weeks, and in another not under several months, depending upon the indi- vidual circumstances of each. For want of this precaution, science has to deplore the sacrifice of a number of lives, in consequence of the rupture of the axillary artery in injudicious attempts to effect restoration long after the period for such an attempt had passed by. The disastrous cases recorded by Loder, Cooper, Pelletan, Flaubert, Bell, Gibson, and others, should serve as a warning to every surgeon how he interferes in accidents of this nature. Perhaps the best plan that can be adopted in these chronic cases is to be guided by the degree of motion that has been acquired by the luxated bone. When this is considerable, it may be assumed that it has succeeded in estab- lishing for itself a new joint, which it might be dangerous to disturb on account of its important relations with the surrounding pants. Another consideration which should have its weight in these cases is the amount of inflammation by which they are followed; if this have been unusually violent, it may be inferred that there has been copious plastic effusion, filling up the original socket, and causing extensive adhesions among the muscles and ves- sels, matting them firmly together, and rendering interference hazardous. When it is thought advisable to attempt reduction, the rules already laid down in the opening section upon dislocations, must be carefully observed ; that is, a certain amount of preliminary treatment should be instituted with a view of facilitating the breaking down of the abnormal adhesions between the head of the displaced bone and the surrounding parts, and thus lessening the danger both of failure and of injury to the axillary vessels and nerves, after the application of the extending and counter-extending forces. In general, a resort to the pulleys will be required, and, in some cases, the ap- paratus of Dr. Jarvis might possibly be advantageously used. Congenital Dislocations.—Congenital dislocation of the shoulder-joint is sometimes observed. The accident has been particularly studied by Mr. Robert W. Smith, of Dublin, who has directed special attention to it in his admirable work on fractures, published in 1847. Since then the malforma- tion has been examined with much care by Gaillard, Guerin, Nelaton, and others. The lesion may be single, or symmetrical, that is, it may occur on one side only, or on both; and there are cases in which it coexists with similar dis- placement in other articulations. Two varieties only of this malformation have hitherto been recognized by dissection, termed, by Mr. Smith, the sub- coracoid and the subacromial, the head of the humerus in the former being 158 DISEASES AND INJURIES OF THE JOINTS. lodged beneath the coracoid process, and in the latter on the dorsal surface of the scapula, below the outer and posterior part of the acromion. The latter might, perhaps, more properly be called the infra-spinous form of the luxation. The symptoms of both these dislocations are well marked. In the sub- coracoid variety, the shoulder has a flattened appearance, especially at its upper and posterior aspect, the acromion is unnaturally sharp and prominent, there is a remarkable hollow in the supra-spinous fossa, and the head of the humerus can readily be felt beneath the coracoid process, forming a distinct ball, which promptly obeys the movements of the elbow. The arm, which hangs along the side, is greatly withered, thus singularly contrasting with the forearm and hand, which generally retain their full development, being in fact quite as well-conditioned as the opposite limb. The movements of the scapula are perfectly normal, while those of the arm are either annulled, or very much impeded, especially abduction ; the forearm can be bent, but not actively extended. The movements, on the contrary, of the hand and fingers are nearly, if not entirely, natural. In the subacromial dislocation the head of the humerus may be easily felt on the dorsum of the scapula, a short distance below the root of the acromion, where it forms a distinct, unmistakable prominence. The deltoid muscle is flattened externally and in front; the acromion is uncommonly salient; the arm, shortened and withered, is rotated inwards towards the trunk ; and the forearm and hand are slightly pronated, supination being executed with great difficulty. The treatment of these dislocations must be conducted according to the general principles laid down in a previous page. In a remarkable instance, Gaillard succeeded in effecting the reduction of a congenital luxation of the shoulder-joint in a girl sixteen years of age, the patient recovering with a most excellent use of the arm. For several weeks prior to the operation, the parts were daily subjected to passive motion and manipulation, so as to induce them #o yield the more readily to the necessary extension and counter- extension. The inflammatory symptoms that followed the reduction were combated by the usual means. Dislocations of the Tendon of the Biceps.—The tendon of this muscle is liable to be dislodged, being violently wrenched from its bed in the humerus, and perhaps partially torn, if not com- Fig- 69- pletely snapped asunder. In the latter case, the upper extremity of the ten- don may float loosely about within the joint. The accident generally happens from falls or blows upon the shoulder, forcing the humerus away from the glenoid cavity of the scapula, generally upwards and inwards against the co- racoid process, or forwards against the ribs. The accident may also occur from falls on the hand or elbow, espe- cially if, at the moment, the limb be very much twisted upon its axis. The nature of the lesion is always obscure, and therefore very apt to be over- looked, or to be mistaken for disloca- tion, fracture, or sprain of the shoulder. Dislocation of the tendon of the biceps muscle. The most prominent symptoms are, ina- bility to flex the arm from the loss of power in the biceps, and pain at the seat of the injury, either alone or united DISLOCATIONS OF THE FOOT. 159 with partial displacement of the head of the humerus. Reduction should be attempted by thorough relaxation of, the muscle by bending the forearm at a right angle with the elbow, and then pressing the tendon back into its pro- per place with the fingers. The after-treatment should be strictly antiphlo- gistic ; otherwise there will be great danger of permanent anchylosis of the joint. If the tendon be completely severed, the limb will always be weak. In the adjoining drawing, fig. 69, from a preparation of Mr. Soden, the tendon of the muscle lay with its sheath on the lesser tubercle of the humerus. 3. INFERIOR EXTREMITY. DISLOCATIONS OF THE FOOT. Luxations of the phalangeal and metatarsophalangeal joints are uncom- mon, and are mostly of so complicated a character as to require amputation. The reduction is always easy. Of dislocation of the great toe at the metatarsal joint, a very uncommon accident, I have seen two cases, one recent and the other old. The follow- ing is a brief history of them. A gentleman, aged forty-two, while walking along the pavement, slipped with his right leg through the hole of a coal cellar. The dorsal surface of the foot striking against a lump of coal, bent the great toe downwards and dislocated it at the metatarso-phalangeal articulation. The accident was productive of considerable pain, and was so well marked as to be at once re- cognized. The toe was inclined somewhat outwards, and lay a little higher than in the natural state. It was fully half an inch shorter than the sound one. The head of the first phalanx rested upon the dorsal surface of the an- terior extremity of the metatarsal bone, where it formed an abrupt, well de- fined prominence. The projection on the plantar surface, formed by the head of the metatarsal bone, was less conspicuous. The adductor muscle of the great toe formed a broad, tense cord at the inner side of the foot, which dis- appeared on the reduction, having been caused by the retraction of the toe. I saw the man within an hour after the accident, when there was no swelling or discoloration of the parts. The patient being placed under chloroform, I applied a clove-hitch knot to the toe, and steadily drew it into place, the extension being made forwards, and slightly downwards, to disengage the head of the phalanx from the an- terior extremity of the metatarsal bone. The foot was steadied by an assist- ant grasping the ankle. In the other case the accident was occasioned by the foot being caught between two steamers, which twisted off the man's boot, severely wrenching the limb, and bruising the soft parts. The phalanx of the big toe was forced below the metatarsal bone, forming a large prominence in the sole, of the foot, which has ever since, now a period of six years, been a source of much annoyance, being frequently so sore and tender as to interfere materially with progression. The reduction of this luxation is occasionally attended with considerable difficulty, depending probably upon the manner in which the adductor muscle and the sesamoid bones are dragged by the displaced phalanx backwards over the extremity of the metatarsal bone. In the event of such a contingency, I should endeavor to effect restoration by means of Dr. Crosby's plan of re- ducing dislocations of the thumb, raising the toe perpendicularly, and then applying stroifg pressure against its base, so as to push it from behind for- wards, and from above downwards. The metatarsal bones are rarely dislocated, owing to the firmness of their connections both with each other and with the lower row of carpal bones. 160 DISEASES AND INJURIES OF THE JOINTS. The accident is most commonly compound. A simple luxation, however, of one or more of these bones is sometimes occasioned by a violent wrench of the foot, or by the passage of the wheel of a carriage, as happened to me in a case a good many years ago, in which the fourth and fifth metatarsal bones were detached from their connection with the cuboid bone, and thrown up- wards upon the tarsus. The reduction was effected with great facility, and, under the employment of leeches and other antiphlogistics, the man was able in the course of a fortnight to exercise on crutches, regaining eventually a good use of his limb. The only case of a complete dislocation of all the metatarsal from the tarsal bones of whjch I have any knowledge, was communicated to me in 1857, by Dr. Traill Green, of Easton, Pennsylvania, as having occurred under his observation and that of Dr. Edward Swift. The patient, a medical gentle- man, aged sixty-five, had fallen down a flight of stairs, injuring the left foot, which was found soon after the accident to be much swollen over the arch and very painful, with deformity at the inner and outer edge. The metatar- sal bone of the great toe was separated from the internal cuneiform bone, and thrown over towards the outer margin of the foot, leaving the latter bone quite prominent at the inner side. A similar condition existed on the oppo- site side, the metatarsal bone of the little toe being thrown off completely from the cuboid bone, so as to present a well-marked projection at the outer border of the foot. In short, the twisted state of the foot, the great defor- mity, and the swelling of the arch, clearly indicated a lateral displacement of all the metatarsal bones. The reduction was easily effected in the following manner. The patient being placed in a half reclining posture on a settee, with his right foot against the arm to brace himself during the operation, an assistant applied his knee to the instep, and while he made extension by grasping the dislo- cated portion of the foot, previously surrounded by a wet roller, to prevent the lac from slipping, Dr. Green, who supported the leg upon his thigh, made strong lateral pressure, in a direction contrary to that of the displacement. The parts soon began to yield, and in a few minutes returned to their proper place with a distinct snap, all deformity at the same time disappearing. Dislocation of the tarsal joints is uncommon, their limited motion and the strength of their ligaments disqualifying them for disunion. The astra- galus is almost the only bone which is liable to displacement, and this acci- dent is also unusual. Dislocation of the cuneiform bones is extremely infrequent. The internal one of these pieces is more apt to suffer than either of the other two. The accident is usually caused by falls from a considerable height, in which the person alights upon the sole of the foot, the force separating the bone from its natural relations. A projection on the inside of the foot, and a slight elevation of the bone, from the action of the anterior tibial muscle, are the characteristic signs of the lesion. The reduction, which is difficult, is effected mainly by pressure. In two cases of this luxation mentioned by Sir Astley Cooper, replacement was found to be impracticable. In general, when this happens, the patient, in time, regains a tolerably good use of the limb. Retention is maintained by adhesive strips, a compress, and bandage, aided by splints, to keep the foot in a quiet, easy position. When the inflamma- tion has sufficiently subsided, a leather strap with a soft pad should be worn, to protect theparts until the reparative process is completed. The scaphoid aud cuboid bones are occasionally separated from their con- nections with the astragalus and calcaneum, in consequence flf the falling of a heavy weight, or of a person jumping from a considerable height and alighting upon the sole of the foot. Under these circumstances the foot is shortened and twisted upwards and inwards, forming a remarkable promi- DISLOCATIONS OF THE FOOT. 161 nence upon the instep, *which gives it a distorted appearance not unlike what occurs in varus. The accident is extremely infrequent, and is easily remedied byfixing the leg and heel, and then drawing the toes outwards, in a direction contrary to that of the displacement. Suitable retentive means will, of course, be required to prevent a recurrence of the luxation. The calcaneum has>been found dislocated from the cuboid bone laterally, in an outward direction, from causes similar to those producing displacement of the other tarsal bones. The accident is easily detected and remedied by manipulation. A remarkable instance of dislocation of the five anterior tarsal bones from' the astragalus and calcaneum has been recorded by Sir Astley^Jooper, as having occurred in a laboring man, in eonsequence of the fall of a very heavy stone. The foot was singularly distorted, exhibiting very much the appearance of club-foot, the forepart being turned inwards upon the astra- galus and calcaneum, so as to give the limb an arched shape. The reduc- tion was easily effected by fixing the leg and heel, and pushing the luxated bones in a direction contrary to that of their displacement. A similar case has been recorded by Petit. In the succeeding pages an account will be given of luxations of the astra- galus from the mortise-like cavity of the tibia and fibula, and, without anti- cipating, in any way, what will then be said, it is important to bear in mind that the class of lesions which is now to be considered is very different from that of the ankle-joint, in which the bone in question plays so conspicuous a part. In the latter affections the astragalus is torn off simply from its con- nections with the tibia and fibula, but in those whjph are next to be described, it not only loses its relations with those bones, but also with those of the calcaneal and scaphoid bones. The displacement may either be partial or complete, the astragalus in the former case still retaining some of its connec- tions, whereas, in the latter, they are entirely lost, complete disruption having taken place, or, in other words, the bone is lifted bodily out of its original position, into one altogether new. It is obvious that such an accident can occur only in consequence of the application of excessive violence, in which the foot is strongly extended upon the leg, and more or less rotated upon its axis. Hence it is always of a grave nature, and rarely unaccompanied by fracture of the inferior extremity of the tibia and fibula, which thus adds still further to its complications and dangers. Occasionally, indeed, the astra- galus itself is severely shattered. Dislocation of the astragalus may take place in two directions, backwards and forwards, the latter, which is by far the more frequent, admitting also of a certain degree of displacement laterally, or*to either side, in consequence of a twist or the foot. In the posterior luxation the bone does not experi- ence any rotation; hence it is more in the course of the median line, suffering no material lateral deviation. In the luxation backwards, of which only a few cases are known as having occurred, the astragalus is thrown behind the ankle, resting upon the supe- rior surface of the calcaneum, where it forms a large characteristic promi- nence. The tendo Achillis is pressed strongly backwards by the displaced bone, there is great tension of the skin of the heel, the muscles of the calf are very rigid, the tibia is slightly pushed forwards, and the instep appears a little shorter than natural. In general, also, there is a slight vacuity in front of the joint. The tibia and fibula are sometime? both fractured. The reduction of this luxation is attended with immense difficulty, owing to the manner in which the surfaces of the astragalus and calcaneum are interlocked with each other, and I am not aware that the operation has ever succeeded, except in one case, which occurred to Mr. Liston, and in which the accident was attended with fracture of the tibia and fibula, which had VOL. ii.—11 162 DISEASES AND INJURIES OF THE JOINTS. probably the effect of rendering the parts more movdble. In attempting to replace the bone, the leg and foot should be as strongly flexed as possible, so as to induce thorough relaxation of the gastrocnemial muscles, and then, while extension and counter-extension are made by means of the clove-hitch, the astragalus should be urged from behind forwards into its natural position. When the difficulty is very great, the parts absolutely refusing to yield to any efforts, however judiciously applied, recourse may be had to the subcu- taneous section of the tendo Achillis, in the hope of thereby promoting resto- ration. The operation has recently succeeded in quite a number of cases. When reduction fails, the patient will in time acquire a tolerably good use of his limb, the parts accommodating themselves gradually to their new rela- tions. In one instance, where the attempts proved unsuccessful, the bone caused sloughing of the soft structures, and was obliged to be extracted. The luxation forwards is generally incomplete, the anterior half of the bone, or a little more, resting upon the dorsal surface of the scaphoid bone, while the posterior half is imbedded in the hollow between the two articu- lating surfaces of the calcaneum. The displaced bone forms a distinct pro- minence over the instep, while a marked vacuity exists at the inner part of the foot, just below the corresponding malleolus. The tibia and fibula either retain their natural position, lying upon the posterior surface of the astra- galus, or, as more commonly happens, they are carried slightly forwards, thus increasing the length of the heel, and inclining the foot towards one side or the other, according to the peculiar relations which the bone may sustain towards the calcaneum, a trifling change of position being capable of deter- mining the nature of the lateral displacement. In the complete form of the accident, the bone is forced away entirely from its natural position, being tilted up in front of the joint so as to rest upon the Scaphoid and cuneiform bones. The signs are characteristic, the large • prominence at the instep, the constrained and twisted position of the foot, the shortening of the leg, and the descent of the malleoli towards the sole of the foot, together with the elevation and lengthening of the heel, being suffi- cient to reveal its nature at a glance. Sometimes the position of the astragalus is almost completely reversed, and there are few cases which are unattended with fracture of the tibia and fibula, or even of the astragalus itself. Moreover, the dislocation is not un- frequently of a compound character, the soft parts toeing severely lacerated, and the wound extending into the ankle and tarsal joints; or, when such an effect has not been the direct result of the accident, the foot is soon reduced to that condition by the ulceration and sloughing caused by the pressure of the displaced bone upon the integuments of the instep. The great obstacle to reduction in this as in the backward dislocation is the malposition of the astragalus, or the change in its axis, which not unfre- quently baffles all the efforts of the surgeon at restoration, however well directed or perseveringly continued. Even when the displacement is only partial, the difficulty will generally be very great, though not as much so as in the complete form, where it is usually insurmountable. In the latter case, indeed, it is questionable whether, after what experience has taught us upon the subject, it will be judicious hereafter to make any efforts at reposition, seeing how much all such trials, rough and protracted-as they necessarily must be, must tend to aggravate the injury, and thus increase the risk of undue inflammation. When the displacement is partial, I would certainly strongly urge the employment of reductive means, consisting of traction and pressure, aided, if the case prove rebellious, by the subcutaneous section of any ligaments and tendons that might seem to act obstructingly. When re- placement is impracticable, the tension of the parts should be relieved by subcutaneous incisions, as this will lessen the risk of sloughing and exposure DISLOCATIONS OF THE ANKLE. 163 of the bone; a circumstance inevitably'productive of necrosis, and the neces- sity of partial excision. When such an accident can be presented, it is con- soling to know that, as in dislocation backwards, the bony surfaces become gradually adapted to each other, thereby ultimately permitting a tolerably good use of the limb. When the bone is entirely displaced, lying immediately beneath the integu- ments and muscles of the instep, the only safe procedure is immediate excision, the ends of the tibia and fibula being placed in the sulcus vacated by the removal which this articulation is exposed, a sudden twist of the leg, while the foot is firmly fixed, being the most . common exciting cause, although it is often produced by direct vio- lence. The articular, pulley-like surface of the astragalus is forced below the outer mal- leolus, and there is always fracture of the inferior portion of the fibula; without this, indeed, the occurrence would seem to be impracticable. This form of luxation has been described by most authors as displace- ment inwards. In this variety of the accidenj;, both malleoli are sometimes broken off, in consequence of which the superior surface of the astragalus slips away from the articulating surface of the tibia, and places itself in the gutter between Dislocation of the-tarsus outward. this bone and the fibula. The foot, in this case, is nearly flat, as the patient stands up, with a slight upward inclination of its inner margin, and the lower extremity of the tibia forms a remarkable prominence, rendered the more conspicuous an account of the displacement of the internal malleolus, which is drawn over towards the fibula. Great deformity also exists on the outer border of the ankle, caused by the projec- tion of the inferior fragment of the fibula. The signs of this luxation are unmistakable. The internal malleolus forms a remarkable projection under the integuments; the foot has a twisted ap- 166 DISEASES AND INJURIES OF THE JOINTS. pearance, and is easily rotated upon its axis, its inner border resting on the ground; a considerable depression exists on the outer surface of the leg, a short distance above the joint, corresponding with the line of fracture of the fibula, and the astragalus can be distinctly perceived below the external malleolus. The reduction is effected by flexing the leg strongly, so as to relax the gastrocnemial muscles, and then drawing the articulating surfaces towards each other in a direction contrary to that of their displacement. The whole procedure is one of great simplicity. Maintenance is preserved by means of adhesive strips, so arranged as to keep the ends of the broken fibula in a straight line, and the articulating surfaces of the displaced bones in close apposition, due support being afterwards given to the foot by a tin case or two side splints. • ' In the dislocation upwards, of which not more than a few cases exist in the records of surgery, the astragalus is forced upwards between the two bones of the leg, the fibula being fractured some distance above the joiat, and widely separated from the tibia. . The astragalus preserves its natural direc* tion, but is so firmly impacted as to render its restoration a matter of diffi- culty. The two malleolar projections are extremely prominent, and descend nearly as low down as the sole .of the foot, which is usually inclined a little to one side. « The luxations now described are all, it will be perceived, more or less com- plicated in their character, and, therefore, require the most assiduous care and attention during the after-treatment to prevent anchylosis. Anodyne and astringent lotions, and, in the more severe forms, free leeching, will be neces- sary to keep the inflammation wjghin due limits. Proper support, in an easy posture, must be given to the leg and foot until all danger of displacement is passed. Passive motion and sorbefacient remedies will complete the cure. In most cases, however, the joint will long remain weak, and, in not a few, loss of motion, partial or complete, will take place in spite of all the care and skill that the surgeon can bestow. The ankle is not unfrequently thje subject of compound dislocations, tbe wound in the so*ft parts penetrating the cavity of the joint, and affecting, per- haps, the principal vessels and nerves of the limb, at the same time that there may he violent contusion of the integuments, and ex- tensive comminution of the bones of the leg. In such a case, which'is well displayed in fig. 72, from a preparation in my collection, the surgeon could not hesitate as to the course that ought to be pursued. Amputation alone can save limb and life, and should be post- poned no longer than is absolutely necessary for the occurrence of the requisite .reaction. The lesion is profound, and an attempt to pre- serve the parts wouW be worse than foolish. When the injury is less violent, and the con- stitution sound, conservative surgery will often effect wonders, and is always worthy of a fair trial. When the ends of the bone pro- trude, excision will, as a general rule, be the only safe course. Whatever conservative measures be adopted, more or less anchylosis will always,be inevitable,though the patient may ultimately regain a tolerably good use-of his limb. Fig. 72. Compound dislocation of the ankle- , joint. DISLOCATIONS OF THE PATELLA. 167 DISLOCATIONS OF THE TIBIO-FIBULAR JOINTS. Dislocation of the tibio-fibular joints is an extremely uncommon occur- rence; for, independently of their peculiar mode of articulation, and the great firmness and strength of the connecting media,- the resistance offered by the interosseous ligament, and the protection which the fibula receives from its relations with the tibia, are so many causes which interfere with the disrup- tion of their surfaces. It is only, indeed, the most violent injury that can give rise to the accident. There is a form of dislocation of the upper joint which occasionally occurs as a result of excessive relaxation of the fibulo- tarsal ligaments, chiefly in weakly, delicate females, allowing the head of the fibula too much latitude of motion; but this is an occurrence very different -from a real luxation, which is always occasioned by external force acting directly upon the componeut elements of the joint. Of the traumatic variety of the lesion, only a few examples are on record. Boyer has published the particulars of a case in which both joints were displaced simultaneously, the foot being at the same time dislocated outwards. Such an accident neces- sarily implies extensive laceration of the interosseous ligament, and can only happen by a fall upon the foot, or a blow upon the inferior extremities of the fibula, driving the bone upwards and outwards with the whole force of its leverage. Whatever may be the nature of the displacement, reduction is always easily accomplished by flexing the leg at a right angle with the thigh, and pushing tb^e bone back in a direction contrary to that of its luxation. Maintenance, which is usually extremely difficult, must be effected by long- continued rest of the limb, and the use of a broad, elastic strap with a closely- fitting pad, acting directly upon the head of the bone. In the subluxation, as it may be termed, of the upper tibio-fibular joint, the proper remedies are chalybeate tonics, with gentle exercise in the open air, and, locally, the cold douche and the tincture of iodine, followed by a series of little blisters, and the use of a proper supporter. If the case be rebellious, a delicate tenotomy knife may be introduced subcutaneously, and carried about in the joint in different directions so as to scratch the.articular » surfaces, with a view to provoke effusion of plastic matter. DISLOCATIONS OF THE PATELLA. It is obvious, from the situation of the patella and the manner in which this bone is imbedded in the tendon of the extensor muscles of the thigh, that it is susceptible of being dislocated only outwards and inwards, or laterally. Displacement downwards is altogether impracticable, while that upwards cannot happen without rupture of the ligament by which this bone is con- nected to the tibia. Either luxation may be complete or incomplete. A remarkable form of the accident has occasionally been met with, chiefly of late years, in which the patella is dislocated edgewise, vertically, or upon its axis. Whatever may be the character of the displacement, the occurrence is extremely uncommon; so much so, indeed, that many practitioners of large experience have never seen an instance of it. It is most liable to happen in thin, feeble persons, in whom it is usually produced by very trivial causes, such, for example, as a sudden twist of the limb in dancing, walking, leaping, or stepping into bed. When there is a faulty conformation of the knee-joint, attended with a relaxed state of the ligaments, it may take place spontane- ously, from the action of the extensor muscles conjoined with slight rotation of the leg, the thigh being fixed in the straight position. Sometimes the displacement is occasioned by direct violence, forcing the bone towards the opposite side of the articulation, or twisting it upon its axis. 163 DISEASES AND INJURIES OF THE JOINTS. Dislocation of the pa tella outward. Dislocation of the pa- tella inward. Of the two lateral dislocations, that outwards, fig. 73, is the more common; the patella lying at the external part of the joint, its outer edge being directed backwards, and the. inner forwards. Fig. 73. Fig. 74. The signs are unmistakable. There is a remarkable depression in front of the knee, with a corresponding prominence on the outside; the inner condyle can be distinctly felt under the skin, and the leg is in a painfully extended posi- tion, without the possibility of being flexed. Restoration is effected by placing the patient upon his back, and flexing the thigh upon the pelvis, the lower part of the leg resting upon the sur- geon's shoulder, as he sits upon the edge of the bed. The object of this procedure is to relax the knee as com- pletely as possible, when; pressure be- ing applied to the bone, with the thumb and fingers, from without inwards, the patella will immediately be drawn into its natural position by the action of the extensor muscles. In the dislocation inwards, fig. 74, the situation of the patella is reversed, its inner border being turned backwards "and the outer forwards. The leg is extended and cannot be bent; the outer condyle looks as if it were depressed, and a characteristic prominence exists on the internal aspect of the knee. The reduction is effected in the same manner as in the former case. Although these lateral dislocations of the patella are generally reduced with-great facility by the method here advised, yet cases occasionally occur in which the operation is attended with immense difficulty, the most accom- plished surgeon being sometimes foiled for a long time, notwithstanding the best directed efforts. It is said that Sabatier completely failed in an instance of this kind ; and Dorsey, on one occasion, nearly experienced a similar fate. Being called to a young lady who had luxated her rotula in stepping into bed, he did not succeed in effecting restoration until after many fruitless attempts, although he saw his patient within five minutes after the accident. When the difficulty is unusually great, it may generally be surmounted by forcibly flexing the leg, and then rapidly extending it; a procedure which will have the effect of disengaging the bone from its impacted position by the side of the condyle of the femur. The dislocation in which the patella is displaced edgewise, vertically, or upon its long axis, is altogether a singular accident, the very possibility of which was denied by nearly all surgeons until a very recent period. It is, indeed, difficult to conceive how a bone, which is so firmly imbedded as this is in tendinous matter, can lend itself to such a freak, which has the effect of turning it completely on its side, so that its outer edge lies immediately under the integuments in front of the knee, while the inner rests in the sub-condy- loid fossa of the femur, being firmly and almost immovably wedged in its new position, the anterior face looking inwards, and the posterior outwards. Sometimes the position of the patella is almost entirely reversed, the surfaces changing situations, the anterior looking backwards, and the posterior in the opposite direction. The occurrence, however, is very uncommon. Among the earlier of the reported cases was that of Dr. John Watson, of New York, in 1839, and another, of much interest, occurred soon after in the practice of DISLOCATIONS OF THE PATELLA. 169 Dr. J. P. Gazzam, of Pittsburg; the patient of the former being thirty-five years old, that of the latter, twenty-one. The details of a very interesting* example of this rare dislocation of the patella, which occurred in the practice of Dr. Wragg, of South Carolina, will be found in the Charleston Medical Review, for May, 1856. The lesion is generally produced by violent muscular action, conjoined with a sudden aira" forcible twist of the knee; occasionally, however, it appears to be caused by a fall, or blow upon the bone, the leg being'semiflexed, and strongly rotated upon its axis. In one of the recorded cases it happened while the person was engaged in wrestling. The signs of this dislocation are characteristic. The leg is perfectly straight, but may occasionally be slightly flexed, though not without exces- sive pain; the patella forms by its outer edge a hard, prominent ridge in front of the knee; a deep depression exists upon each condyle; and the extensor muscles are in a state of great tension. The reduction of this luxation has generally been found extremely difficult, owing, apparently, to the trouble which is experienced in disengaging the bone from the sub-condyloid fossa, where it is almost as firmly impacted as if it were screwed fast. On several occasions, indeed, the most violent efforts, conjoined with the division of the ligament of the patella, were hardly suffi- cient to accomplisb>the object. In the case mentioned by Dr. Gazzam, the only effect which the operation produced was to render the bone a little more movable, but the attempts afterwards to reduce it were just as unavailing as before. In another instance, the surgeon, Dr. Wolff, divided both the ligament below, and the extensor tendon arlbve the bone, and yet he found it impossible to restore the parts to the^x natural relations. Violent disease of the joint ensued, and the patient at length perished from profusa discharge and hectic irritation. Fortunately, such measures are not likely to be again repeated, since experience has not only shown that they are inefficacious, but dangerous. The proper method of reduction consists in flexing the thigh strongly*iipon the pelvis, and in bending the leg forcibly, and to the-fullest extent, upon the thigh, the limb being again immediately brought into a straight line, at the same time that an effort is made to push the bone strongly over towards the inner part of the joint. By repeating this manoeuvre several times, in rapid succession, the patella suddenly leaves the sub-condyloid notch, and jumps back, with a distinct snap, into its natural situation. Extension, even when carried to excess, does no good in effecting reduction; on the contrary, in every case in which it has been tried it has signally failed, having only ap- parently produced still further impaction of the bone. After the reduction of these different dislocations, the patient must be subjected for some time to rest and the usual antiphlogistic measures; and when he is able to move about, it will be necessary to support the joint for many months with a laced gum-elastic cap. Displacement of the patella upwards can only occur when there is a rup- ture of the ligament of that bone, in consequence of the inordinate action of the extensor muscles, or violence applied to the anterior surface of the knee. The injury is easily recognized by the flattening of the joint, by the projection upon the inferior part of the thigh, and by the inability of the patient to ex- tend the limb. Th.e treatment is precisely the same as in fracture of the patella. A few instances of congenital luxation of the patella are upon record; some of them of an equivocal character, others well authenticated. The occurrence is very uncommon. 170 DISEASES AND INJURIES OF TnE JOINTS. DISLOCATIONS OF THE KNEE. Dislocation of the tibio-femoral articulation, or of the tibia from the con- dyles of the femur, is of very infrequent occurrence, owing, mainly, to the numerous and powerful ligaments by which their articulating surfaces are united together. In this respect, there is no other joint in the whole body so well* provided. If it were not for this arrangement, luxation could liardly fail to be very common, as the knee not only admits of extensive motion, but has unusually shallow surfaces, with no very strong support from the neigh- boring muscles, such as we observe, for instance, in the hip, shoulder, and elbow. The tibia may be thrown from the condyles of the femur in four different directions, namely, forwards, backwards, inwards, and outwards, or to either side. The latter two are the most common, and are always incomplete, owing to the great extent of the articular surfaces, and the difficulty of rup- turing all the. ligaments in the lateral direction of the joint. In regard to the dislocations forwards and backwards, it was generally supposed, until lately, that they were always complete, but the accurate researches of Mal- gaigne have proved that they are most frequently partial. Besides these displacements, the knee is subject to a species of sub-luxation, dependent upon a change of location of the semilunar cartilages. This, indeed, is more common than all the other.forms of the lesion together, and is, therefore, of sufficient importance to demancT^eparate notice. 1. Dislocation forwards, fig. 75, i§ occasioned by falls upon the foot while the knee ia in a bent position, or by force acting upon the anterior aud in- ferior part of the thigh, driving the femur Fig. 75. backwards behind the head of the tibia; in either case, the occurrence will be promoted if, at the moment of the injury, the leg is slightly rotated on its axis, so as to increase the strain upon the joint. The head t)f the tibia is pushed upwards and forwards, lying in front of the condyles, and geuerally presenting a somewhat twisted • arrangement; the patella is drawn up beyond its natural level, into a sort of hollow, just ■ above the tibia, and may* easily be lifted up with the thumb and fingers'; the tendon of the extensor muscles is much relaxed; and there is shortening of. the leg from an inch and a half to two inches. The condyles of \ the femur are situated in the ham, where they form a large tumor, which gives the part an unusually prominent appearance, end which Dislocation of the tibia forward. occasionally exerft such a degree of compres- sion upon the vessels as to interrupt the circu- lation in the dorsal artery of the foot. The complete form of dislocation of the tibia, whether forwards or back- wards, must necessarily be attended by most extensive rupture of the liga- ments of the joint, and is, therefore, always to be regarded as a very serious accident. When the condyles are impelled backwards with unusual violence, there will be great danger of laceration of the popliteal vessels, especially of the artery of that name, either in the shape of direct rupture, or of a partial destruction of its inner and middle tunics ; occasioning, in the former case, copious subcutaneous hemorrhage, the pressure "of which may finally cause DISLOCATIONS OF THE KNEE. 171 gangrene of the limb ; and, in the latter, the gradual dilatation of the artery into an aneurisraal tumor, the ultimate effects of whic*h may not be less dis- astrous. In all cases, there is rupture qf the popliteal muscle. When the injury to the joint and the parts abound is very grave, the danger to limb and life may be such as to require amputation ; but, in ordinary cases, the patient will rapidly recover from the immediate effects of the lesion, and eventually obtain a useful limb, although it will remain weak for a long time. The reduction is readily effected by counter-extending the thigh and pulling the leg somewhat backwards, the surgeon's arm resting in the ham, and pres- sure being made upon the head of the tibia. The following case, the only one that I have ever seen of dislocation of the head of the tibia forwards, will afford a good idea at once of the symp- toms of the accident, and of the proper method of reduction :— A very large, fat woman, weighing nearly two hundred pounds, married, and forty-eight years of'age, while engaged in feeding her poultry, sustained a severe fall in consequence of the sudden slip of the right foot, which, bend- ing outwards, thus caused the whole weight of the body to be thrown upon the corresponding knee. I saw her four hours after the occurrence of the accident, when several fruitless attempts had already been made at reduction. The knee, which was very painful and a good deal swollen, especially on the inside, appeared to be unusually wide from side to side ; a circumstance partly due to the tumefaction of the soft parts. The leg was one inch and a half shorter than the opposite one, and in a straight line with the thigh. The patella had sunk behind the head of the tibia, into a sort of hollow, which gave to the front of the joint a flattened appearance. Upon grasping the bone, however, with the thumb and fingers, it was easily drawn forwards, leaving a remarkable vacuity behind, in consequence of its distance from the inferior extremity of the femur. The condyles of the thigh-bone lay in the popliteal space, posterior to the head of the tibia,' where they formed a large prominence, more distinct on the inside than on the outside, and situated, as •it were, in the upper and back part of the leg, the muscles of which were unusually tense. The head of the tibia lay in front of the condyles, where its outlines could easily be traced with the eye and finger. Above this bone, as already stated, was the patella with its ligament and the tendon of the extensor muscles, forming a broad, thick cord in front of the thigh-bone, from which it was removed more than two inches. The leg was easily drawn away from itsfellow, but could not be carried inwards, showing that there was ex- tensive rupture of the internal lateral ligament. There was no contusion of the soft parts, nor any discoloration of the integuments. Chloroform having been administered, a stout lac was applied to the upper part of the thigh, and confided to an assistant, to make the requisite counter- extension, while extension was made by another assistant grasping t°he foot, the limb being in the extended position. Placing now my left forearm be- hind the knee, and requesting the aids to pull gently and steadfly, I suddenly, , with my right hand, bent the leg backwards, and thus in a few seconds effected the reduction ; the bone slipping into its proper situation with a distinct snap. The limb being placed in an easy position, cold cloths were applied to the knee, and a grain of morphia administered to allay pain and prevent spasm. Xo untoward symptoms appeared after the reduction. The patient kept her bed for nearly a fortnight, and medicated lotions were applied, after the first twenty-four hours, to moderate aud subdue inflammation. Purgatives and light diet were also enjoined. In due time passive motion was instituted ; the limb was frequently bandaged ; and in less than a month from the time of the accident, the woman was able to. walk about the house with the aid of crutches. The joint, however, remained weak for a long while, and even now, 172 DISEASES AND INJURIES OF THE JOINTS. several years after the occurrence of the injury, the slightest fatigue is attended with temporary lameness. 2. Luxation of the tibia backwards, fig. 76, is so rare an accident that the possibility of its occurrence was called in question by many of the older sur- geons. Modern experience, however, has not only shown the error of this opinion, but has pointed out with great accuracy the mechanism, signs, and method of reduction of the displacement. The causes by which it is produced are similar to those which give rise to luxation forwards. The head of the tibia lies in the popliteal region, where it compresses the vessels and nerves of that name, at the same time that it pushes back the popli- teal and other muscles, and.forms a distinct promi- nence, easily perceptible by the sight and touch. In front of the joint is the large projection representing the condyles of the femur, and immediately below these again is the patella, with a strongly marked depression on each side, its ligament being drawn tightly under the articular surface of the thigh-bone, and the tendon of the extensor muscles firmly stretched.. The leg has the appearance of being slightly rotated, and is always considerably shortened, though less so than in the luxation forwards. In regard to its posi- tion, no definite rule can be laid down, as it varies much in different cases, being at one time in a state of flexion, and at another in a state of extension, both extremely uncertain in their extent. The reduction is effected upon the same principles as in dislocation forwards, the thigh 'and leg being pulled in opposite directions, and pressure made upon the head of the tibia/while the patella is fixed by the hand in front. 3. The lateral dislocations of the tibia are always incomplete. They occur with nearly equal frequency, generally in consequence of falls, or of the pas- sage of the wheel of a carriage, in which the femur is violently twisted while the leg itself is firmly fixed. Another cause is force applied to the lower and lateral part of the leg at a mo- Dlslocation of the tibia back ward. Fig. 77 Dislocation of the tibia inward. Dislocation of the tibia outward. ment when the knee rests' upon a hard, resisting object and the trunk is inclined sideways, thus throwing the whole strain upon the edge of .the joint. Much injury of the soft parts almost always attends these displace- ments, and the leg generally presents a remarkably twisted, appearance. In the luxation inwards, fig. 77, the head of the tibia is thrown off the corresponding condyle of the femur, and forms a- large tumor at the inner side of the knee. In the displace- ment outwar&s, fig. 78, the signs are reversed, the tibia project- ing at the external aspect of the joint, and the condyle at the DISLOCATION OF THE SEMILUNAR CARTILAGES. 173 inner. The leg, in both cases, is slightly flexed and rotated on its axis, the extensor muscles are relaxed, and a marked depression exists in the natural situation of the patella, which js pushed to one side or the other, according to the character of the displacement. The diagnostic signs are the twisted state of the limb, and the great increase of the width of the joint. Owing to the extensive laceration of the ligaments of the joint, the lateral dislocations are reduced with great facility. All, in fact, that is necessary, is, ■ while the thigh is fixed by an assistant, to pull the leg by grasping it just above the ankle, and to push the head of the tibia in a direction contrary to that of its displacement. The after-treatment of all these luxations must be conducted upon strictly antiphlogistic principles. The patient should be confined to his bed for at least a month, and blood should be taken freely by leeches, and even by the lancet, if he be robust, or the inflammation run at all high. The great danger is anchylosis, which it will require the utmost care and diligence to prevent. The*joint must be supported in an easy position, and passive motion must not be instituted too%oon, lest it interfere with the reunion of the ruptured ligaments. When the patient is able to walk about, the knee must be pro- tected with ajaced-cap, and its tone improved by the cold douche, stimulating embrocations, and dry friction. Compound dislocations of the knee are not of unfrequent occurrence, and are always to be dreaded on account of the constitutional sympathies which they are apt to awake. When the joint is freely laid open, and the soft parts are otherwise seriously injured, there can hardly be any doubt as to the propriety of immediate amputation, for such cases nearly always terminate unfavorably, the patient dying either or* tetanus, pyemia, traumatic fever, or excessive suppuration ; or, if he chance to recover, he will owe his life rather to his good luck than to the good management of his attendant. It is gene- rally difficult to make the patient comprehend the importance of what will always appear to him so harsh a measure, especially if he be a young man of temperate habits, and in excellent health $t the time of the injury; he will resist the operation in spite of the arguments and entreaties of his surgeon, and win only consent when it is too late for him to be benefited. I am satis- fied that there is no class of lesions more dangerous both to life and limb than compound dislocations of the knee, especially when at all severe; and I, therefore, do not hesitate to recommend the prompt adoption of decisive measures. When the#oft parts are not too much affected, resection may be advantageously substituted for amputation, though, in general, the latter is 'unquestionably the safer procedure. Examples of congenital luxation of this joint have been reported by differ- ent authors, as Cruveilhier, Robert, Gueriu, Kleeberg, and Bard. The displacement, which is generally incomplete, and associated with other mal- formations, may occur in any direction, but that forward is by far the most common. DISLOCATION OF THE SEMILUNAR CARTILAGES. The semilunar cartilages are subject to a species of displacement known under the name of subluxation, an affection which was first described by Mr. Hey, of Leeds, and which is most commonly met with in feeble, delicate per- sous, who have suffered from chronic disease of- the knee. A sudden and forcible twisLof the joint occasioned by striking the toes against a stone, or an accidental slip in walking while the foot is turned inwards and the thigh outwards, is the usual cause of the mishap. The lesion essentially consists tin the partial removal of the semilunar cartilages from their natural position, tnirs allowing them to become wedged in between the tibia and femur, simply 174 DISEASES AND INJURIES OF THE JOINTS. in consequence of the relaxed condition of their ligamentous connectipns. Occasionally, however, the wrench is so violent as to detach some of these connections from the bone. Well-marked symptoms always attend this form of luxation. The patient is suddenly rendered conscious of some accident, which causes him to feel faint and sick, and immediately compels him to sit down. The pain is very excruciating, and he is unable to stand, or to extend the limb, which is gene- rally semiflexed. If the joint be examined within a few minutes after the occurrence of the injury its size and shape will be found to be perfectly natural, and the inexperienced surgeon will probably conclude that the case is one merely of slight sprain. In a short time, however, considerable swell- ing sets in, and the articulation before long imparts a distinct sense of fluc- tuation from a deposit of synovial fluid, consequent upon inflammation of its lining membrane. The excessive pain and shock are due to the pressure which the tibia and femur exert upon the displaced cartilages, in consequence of the changes in their mutual relations, and, also, to the forcible distension of some of the ligamentous structures of the joint. Trfe dislocation, having once taken place, is extremely liable to recur from the most trivial causes; and under such circumstances I have repeatedly noticed that, although the patient was always obliged to keep his leg in a slightly bent position, yet he was able, when he sat on a high seat, to move it nearly as well as the sound one. The reduction should not be attempted unless the patient is under the in- fluence of chloroform, as otherwise it will be very painful. The most eligible position is the recumbent, the thigh being strongly flexed upon the pelvis. -The surgeon, placing his arm in the pqpliteal hollow, and grasping the limb just above the ankle, bends the knee suddenly and forcibly, and then rapidly extends it, at the same time imparting a movement of rotation to the leg. By this triple manoeuvre the pressure of the condyles is taken off from the semilunar cartilages, and the parts are enabled to return to their natural situation. Sometimes the ingenuity of the patient will enable him to effect reduction when that of the surgeon fails. Sir Astley Cooper mentions the case of a gentleman who was in the habit of relieving himself by bending.the thigh inwards and pulling the foot outwards, as he was sitting on the floor. In some instances, again, the parts are found'to return of their own accord after the usual means have failed, either while the patient is seated, or lying asleep in bed. „ . • It is always proper after such an occurrence that the joint should be kept for a few days perfectly at rest until it has, in some degree, recoveredjts original tqne ; and when the patient begins to exercise he should wear a laced knee-cap, and guard against any sudden twist of the limb, a recurrence of the dislocation being, as already stated, extremely prone to happen after all in- juries of this kind. Sorbefacient liniments and the cold douche will be of service in promoting the removal of effused fluids, and imparting vigor to the relaxed structures. DISLOCATIONS OF THE HIP-JOINT. Dislocations of the ileo-femoral joint are far less frequent than those of the shoulder, a circumstance which evidently depends more upon the peculiarity of structure of these articulations than upon any difference in their motions, which are sufficiently free and varied in both, though certainly Jess so in the former than in the latter. The hip-joint affords the best type of the ball and socket joint with which we are acquainted. The acetabulum is of immense depth, and, therefore, furnishes ready accommodation to the large and well- formed hemisphere which constitutes the head of the femur. The glenoid DISLOCATIONS OF THE HIP-JOINT. 175 cavity of the scapula, on the other hand, is very shallow, and yields very in- adequate support to the head of the humerus, in the varied and extensive movements of the shoulder. Besides, there is a great difference in the liga- ments which bind the bones to each other in these articulations. The capsu- lar ligament of the shoulder is comparatively weak, while that of the hip is by far the most powerful in the body, at the same time that it is most closely and firmly fitted round the parts which it is designed to retain and to protect. In addition to this, the latter has a ligament peculiar to itself, the inter-ar- ticular, which serves to connect the head of the bpne directly to the margin of the acetabulum, an arrangement which is altogether wanting in the shoulder, the long.head of the biceps forming a very imperfect substitute. Finally, the hip-joint is under the cover an'd protection of large and powerful muscles, which are much more capable of resisting the effects of dislocating agents than those of the shoulder, which, in fact, often rather promote the occur- rence of the accident, if they do not actually produce it by their own ill-di- rected efforts. Dislocations of the hip-joint are much less frequent in women than in men, owing, no doubt, simply, to the differences in their occupations. If women were as constantly exposed to all kinds of external violence, es- pecially to falls and blows, as men are, we could not hesitate to believe that they would suffer quite as oftgn, not only from luxations of the hip-joint, but from those also of the other articulations, which, however, as is well known, is far from being the case. Dislocations of the shoulder occur at least from sfx to eight times as frequently in the male as in the female, and in the ileo- femoral joint the difference is still more remarkable. Displacement of this joint is, next to that of the shoulder, more frequent than in any other joint of the body. Of the cases collected by Malgaigne, 491 in all, 321 occurred in the shoulder and 34 in the hip, the clavicle coming next in order. Age exerts an extraordinary influence upon the production of these acci- dents. It is a very uncommon thing to meet with a luxation of the hip-joint in children, because a degree of force capable of causing the mischief in the adult would be more likely to lead to separation of the epiphyses of the bone, owing to its imperfect development, and consequent inability to resist external injury. In the aged the lesion is also unusual, for at that period of life the osseous tissue being very brittle is extremely liable to be broken by the slightest causes. Hence, fracture of the neck and upper extremity of the femur is much more frequent in both sexes after the age of fifty-five "than displacement of the head of that bone from the acetabulum. The accident often occurs in young men from twenty to twenty-five, but there is no time of life in which it is so frequent as in that which intervenes between twenty-five and forty- five. The youngest case of dislocation of the hip-joint probably on record is one related by Mr. Image, of England, as having occurred in a boy only three years and a half old. Sir Astley Cooper refers to one which happened to a child of seven, and Mr. Benjaman Travers, Jr., saw one at the age of five. The head of the femur is susceptible of being dislocated in four principal directions; upwards, upon the dorsal surface of the ilium ; backwards, into the sciatic notch ; downwards.into the thyroid foramen ; and forwards, upon the pubic bone. Of these displacements the first is by far the most common ; next in order of frequency is that into the sciatic notch, and the rarest of all is Uie last. Sir Astley Cooper, whose experience in dislocations of .the hip- joint was very great, estimated that out of every twenty cases twelve would be on the dorsal surface of the ilium, five in the sciatic notch, two in the thy- roid foramen, and one on the'pubic bone. I am sure that the observation of most surgeons must accord, in a general manner, with this opinion. To, the extreme rarity of the last two forms of luxation every one can bear testimony. 176 • DISEASES AND INJURIES OF THE JOINTS. The reason of the great frequency of iliac dislocations is to be found, I pre- sume, rather in the position in which the thigh is usually placed at the mo- ment of the accident than in any differences in the structures of the hip-joint at particular portions of its extent, certain attitudes of the limb always favor- ing the occurrence of certain displacements. Besides the varieties of luxations now enumerated, there are several others which, although extremely infrequent, are too ituportant to be omitted in a systematic treatise on surgery. These will, therefore, be briefly described under another head, as rare, unusual, or anomalous dislocations of the ileo- femoral articulation. It will greatly simplify the study of the four principal varieties of this acci- dent if we describe them as the iliac,-sciatic, thyroid, and pubic, terms which every one understands, and which cannot fail to convey a clear general idea of the locality of each displacement to which they refer. All these luxations are complete, the head of the femur being forced en- tirely out of its socket. Great violence is necessary for their production, and they always take place so much the more easily in proportion as the force is diffused over a large surface. I am not acquainted with a solitary instance in which they were the direct and immediate result of muscular contraction, as occasionally happens in dislocations of the shoulder-joint. Such an event could occur only where there is previous disease of the articulation, destroy- ing its ligamentous connections. The violence may act either directly upon the hip, or indirectly through the knee or foot, and the nature of the dis- placement will depend upon the direction in which it is applied. Thuf, luxation into the thyroid foramen can only be produced when the limb is powerfully abducted at the moment of the accident, and the occurrence will be promoted if the strain be increased by the person having a heavy weight upon his shoulder. In every dislocation of the hip there must necessarily be extensive injury to the soft parts. The capsular and inter-articular ligaments are of course torn, and the same fate is nearly always shared by the rotator muscles of the femur. The two large gluteal muscles, however, and the psoas and iliac, which are attached to the small trochanter, usually escape, or are, at most, only put upon the stretch. When the external violence has been uncom- monly severe, a considerable effusion of blood may be expected in and around the joint, and there will be likely also to be more or less contusion of the integuments and muscles, especially if the injury has been direct. 1. In the iliac dislocation, the head of the femur is thrown upwards and backwards upon the dorsal surface of the ilium, fig. 79, resting in the fossa of that bone, on the small gluteal muscle. In some cases, though rarely, it is thrust a good deal forwards instead of backwards. The signs of the accident, fig. 80, are sufficiently obvious, exhibiting rarely any material variation. The hip is considerably deformed, being more salient than naturally, the upper part of the thigh is unusually full, and the gluteo- femoral crease is on a higher plaile than common. The great trochanter is carried upwards and inwards, in closer proximity with the anterior superior spinous process of the ilium, and is more conspicuous than in any other acci- dent, except coxalgia. The head of the bone can be felt in its new situation, particularly in thin, lean subjects, and on rotating the thigh it is found to roll about under the finger. The limb is from an inch aud a half to two inches and a half shorter than in the normal state; the foot is strongly in- clined inwards, the big toe pointing towards the opposite tarsus; the knee, as the patient stands, is. seen to be a little above and somewhat in advance of the sound one, any attempt to turn it out? proving impracticable, and causing severe pain; the thigh is slightly bent upon the .pelvis, and may with a little effort be carried across the sound one; the leg is flexed upon the DISLOCATIONS OF THE HIP-JOINT. 177 * thigh; the heel is raised off the floor; and the limb, firmly fixed in its con- strained position, cannot be restored to its proper length without reducing the dislocation, nor can it be moved except a little inwards. When the pa- tient Jies down, the foot rests on the bed, but the knee is considerably raised, and all attempts to extend it are found to be unavailing. Fig. 79. Fig. 80. Dislocation on the dorsum of the ilium. The luxation is generally occasioned by falls upon the knee or foot while the thigh is strongly adducted and thrown forwards beyond the line of the body. In this way the head of the femur, being powerfully rotated inwards, is thrust forcibly upwards and backwards, tearing the capsular ligament in that direction, escaping from the acetabulum, and lodging in the lower part of the iliac fossa, under the small gluteal muscle. The accident may also be produced by violence applied directly either to the hip or to the upper ex- tremity of the femur, as by the fall of a heavy body, when the limbs are widely separated, and the trunk is inclined strongly forwards. The two ob- turator, geminal, square and pyriform muscles are greatly stretched, and sometimes even partially ruptured, while the psoas and iliac are both relaxed, as are also the adductor, pectineal, aud gluteal. The round ligament is of course torn. The powerful tension into which the external obturator muscle, a fleshy mass of large size and great strength, is thrown by the accident, is the immediate cause of the immobility of the limb, of the inversion of the foot and knee, and of the excessive pain which follows any attempt at rotation and abduction. The diagnostic signs of the dislocation are, the great prominence of the trochanter and its proximity to the anterior superior spinous processes of the ilium ; the inverted and shortened state of the limb ; the fixed position of the head of the bone in its new situation; and the impossibility of abducting and rotating the knee. The only accident with w,hich this luxation is at all likely to be confounded is fracture of the neck of the femur, fig. 81, within the capsular ligament. In general, however, the diagnosis is established with great facility. All, vol. n__12 178 DISEASES AND INJURIES OF THE JOINTS. in fact, that the surgeon has to do, is to remember that, in fracture, the trochanter is drawn backwards, and less salient than usual; that the foot is everted instead of being inverted, as in luxation; Fig. 81. that the limb can be readily restored to its proper length by extension, but that it will immediately resume its former position when the extension is discontinued; and, finally, that, when the ends of the fragments are brought in contact with each other, crepitation may promptly be elicited by rotating the thigh. Moreover, the limb may be moved, although not without great suffering, in every direction, and not merely inwards and slightly upwards, as in dislocation. Difficulty in regard to the diagnosis occasionally arises from injury of the superior extremity of the femur, attended with fracture of the great trochanter, in consequence of the detached fragment being drawn upwards and backwards by the action of the muscles, into the fossa usually occupied by the head of the bone in luxation. The signs of distinction are, the mobility of the broken piece, the absence of inversion of the limb, and our ability to qarry the thigh about in dif- ferent directions, although not without severe pain. The degree of shortening attending the iliac variety of displacement is best ascertained by extending apiece of tape, or a graduated measure, from the anterior superior spinous process of the ilium to the centre of intra-capsuiar fracture of the tuberosity of the internal condyle on each side; the thigh-bone. Or, instead of this, the tape may be carried along the middle line of the body, from the centre of the fourchette of the sternum to the sole of the foot, placed at a right angle with the leg. The difference in the#result will indicate the extent of the defect. There is considerable variation in regard to the amount of shortening in different cases. On an average, it may be stated to range from two inches to two inches and a half; but occasionally it is as much as three inches and a half, and, on the other hand, as little as an inch and a half. It is surprising that writers .should invariably insist upon stating that there is less prominence of the great trochanter in this variety of luxation than natural, whereas a little reflection will serve to convince any one that such an opinion is altogether untenable. To prove the truth of this remark it is only necessary to examine the position which the femur assumes in consequence of the dislocation. The whole limb being strongly rotated inwards, the tro- chanter, as it lies in its new situation just above the rim of the acetabulum, or partly above and partly below, is necessarily tilted up and brought for- wards, so as to augment, in a very striking degree, its saliency beneath the integuments and muscles of the gluteal region. An excellent idea of the changes produced in the projection of the trochanter may be formed by alter- nately everting and inverting the foot strongly in the ordinary standing atti- tude, so as to make, on the one hand, the big toe of the rotated limb point against the opposite tarsus, and, on the other, against the hollow between the tendo Achillis and the inner malleolus. In the former position, the bony eminence will be remarkably prominent, jutting out as a rounded mass, whereas in the latter it will hardly be perceptible, or, at all events, compara- tively small. In displacement of the head of the bone upwards and back- wards, the projection is abnormally distinct, and js, therefore, a sign of great diagnostic value. The reduction of this dislocation, thanks to the researches of Dr. W. W. DISLOCATIONS OF THE HIP-JOINT. 179 Reid, of Rochester, is no longer, as it once was, the dread of the surgeon and the terror of the patient. In a paper, characterized by great clearness of 'style, published in 1851, that gentleman showed, for the first time, by a series- of admirably conducted experiments, dissections, and clinical observations, that the chief impediment to restoration is not, as was formerly supposed, the contraction of the muscles that are affected by the accident, but the indirect action of the muscles that are put upon the stretch by the malposition of the dislocated bone, and that the operation may always be safely, certainly, and expeditiously performed, simply by manual 'effort, without any assistants, pulleys, or, in short, any extraneous aid whatsoever. In awarding to Dr. Reid the honor of this method of reduction, I am not unmindful of the circumstance that some of the older practitioners occasionally pursued a similar procedure; nay, that the method is even dimly shadowed forth in the writings of Hippocrates; that it was distinctly taught for a num- ber of years by Dr. Nathan Smith, in his annual courses of lectures; that attention was called to the subject afterwards, namely, in 1831, by his son, Dr. X. R. Smith, of Baltimore, in his Medical and Surgical Memoirs ; that Physick performed the operation successfully before his class early in the present century; and that, in later times, cases have occasionally appeared in the foreign medical journals, showing that it had also now and then suc- ceeded in the hands of European surgeons. All this is matter of history. But Dr. Reid may justly claim for himself the great credit of having dis- covered the principle upon which the method is founded, and of having pre- sented the whole subject in so clear and forcible a manner, to the notice of the profession, as to acquire at once its undivided confidence. The operation, as performed by Dr. Reid, consists of certain processes and evolutions, in which the shaft of the femur is employed as a lever, and the pelvis as a fulcrum, the object being, in the first instance, to dislodge the head of the bone from its new situation, and then to induce the muscles to pull it downwards and inwards into the acetabulum, thus compelling it, as it were, to retrace its steps along the route which it travelled in the dislocation. In conducting the operation, the most eligible plan is to make the patient lie . upon the floor, as this affords a much firmer resistance than a lounge, bed, or low table, and gives the surgeon, moreover, a better opportunity of placing himself in any attitude that may be deemed requisite. The patient should be thoroughly anaesthetized, and if he be unusually stout and plethoric, it will not be amiss to bleed him copiously at the arm, as a preliminary measure, though in general this will not be necessary. In the female, exposure of the person is avoided by means of a sheet. The operation may be described, for the sake of greater simplicity, as con- sisting of three stages. In the first, the surgeon, grasping the knee with one ' hand, and the leg just above the ankle with the other, flexes the thigh upon the pelvis, and the leg on the thigh, carrying the limb across the sound one, and the knee over the abdomen as high up as the umbilicus. In the second stage, the knee is turned outwards on a line with the injured side, a procedure which will draw the big toe from its inverted into an everted position, and, of course, incline the heel proportionately inwards, or in the opposite direc- tion. In the third stage, the foot is carried across the sound limb, and the knee pushed outwards and downwards, when, the thigh being gently rotated, the head of the bone slips at once into its socket, with an audible jerk, and the injured limb resumes its natural position. The whole operation may usually be performed in less than two minutes. On one occasion, I am sure, it did not occupy'me* half that time. It is impossible to conceive of anything more simple, efficient, and philosophical, than the whole proceeding. As Dr. Reid'justly observes, it not only relaxes the muscles concerned in the dis- placement, but it absolutely compels them, by their own efforts, to draw the 180 DISEASES AND INJURIES OF THE JOINTS. bone into its proper position, making them thus, with a little effort on the part of-the surgeon, the reducing agents. 2. The sciatic dislocation commonly results from falls or other violence applied to the foot or knee while the body is strongly inclined forwards upon the thigh, or the thigh upwards upon the pelvis. * In either case the head of the bone/breaking through the posterior and lower part of the capsular liga- ment, slips backwards from its socket, and takes up its abode in the sciatic notch, resting upon the pyriform muscle, between the sacro-sciatic ligaments and the convex surface of the iliac bone. The capsular ligament is severed, and the psoas, iliac, and obturator muscles are put upon the stretch, and occasionally otherwise injured. The symptoms of this dislocation bear so close a resemblance to those of the iliac that several late writers are disposed to regard them merely as modi- fications of the same lesion, the one being an exaggerated form of the other. I have myself always looked upon them as separate and distinct varieties, and shall, therefore, so con- sider them on the present occasion. The adjoining sketch, fig. 82, conveys an excellent idea of the ap- pearances presented by the injured limb, and a com- parison between it and the preceding will serve to show that they differ from those of the iliac luxation only in being less marked. The limb is shortened from half an inch to an inch, and so firmly impacted in its new position that it is impossible to bend or rotate it; the great toe rests against the ball of the sound one ; the knee is turned in and advanced over the opposite one, but not so much as in the disloca- tion upwards; the trochanter, which is uncommonly prominent, is lower down than natural, and conse- quently further off from the anterior superior spinous process of the ilium ; and the head of the bone is so deeply buried in the sciatic hollow as to render it very difficult to detect it by the finger, except in thin, emaciated persons. Both the thigh and leg are slightly flexed. The characteristic signs of the dislocation are, the situation of the head of the bone behind and below the acetabulum, a short distance above the tuberosity of the ischium ; the comparatively slight shortening of the limb; the firm impaction of the thigh in its new locality; and the unusual distance between the Dislocation into the sciatic trochanter and the spine of the ilium. notch. In a case of sciatic dislocation .which was recently under my charge, in a rather thin man, twenty-eight years of age, I took special pains to make a most accurate examination, and, from notes taken at the moment, I am enabled to append the following state- ment. The limb was nearly one inch shorter than the sound one, and strongly flexed at the knee. Wrhen an attempt was made to bring the thigh and leg in a straight line, the man complained of severe pain, and immediately raised his loins, so that it was quite easy to pass the fist and arm underneath. When the body was extended, the knee became immediately bent, just as it was at the time of the accident. The limb lay close by the side of its fellow, and could neither be carried backwards nor outwards, but'was easily flexed on the pelvis. When the man stood up, he threw his body very much forward, and the limb hung close by the side of the other, the knee being far in ad- vance of the sound one and crossed somewhat over it; the foot was almost DISLOCATIONS OF THE HIP-JOINT. 181 parallel with the other, but the heel was raised from the floor nearly two inches. Both in standing and lying, the trochanter was at least one inch further off from the anterior superior spinous process of the ilium than the opposite one, besides being unusually prominent; and the head of the femur could be distinctly felt on the dorsal surface of the ilium, at the upper part of the sciatic notch, rolling under the finger when the limb was rotated upon its axis. The following case of unreduced sciatic dislocation of the left side, which I had an opportunity of dissecting some time ago, will serve to illustrate the morbid anatomy of this form of injury. The patient was a man, aged twenty- five, who had met with the accident more than eight years previously. The knee and foot were much inverted, there was shortening of nearly one inch and a half, and the whole limb had a wasted aspect. The external gluteal muscle was nearly normal, but the middle and internal were exces- sively atrophied, shortened, and confused together, their fibres being very pale, sparse, and partially transformed into fatty and fibrous tissue. The pyriform, also much reduced in size, was stretched over the head of the femur, and inseparably blended with the inner and middle gluteal. The geminal muscles and the tendon of the internal obturator were elongated, and twisted round the neck of the bone. The quadrate was lengthened, but not other- wise perceptibly changed. » The great trochanter was three inches and a half from the anterior supe- rior spinous process of the ilium, and four in- ches and a half from the crest of that bone, its Fig. 83. top being on a line perpendicular with it. The head of the femur lay across the upper part of the sciatic notch, being two inches from the tuberosity of the ischium, and a few lines from the posterior inferior spinous process of the ilium, its distance from the crest of-that bone being two inches and threes-quarters. It was nearly completely divested of cartilage, and very rough, being studded with numerous little bony eminences. Surrounding it was a false capsule, varying in thickness from a fourth of a line to a line and a half, and composed princi- pally of the remnants -of the pyriform and the two small gluteal muscles ; it was translucent at several places, rough on its inner surface, with here and there a serous, glistening point, and presented a large quantity of reddish fila- mentous tissue, just below the head of the bone, to which and to its neck it was firmly adherent. The ilium and sciatic ligaments, which accommo- dated the bone Were SOUnd, and it Was evident, Dislocation into the thyroid foramen. from the manner in which the parts had been impacted, that but little motion existed after the accident. The acetabulum was nearly filled by a fibro-cartilaginous substance, its edges having been rounded off'by absorption. No trace could be discovered of the capsular and round ligaments. 3. In the thyroid dislocation, fig. 83, the head of the femur is thrown downwards and forwards into the thyroid foramen, resting upon the external obturator muscle by which that opening is covered in, the great trochanter being turned backwards towards the acetabulum. It is caused by falls upon the foot or knee while the- thigh is widely separated from its fellow, and in- clined sharply backwards. It may also be occasioned by a heavy body, such, 182 DISEASES AND INJURIES OF THE JOINTS. for example, as a sack of corn, striking the hip while the limb is in a state of abduction, and the trunk bent forwards. The gluteal muscles are drawn downwards, considerably flattened, and put upon the stretch ; the pyriform is elongated and tense; the inter-articular ligament and the lower portion of the capsular ligament are torn; and the extensor muscles of the thigh form a hard, firm mass, reaching from the pubic bone to within a short distance of the knee. The symptoms, as seen in fig. 84, are remarka- bly prominent and distinctive. The hip has lbst its convexity, and in place of the projection formed by the trochanter there is a decided flattening, and sometimes even a positive depression ; the tro- chanter, moreover, is removed considerably further from the anterior superior spinous process than in the natural state. The limb is increased in length from an inch and a half to two inches, and, owing to the tension of the gluteal muscles, stands off in an awkward and constrained manner from the sound one, the knees being in consequence widely separated from each other. TJie trunk is bent forwards by the actjon of the psoas and iliac mus- cles, which are greatly stretched ; and a large tu- mor is perceptible in the region of the thyroid notch, caused by the presence of the head of the femur, which, however, can only be felt distinctly in thin subjects, and in the absence of swelling. The knee is flexed, and much in advance of the sound one, and the foot, usually a little everted, is widely separated from its fellow. The move- ments of adduction, extension, and rotation are impracticable, bfit those of abduction and flexion may be executed by the surgeon, although not without excessive suffering. When the patient stands erect and is viewed in profile, the body and limbs are found to form an obtuse angle with each other, owing to the contraction of the gluteal muscles, on the one hand, and to that of the iliac and^soas on the other, the latter forming at the same time a tense ridge on the side of the thigh, perceptible both to sight and touch ; the toes rest on the floor, while the heel is usually somewhat elevated; the hip, by its flattened condition, contrasts strikingly with its fellow ; the femoro-gluteal crease is lower down than natural; and the knee is observed to be greatly in advance of the opposite one. If the patient be requested to extend bis body so as to bring it on a line with the thighs, he will find himself incapable of doing it, and will suffer severe pain in consequence of the attempt. The diagnostic signs are, the widely separated state of the knees, the elon- gation of the limb, which does not exist in any of the other luxations of the hip, the forward inclination of the body, the flattened state of the nates, the excessive tension of the iliac and psoas muscles readily felt by the finger, and the impossibility of adducting, extending, and rotating the leg. Another good sign is afforded by the great trochanter, which will be found to be far- ther off from the anterior superior spinous process of the ilium in dislocation than its fellow is on the opposite side. ' • 4. The pubic variety of dislocation is extremely uncommon, -and might therefore almost be classed among the rare forms of the accident. As the name implies, the head'of the femur lies upon the horizontal branch of the Dislocation into the thyroid foramen. DISLOCATIONS OF THE HIP-JOINT. 183 pubic bone, ,fig. 85, above Poupart's ligament, and external to the femoral vessels, under cover of the iliac, psoas, and straight muscles. The displace- ment is caused by falls while the limb is pushed backwards and outwards, and there is a heavy load upon the shoulder, as when a man carries a bag of wheat, and his feet suddenly give way under him. Another mode in which it may be produced is by the sudden bending of the body backwards; while the foot is implanted in a ditch or hollow, and the femur is kept straight by the action of its extensor muscles. Under these circumstances the head of the bone ruptures the upper and inner portion of the capsular ligament, and slips out of its socket into the situation adverted to. Fig. 85. Fig. 86. Dislocation on the pubes. In this luxation, fig. 86, the limb is about an inch shorter than the other; the foot and knee are everted, and separated from their fellows, though in a less degree than in the thyroid displacement; the buttock is flattened; the great trochanter lies nearer the middle line than naturally; the femoro-gluteal fold is above its ordinary level; and a distinct prominence, hard, rounded, and easily impressed by rotating the leg, exists in the groin, just above Poupart's ligament, representing the head of the femur. Adduction and rotation in- wards are impracticable. In a case of pubic, dislocation seen by Physick, in 1805, the head of the bone lay beneath Poupart's ligament, and the limb was a little longer than the sound one. Larrey saw an instance in which the femur lay nearly at a right angle with the body. The flattening of the buttock, the slight shortening of the limb, the ever- sion of the toes, the impossibility of rotating the thigh, and the existence of the head of the bone in the groin, are marks which sufficiently characterize the accident to prevent mistake. General Diagnosis.—If we compare these four varieties of luxations with each other, we shall find, with the exception of the first two, sufficiently broad 184 DISEASES AND INJURIES OF THE JOINTS. marks of dissimilarity to render the diagnosis, with a little care, quite easy. The thyroid is the only one in which there is any lengthening of the limb;*in all the others it is shortened, least in the pubic, and most in the iliac. In the iliac and sciatic the hip is abnormally prominent; in the other two it is flattened; in the former the knee and foot are inverted, in the latter they are everted, decidedly in the pubic variety, and generally very slightly .in the thyroid. In all the head of the bone may generally, with a little care and patience, be perceived by the touch in its abnormal position, especially in thin persons, and before the occurrence of much swelling, rolling about when the leg is rotated upon its axis. The great points to be attended to, when- ever there is any doubt respecting the diagnosis, are the state of the limb as to the change in its length, axis, and movements; the position of the great trochanter, especially its distance from the anterior superior spinous process of the ilium; and the location of the head of the bone and our ability or inability to feel it in its new situatidn. If the surgeon will only give proper heed to these considerations, he will seldom be long in doubt as to the cha- racter of the injury he is obliged to diagnosticate and treat. The investiga- tion will, of course, always be materially facilitated by the use of chloroform. When all the ordinary means, such as the most thorough and patient exa- mination with the touch, sight, and mensuration, fail, the mystery may often be solved with the exploring instrument, inserted at various points of the hip, and moved about in different directions in search of osseous prominences and depressions. A long, slender needle, sinking in to a great depth in the natural situation of the acetabulum, would infallibly declare the absence of the head of the thigh-bone, as the existence of an unusual osseous tumor out- side of that cavity would certainly indicate the location of that bone in its new position. As there are no important vessels or nerves in and about the hip, such a procedure would be entirely free from the danger of hemorrhage and even pain. My opinion, however, is that this method of exploration, although perfectly safe and easy, will rarely be necessary in any case, the nature of the lesion being generally too well marked to elude detection. GENERAL REMARKS ON REDUCTION IN HIP-JOINT DISLOCATIONS. Having already described what is, in my opinion, the most unexceptionable method of reduction in the iliac dislocation, it is only necessary to add that the same mode of treatment is applicable to the other varieties. I restored by this method, three years ago, with the greatest facility, a sciatic luxation of seventeen days' standing, and cases have of late been reported in the medical journals where it was employed successfully and without difficulty in the thyroid and pubic forms of the accident. Indeed, there can no longer be any doubt that it is the only true method in all dislocations of the hip- joint, the only exception being in chronic cases ; but even here it will proba- bly be found that it will generally succeed, provided it be applied in a proper manner, and with the requisite degree of patience and perseverance. In a case of iliac displacement of one month's duration, which I had under my care in 1855, in a stout, muscular man, aged twenty-two, I succeeded per- fectly, by manipulation alone, after complete failure with the pulleys employed for nearly an hour and a half, the patient being all the while thoroughly re- laxed by chloroform. In the pubic and thyroid dislocations, reduction has occasionally been effected by the heel in the perineum, the patient and surgeon lying in oppo- site directions, as in luxations of the shoulder. The pelvis being thus firmly fixed by the foot, extension is made by grasping the leg above the ankle, the limb being gradually carried over the sound one as the head of the bone approaches the cotyloid cavity. Or, instead of this, the leg may be flexed DISLOCATIONS OF THE HIP-JOINT. 185 at a right angle ivith the'knee, and a long, stout noose' secured round the lower part of the thigh, and thrown over the operator's neck and shoulder, which will thus afford him much greater control over the limb. This method, however, which recommends itself by its simplicity, is applicable only in very thin, feeble subjects, offering but little muscular resistance. In the dislocation into the thyroid foramen, Dr. Brainard has of late adopted a plan which seems to be worthy of constant trial. It consists in placing a piece of wood, properly padded, as a fulcrum, into the perineum, between the thighs, which are then used as levers, the knees being extended during the operation, and the limbs closely approximated, or even slightly crossed. In this manner he has promptly succeeded in effecting reduction in four cases, in one of them after the fruitless employment of the pulleys and Jarvis's adjuster. The diameter of the fulcrum should not, on an average, exceed four inches and a half, otherwise it might prevent the head of the femur from rising out of its abnormal position, and thus endanger the occur- rence of fracture of its neck. When manipulation fails, as it occasionally will, especially in very stout, robust persons, and in cases of a chronic character, recourse must be had to the pulleys, for then even severe measures would be preferable to leaving the dislocation unreduced, and letting the patient remain a cripple for life. The general principles which should guide the practitioner in the use of these instruments have already been pointed out. I shall, therefore, limit myself here to a brief description of the operation as applicable to the several varie- ties of dislocations of the hip. The patient should be laid on his back on the floor, or on a firm table, lounge, or bed, between two strong objects, from ten to twelve feet apart, in each of which a large hook is fixed. A stout piece of muslin, neatly folded, soft, and at least four yards in length, is placed in the perineum, and being carried over the groin and buttock, its ends are tied together, and fastened to the hook behind the patient's head. Another band is carried round the upper part of the pelvis, and given to an assistant, its object being to prevent the injured, hip from being drawn down during the operation. Finally, a large wet napkin js rolled round the lower part of the thigh, and over this is buckled a leather'band, having two lateral straps provided each with a ring. Or, instead of the strap, a stout fillet is employed, being fastened by means of a wet roller, or the French knot, the ends being so disposed as to come down on eacb side of the knee, a little below which they are to be tied. The knee being now bent nearly at a right angle, and inclined a little across its fellow, the pulleys, secured to the extending band and the staple, are put in motion by gently pulling at the cord. As soon as it is discovered that every part of the apparatus is put upon the stretch, and the patient begins to evince symp- toms of suffering, as he will be sure to do if he has not taken chloroform, the efforts are to be relaxed, to allow the muscles time to become fatigued. After having.waited a few minutes, the cord is again tightened, so as to in- crease the tension a little further, when the efforts are to be again intermitted. Taking care to proceed in this slow, gentle, and gradual manner, until the head of the femur has reached the edge of the acetabulum, the surgeon now intrusts the management of the cord to an assistant, while he himself, grasp- ing the upper part of the leg, rotates the limb in a direction contrary to that of its displacement, and thus promotes the return of the bone to its socket, the reduction being generally indicated by a distinct snap. When the head of the bone hitches against the brim of the acetabulum, its disengagement may be materially facilitated by means of a fillet placed round the groin, and thrown over the operator's neck and shoulder, so as to enable him to lift the bone up to a level with the cotyloid cavity, into which it will then be drawn by the contraction of the muscles. The length of time during which the 186 DISEASES AND INJURIES OF THE JOINTS. action of the pulleys is to be maintained must depend upon circumstances; in some cases the restoration is effected in a few minutes, in others not under .several hours. The annexed cut, fig. 87, illustrates the position of the patient during this Fig. 87. Reduction with the pulleys. Fig. 88. operation, the arrangement of the pulleys and extending bands, and the posi- tion of the limb; In the iliac and sciatic dislocations the rule is to let the patient lie on his back, and, after the extension and counter-extension have been kept up for some time, to carry the affected limb across the opposite one, as this enables the head of the bone the more easily to disengage itself from the brim of'the pelvis. In the thyroid and pubic varieties the extension is directed downwards and backwards, the foot of the affected limb being carried he- hind the sound one, and the patient 'lying upon the uninjured side.. The manner of conducting the proceeding is represented in the adjoining cuts, figs. 88 and S9. In our attempts at reduction, it occasion- ally happens that the head of the bone, instead of returning to its socket as it is being lifted out of its abnormal position, drops into some other, from which it is found to be more difficult to dislodge it than it was in the first instance. This accident is most liable to occur in the iliac luxation, .which, as the head- of the femur is moved about to disengage it from the iliac fossa, is readily converted into the sciatic. Occasionally the pubic displace- ment is changed "into the thyroid ; and an instance happened not long ago at the Pennsylvania Hospital, in the service of Dr. Neill, in which, during the re- duction, the bone was thrown out of the thyroid foramen into the sciatic notch, from which it was afterwards returned with great difficulty by means of the pulleys. These accidents are generally unavoidable ; but a knowledge of the possibility of their occurrence should put the surgeon upon his guard, that he may not be deceived under an idea that he has effected reduction when he has only succeeded in producing another displacement. Reduction of the thyroid dislocation. DISLOCATIONS OF THE HIP-JOINT. 187 When the head of the bone has resumed its original position, as may always be known by the disappearance of the symptoms, and by a comparison Fig. 89. Reduction of the pubic dislocation. of the length of the limb with that of its fellow, a return of the accident "is to . be prevented by keeping the thighs close together by means of a handkerchief or strip of bandage tied just above the knees. Recumbency will be necessary for at least three weeks; and during the first eight or ten days the hip should be kept constantly covered with cloths wrung out of a hot solution of acetate of lead and laudanum. If the inflammation run high, leeches, active purga- tion, the antimonial and saline mixture, and even general bleeding may be demanded. After the morbid action has measurably subsided, sorbefacient lotions, and passive motion of the joint will be required, to promote the re- moval of plastic matter, and prevent anchylosis. It is seldom that any of the luxations of the hip recur after the bone has been properly replaced, for such is the depth of the acetabulum and the nice adaptation of the head of the femur as to render an event of this kind ex- tremely difficult after recovery from the immediate effects of the injury. A remarkable instance, however, occasionally occurs, in which the same dis- placement happens many times in pretty rapid succession in the same person. Thus, Mr. John F. South, of London, gives the case of a woman, who, in the space of thirteen years, dislocated her femur upwards and backwards upon the ilium not less than twenty-one times; latterly from so trivial "h cause as stooping, or turning in bed. The accident first happened when she was twenty-four years old, in consequence of her slipping down on a piece of orange peel. ANOMALOUS DISLOCATIONS OF THE HIP-JOINT. The hip, like the shoulder, is subject to certain forms of displacement, to ■ which, from the infrequency of their occurrence, the term rare, irregular, or anomalous may be applied. They are perhaps, for the most part, merely exaggerated states of the more ordinary varieties of the accident, as will be rendered evident from the annexed account, comprising a succinct outline of the principal reported cases. In a majority of these the head of the femur was thrown downwards against some portion of the ischium; in one it was lodged in the perineum, and in one it was pushed upwards and inwards against the ilium, lying in the space between its two anterior superior spin- ous processes. In a case which happened to Mr. Robert Keate, the head of the bone lay close to, and on a level with, the tuberosity of the ischium, where it could be distinctly felt rolling about under the finger on moving the thigh, which was more than three inches longer than natural, much flexed upon the pelvis, and 188 DISEASES AND INJURIES OF THE JOINTS. widely separated from the sound one. The leg was greatly bent, the foot much everted, and the large trochanter extremely sunk. By drawing the upper part of the femur outwards, and pressing the knee sharply inwards, the head of the bone returned to its natural place, with a decided snap. Immediately afterwards, however, the limb could be elongated by slight traction, inducing the belief that a portion of the cartilaginous rim of the acetabulum had been broken off in the accident, which had been caused by the man falling from his horse into a deep, narrow ditch, the animal tumbling backwards upon him. A case has been described by Mr. Thomas Wormald, in which the head of the femur was dislocated downwards and backwards upon the upper part of the tuberosity of the ischium, above the quadrate muscle. It was caused by a leap from a third story window, and was attended with other injury, which soon proved fatal. The head of the femur was easily recognized in its new situation. The limb, considerably shortened and inverted, formed half a right angle with the body, and the shaft of the thigh-bone, crossing the pubic symphysis, was immovably fixed in this position. Mr. Earle was called to a case, where the head of the bone lay upon the spine of the ischium ; the limb was lengthened about half an inch, but there was neither eversion nor inversion ; the trochanter was farther back and less prominent than natural; an extraordinary vacuity existed in front of the hip; and the outline of the sartorius and tensor muscles was uncommonly distinct, their edges being tense and almost sharp. Dr. Kirkbride, of this city, met with an instance where the head of the femur rested upon the posterior part of the body of the ischium, between its ^tuberosity and spine. The thigh lay across the sound one, the leg was flexed, the limb was lengthened at least an inch, and the interval between the great trochanter and the anterior superior -spinous process of the ilium was much increased. Rotation was difficult, and extension impossible. The head of the bone was easily felt in its new situation. The reduction was effected by the pulleys, but not without difficulty, for the man was very muscular, and the bone was firmly impacted. The accident was caused by a fall from a considerable height, in which the body was crushed by a heavy piece of timber. Dr. J. M. Warren has met with two cases in which the head of the bone rested against the ascending ramus of the ischium, the thigh projecting out laterally at a right angle with the trunk. A deep hollow existed at the spot naturally occupied by the great trochanter. The reduction was effected, in one case, by manipulation, in the other, by the pulleys. Professor Willard Parker has reported a case of dislocation of the femur down into the perineum, which happened to a man, aged thirty-five, in calk- ing a boat, his body being bent strongly forwards, and his feet widely sepa- rated. Wrhile in this position, the boat fell upon him, throwing him down by the side of the timber over which he had been standing, so as to force the right thigh between it and the bottom of the vessel. Wrhen extricated from this position, the left limb was found to project at a right angle with the trunk, the nates being flattened, and the toes turned slightly inwards. The head of the bone, upon rotating the thigh, could be distinctly felt in the perineum behind the scrotum, and near the bulb of the urethra. The reduc- tion was readily effected by confining the pelvis, and extending downwards and outwards, aided by moderate rotation. In this way the head of the bone was made to ascend over the ramus of the pubes into the thyroid foramen, f'rom^ which it was afterwards conducted into the acetabulum by carrying the lirab"strongly across the sound one. A case similar to the above occurred to Professor Pope, of St. Louis, in a man, aged forty, who had his body crushed by the caving in of a bank of DISLOCATIONS OF THE HIP-JOINT. 189 earth, at a moment when he was standing in a bent position, with his limbs widely separated. The thigh, inclined somewhat forward, formed a right angle with the body, the head of the bone being felt under the skin of the raphe of the perineum. The accident was associated with fracture of the leg and arm. Reduction was effected with the pulleys, the bone returning with a loud snap. Several cases have occurred in which the head of the femur was dislocated" upwards and inwards into the space between the two anterior spinous pro- cesses. In one, examined by Mr. Morgan, the borie lay in this precise spot, and could be distinctly felt under Poupart's ligament, upon the brim of the pelvis. The prominence of the great trochanter was entirely lost, the thigh was shortened at least two inches, the toes were excessively everted, and the injured limb had a tendency to cross the sound one. Rotation was impos- sible, but all the other motions could be performed, though only in a limited decree, and not without great pain. Reduction was easily effected. A similar case has been described by Mr. Benjamin Travers, jr., caused by a fall from a height of twenty feet, in which the left buttock struck upon a coil of chain cable. Here, however, the neck, and not the head of the bone, lay between the two anterior spinous processes, the head not being perceptible. The left nates was flattened, and the limb, shortened and everted, had the appearance, when the patient stood erect, of being suspended from the anterior and lateral part of the ilium. A little below and to the outer side of this point was the great trochanter, easily distinguished by the finger. In 1858, a case occurred to Mr. Luke, at the London Hospital, in which" the head of the bone was lodged midway between the thyroid hole and the ischiatic notch, immediately beneath the lower border of the acetabulum. The limb was lengthened one inch, without eversion or inversion, and the head of the bone was easily felt in its new position. The reduction was accomplished without difficulty. The man dying from the effects of other injuries, the dislocation was reproduced in the dissection of the joint. The inferior gemellus and square femoral had been torn, the lower part of the capsular ligament had given way, and the round ligament was completely detached. The patient was a stout man, fifty years of age, and the accident was caused by a fall into a dry dock. The above cases will serve as types of most of those anomalous forms of ileo-femoral dislocations that will be likely to occur in practice. The symp- toms which attend them are usually prominent, if not positively characteristic. The treatment must be conducted according to the general principles which guide the practitioner in the management of the ordinary varieties of luxation of the hip-joint. Manipulation alone will frequently suffice to effect reduc- tion, as there is always necessarily extensive ruptare of the soft parts; where greater force is required, recourse must be had to the pulleys. In some of the cases above mentioned, the restoration was effected by a kind of compound process, the dislocation being first changed into a common one, from which the head of the bone was afterwards returned to its natural position by a second effort. CHRONIC DISLOCATIONS OF THE HIP-JOINT. Chronic dislocations of the hip-joint are occasionally brought under the observation of the surgeon, and the question, therefore, necessarily arises, when should such displacements be considered as irreducible ? It has been seen elsewhere that Sir Astley Cooper asserts that, as a general rule, it is imprudent to attempt restoration after the eighth week, except in persons of a debilitated frame, or very lax habit of body; and most English and American surgeons, adopting this view, have inculcated similar precepts. I 190 DISEASES AND INJURIES OF THE JOINTS. believe this opinion to be in the main correct, and it may even be assumed that there are not a few cases which will resist all efforts at reduction long before the expiration of this period. In an especial manner is this true of the dislocations backwards into the sciatic notch and downwards into the thyroid foramen, in which the head of the femur becomes much sooner firmly and immovably fixed in its new position than in the iliac and pubic varieties. 'Sir Astley Cooper himself admits the existence of exceptions, and he has published the particulars of,a case of luxation, upon the dorsum of the ilium, reduced after the lapse of five years. Numerous instances of a similar pur- port, only of much shorter duration, have been' narrated by other writers, all tending to show that there are circumstances in which reduction may be hoped for after a joint has been out of place for several months. It is not necessary to repeat here what has elsewhere been insisted upon in regard to the considerations which should influence the surgeon in the choice of his cases; or, in other words, the circumstances which should induce him to attempt or decline interference. Full instruction has already been given upon this subject, and yet, in view of its paramount importance, it may not be amiss to subjoin a few remarks, if it be only for the purpose of insuring greater care and caution. The circumstances which may usually be considered as forbidding any efforts at restoration are, first, the absence of mobility in the luxated bone; secondly, occlusion of the acetabulum by fibrinous deposits; and thirdly, great disorder of the general health, rendering it probable that the system could not withstand the shock and irritation following the operation. The first of these points can usually be determined by moving the limb about in different directions, and watching the degree of displacement suf- fered by the femur. The examination should be conducted by taking hold of the knee, or, better still, of the knee and ankle, and it will be most efficient if, while the limb is rotated, or attempted to be rotated, the hand be applied to the head of the luxated femur. When-there is no motion, or motion only in a limited degree, it may be assumed that the adhesions are too strong to admit of rupture without risk of serious injury to the parts. It is not always, indeed not generally, easy to determine whether the aceta- bulum has been filled up or not by plastic deposits. The probability of such an occurrence maybe inferred if the accident has been followed by severe inflammatory action, if the parts have ceased to be tender on pressure, and if the head of the bone has contracted, firm adhesions to the surrounding tissues. If any doubt remain, the exploring needle might be used, its point being carried about in different directions, to ascertain the amount and con- sistence of the obstructing substance. It may be stated that, other things being equal, the acetabulum will he filled up much sooner in young, robust subjects, than in the aged and feeble, and that, as a general rule, the likelihood of its being so is always in pro- portion to the length of time that may have elapsed since the occurrence of the displacement. Finally, the patient's health may be so much reduced as imperatively to prohibit all attempts at reduction, not on account of any pain that might be experienced, for chloroform would prevent all that, but because so much violence might be done in the operation as to cause the most intense inflam- mation and constitutional irritation, placing life in imminent peril. Wrhen it is deemed advisable to undertake the treatment of such cases, it will generally be necessary to use the pulleys, subject to the rules and regu- lations already laid down for their employment; but sometimes the object may readily be attained, or, at all events, without much difficulty, simply by manipulation. Thus, Dr. Dupierris, of Havana, met, not long ago, with a case of iliac luxation of six months' standing, in which he succeeded most DISLOCATIONS OF THE HIP-JOINT. 191 satisfactorily by this method alone ; and a number of instances of a character nearly equally remarkable have occurred in the practice of other surgeons. Such examples are full of instruction, and deserving of the most attentive consideration, conveying, as they do, a highly valuable practical lesson. Nevertheless, they must be regarded merely as exceptions, nothing more: to view them as rules would be to contravene the laws of morbid action, and would, practically, lead to the worst results. Finally, a case has occasionally occurred in which, in an attempt to reduce a*chronic dislocation of the hip-joint, the femur has given way at its neck within the capsular ligament, and such an accident has been known to be followed by" a good use of the limb. An instance of this kind fell under my observation last winter, in consultation with my colleague, Professor Pan- coast, in a gentleman between thirty-five and forty years of age. The head of the femur lay upon the iliac bone, the displacement having occurred nearly three months previously. There was great lameness, accompanied with much deformity, and, as the patient was very anxious for relief, he was accordingly chloroformized and subjected to the use of the pulleys, as well as to manipu- lation. During the progress of our efforts, the bone suddenly broke at its neck, and the result was a very good use of the limb, the patient being able in a few weeks to move it in every direction instead of being obliged to hold it in the stiff and unseemly position in which it had been previously. The shortening did not exceed two inches. I wvould certainly not advise such a procedure as a rule of practice, and yet it is worthy of consideration whether, in cases of irreducible dislocations, attended with great deformity, and a useless condition of the limb, it would not be proper. The patient here alluded to did not seem to suffer any pain from the accident, and he was certainly highly gratified with the result. It is to be borne in mind that, from the softening which the articular extremi- ties of the bones undergo in old and neglected luxations, such a fracture is a comparatively easy and simple occurrence, not liable to be followed by serious inflammation. Without such an effort, it is evident that the patient must remain a cripple for life. CONGENITAL DISLOCATIONS OF THE HIP-JOINT. Congenital luxation of the hip-joint is sometimes met with, though on the whole a very rare affection, especially in this country. Female children are more apt to suffer from it than males, and it is also more common in such as are of a scrofulous habit than in such as are endowed with a good constitution. Of forty-five cases of this malformation reported by Dupuytren and Pravaz, only seven were males; a disproportion which it is impossible to suppose to have been altogether, if at all, dependent upon chance. The immediate causes of this variety of displacement are, first, shortness, total absence, or extreme obliquity of the neck of the thigh-bone; secondly, partial or entire obliteration of thecotyloid cavity ; thirdly, deficiency, extraordinary elongation, or complete absence of the round ligament. The characters of this malformation are, shortening of the affected limb, unnatural projection of the great trochanter, ascent of the head of the femur into the iliac fossg,, inversion of the leg,, and obliquity of the pelvis. The motions of the joint, particularly those of abduction and rotation, are con- strained and imperfect; the muscles of the upper part of the thigh are retracted, or drawn towards the iliac crest; the limb is thin, wasted, and out of all proportion to the rest of the body ; the tuberosity of the ischium is almost uncovered, and consequently unusually prominent; the upper part of the trunk is thrown backwards, while the lumbar portion of the spine projects forwards, being concave behind ; the pubes is placed almost horizontally on 192 DISEASES AND INJURIES OF THE JOINTS. the thighs; and the ball of the foot alone touches the ground when the child stands erect. In the recumbent posture, when the weight of the trunk is taken off, and the muscles are relaxed, most of the symptoms of the luxation disappear, and the limb may be shortened or elongated at pleasure. In walking, the body is inclined towards the sound side, and the head of the dislocated bone sinks towards the cotyloid cavity by its own weight. As age advances, the limb becomes shorter, in consequence of the femur ascending higher and higher on the ilium ; the obliquity of the pelvis augments; and the power of loco- motion, already so much impaired, is completely destroyed. Congenital dislocation of the hip-joint may, in general, be easily distin- guished from other accidents or maladies, by the affection being observed at or soon after birth, by the obliquity of one or both thighs; by the absence of pain, swelling and ulceration; by the head of the femur being displaced without any external violence ; and by the ability of the surgeon to lengthen or shorten the limb at pleasure. In disease of the hip there is always more or less pain, with a feverish state of the system, and gradual failure of the strength ; the parts about the joint are tense and swollen ; the limb, at first somewhat lengthened, becomes afterwards shortened, and cannot be extended without the greatest suffering; and the motions of the ileo-femoral articula- tion are permanently impaired. The pathological appearances vary. In general, the cotyloid cavity is par- tially obliterated, or entirely deficient, being replaced by a small, irregular osseous prominence, devoid of cartilage and synovial membrane; the head of the femur, often flattened at its antero-internal aspect, rests in a sort of superficial fossa on the dorsal surface of the ilium ; the round ligament, as was before remarked, is elongated, partially worn away, or even altogether absent; and the surrounding muscles are either atrophied, transformed into a yellowish, fatty, fibrous tissue, or preternaturally developed. In the latter case, their action is preserved; in the former, it is very much restricted, or totally annihilated. The prognosis is always unfavorable, as the patient dies either young, or remains permanently lame and deformed. The treatment of congenital dislocation of the hip-joint can generally be little more than palliative. In cases of recent standing, permanent exten- sion, by means of Desault's fracture apparatus, or some other suitable con- trivance, may be tried with a prospect of advantage, though seldom with a hope of permanent cure. When both joints are involved, the patient should be kept for a long time in the recumbent posture, in order to take off the weight of the body from the limbs, as this is the main agent in aggravating the displacement. As an important auxiliary measure, recourse may be had to the shower-bath, followed by dry friction, or friction with ammoniated and other stimulating liniments. The pelvis may be encircled with a broad, well- padded belt, so as to steady the trochanters, and counteract the tendency of the thigh-bQnes to ascend towards the iliac crests. If debility exist, tonics will be required, especially quinine and some of the preparations of iron. INJURIES AND DISEASES OF THE HEAD. 193 CHAPTER II. INJURIES AND DISEASES OF THE HEAD. • Injuries of the head have at all times been objects of the deepest interest and study with the surgeon. Independently of the frequency of their occur- rence, they merit the greatest attention, on account of the obscurity of their diagnosis, the stealthy character of their progress, the difficulty of their management, and the uncertainty of their termination. It was remarked, long ago, by Mr. Pott, and the observation has been verified a thousand times since, that there is no lesion of the head so trifling, on the one hand, as hot to endanger life, or so severe, on the other, as not to be followed by recovery. But these affections are interesting on another account. Notwithstanding the vast amount that has been written respecting them, there are numerous points, both as it regards their diagnosis, pathology, and treatment, which are hardly any better understood now than they were centuries ago, and which, there- fore, 'require farther and more extended observation than they have yet re- ceived, before they can be considered as being fully settled. SECT. I.—LESIONS OF THE SCALP. 1. WOUNDS. Wounds of the scalp exhibit the same general'features as wounds in other regions. Thus, they may be simple or complicated, incised, lacerated, punc- tured, contused or gunshot, superficial or deep. The only real difference is* that they are more liable to be followed by erysipelas, inflammation of the brain, neuralgia, and certain nervous symptoms, which are often as perplex- ing to the practitioner as they are distressing to the patient. • Incised wounds, whatever may be their extent or depth, should always be treated with reference to the production of immediate reunion. With this view, as soon as they have been divested of blood and foreign matter, their edges should be carefully approximated with a suitable number of twisted sutures, care being taken to carry the ligatures from one needle to the other, so as to obviate the tiecessity for the application of adhesive plaster, which, while it always adheres badly, and never can be used without extensive shav- ing of the scalp, very frequently predisposes to the occurrence of erysipelas. Y\ hen the cut is very slight, contact may often be effectually maintained by tying together at their base a few little locks of hair on each side of it; the threads should be very fine, and be well waxed, otherwise it will be difficult for them to retain their hold until the adhesive process is sufficiently advanced to admit of their removal. When the wound is very large, the scalp should always be well Shaved, as a preliminary step, but under opposite circum- stances such a precaution will, in general, be entirely unnecessary. It is difficult, at this day, to conceive why so much opposition should have been made in former times to the use of sutures in wounds of the scalp. In reading the accounts of some of the older surgeons of this mode of treatment, one is almost tempted to conclude that they must have thought that there VOL. II.—13 194 INJURIES AND. DISEASES OF THE HEAD. was something peculiarly poisonous in it; a violent war was waged against it for nearly half a century, and it is questionable whether its influence has yet altogether disappeared. However this may be, it cannot be doubted that sutures of the scalp, in whatever form they may be used, are as harmless as any mode of dressing, of which it is possible to form any conception. If they were formerly a source of irritation, a circumstance which can hardly be denied, the occurrence was in all probability due to the coarseness of their material, and the manner of their introduction. These objections certainly do not exist at the present day, and no one who has once tried them in* this situation will ever be likely to dispense with them. These remarks are par- ticularly applicable to the twisted suture, which, in addition to the benefit already ascribed to it, has the advantage of compressing the orifices of the divided vessels, and of thus effectually controlling hemorrhage. It has oc- curred to me again and again to see the edges of a wound in the scalp, ap- proximated simply with adhesive plaster, forced apart, and prevented from uniting, by the interposition of coagulated blood. When the twisted suture is properly made, no other dressing whatever is needed; the part is constantly exposed to view, and the moment any. change of an untoward character arises it is detected, which it cannot be when the ordinary retentive means are em- ployed. The sutures should not be-withdrawn before tbe fourth or fifth day. Lacerated wounds of the scalp are generally caused by blows or falls on the head, or by the passage of the wheel of a carriage. One of the most severe and extensive injuries of this kind which I have ever witnessed was inflicted by the horns of an infuriated cow. Owing to the manner in which they are produced, more or less foreign matter is usuajly entangled in these wounds, and for the same reason they are often followed by violent inflam- mation, suppuration, and even gangrene. The rule of treatment is the same as in incised wounds, but special care should be taken not to draw the edges so firmly together, lest the resulting swelling, which will always be consider- able, should induce undue tension, and thus necessitate the premature detach- ment of the sutures. The scalp, too, should always be pretty extensively shaved, and cold water-dressing should be freely used, to prevent the unto- ward occurrences adverted to. With proper attention, it is surprising how 'much of the'wound may, even in apparently the most unpromising cases of this kind, unite by the first intention. A punctured wound of the scalp, apart from its tendency to erysipelas and suppuration, is usually a very simple affair. The proper remedy is the cold water-dressing, simple or medicated ; and, if inflammation run high, th,e ap- plication of leeches, followed by e'mollient poultices. If matter form, or even if there be merely severe tension, appropriate incisions are made. In contused wounds, the rule is, after thorough shaving of the scalp, and the removal of foreign matter, to approximate the edges very lightly with the interrupted suture, aided, if necessary, by a few strips of adhesive plaster. Proper allowance is made.at the start for swelling and tension, which are often severe. If the edges are shreddy, or tattered, they are neatly trimmed with the scissors, but in no case should any flaps, even if violently bruised and apparently dead, be cut off; for no one can ever positively determine, beforehand, whether such a part is really deprived of vitality or not^and it is best, therefore, always to afford nature an opportunity of saving all she can. The leading indication is to circumscribe inflammation, and the best remedy for meeting it is the warm water-dressing, rendered slighfly stimulating by the addition of a small quantity of laudanum, afbobol, or spirits of camphor. • In this way an attempt is made to impart tone to the contused vessels and nerves, to enable them more effectually to withstand the effects of inordinate action. Pencilling the surface immediately around the wound with a weak solution of iodine or nitrate of silver is sometimes beneficial. CONTUSIONS OF THE SCALP. 195 2. CONTUSIONS. Contusions of the scalp, properly so termed, present themselves in various degrees, from the slightest bruise, as it is vulgarly called, to a mashed, soft- ened, and pulpified condition of its component elements. They may be superficial or deep-seated, circumscribed or diffused, simple or complicated. Their tendency, even when slight, is to terminate in violent inflammation, especially of the erysipelatous variety, in abscess, and even in gangrene. Such events will, of course, be most likely to happen in persons of intem- perate habits, or of a broken-down constitution, though the most healthy individuals do not always, indeed—perhaps, not generally—escape them. Another effect of a severe contusion of the scalp is its liability to produce mischief in the brain and its membranes. Two circumstances suggest them- selves as likely to bring about this state of things. The first is the shock sustained by the cranial contents by the violence of the blow inflicting the contusion, and the other, the disposition in the resulting inflammation to extend to the meninges through the vessels and fibres of the pericranium. Accidents of this kind are occasionally complicated with fracture of the skull, detachment of the dura mater, or concussion of the brain. Sometimes, again, a portion of bone is. merely bruised, and yet the action consequent upon the lesion is so great as ultimately to cause its death. When the contusion is at all severe, there is usually a considerable effusion of blood, presenting itself generally in the form of a circumscribed tumor; in rare cases the blood is widely diffused, extending, in fact, nearly over the whole head. The secondary effects of these accidents should not be overlooked. These consist, for the most part, of certain nervous symptoms, as numbness of the scalp, partial paralysis of the face, headache, muscular twitchings, strabismus, and neuralgic pains. Occasionally the scalp remains very tender at one par- ticular point, a spot perhaps not larger than half a dime, so that the patient is unable to bear the slightest pressure of the finger, or even of his hat. Finally, these contusions are at times followed by epilepsy, abscess of the liver, and atrophy of the testes. Contusions of the scalp, however slight, should always, for the reasons above mentioned, be regarded as accidents of serious import. The patient should be cautioned about his diet; the bowels should be properly regulated, and he should avoid premature exposure. Under this management, the •affected parts will generally, in a very short time, be restored to their pristine condition, without, perhaps, the slightest topical medication, or, at all events, without anything else than cold water, or some mildly astringent lotion. When the injury is more extensive, the warm water-dressing should be used, and its efficacy will usually be much increased by the addition of opium and hydrochlorate of ammonia, alcohol, or spirits of camphor. These ingredients are particularly valuable in such cases, not only by imparting tone to the affected tissues, but by promoting the absorption of extravasated blood, and should seldom be dispensed with. Warm applications are nearly always borne better, both by the scalp and the system at large, than cold, whether simple or medicated, and they are also much less likely to cause injurious metastasis to the brain and its membranes. In regard to this matter, how- ever, the practitioner will always do well to consult the feelings of his patient. When the inflammation is at all severe, leeches will be demanded, especially if there be impending cerebral involvement, and they should be profusely scattered over the affected surface. Tension and swelling must be remedied by multiple punctures; and, if abscesses form, they must be opened early and freely, tp relieve pain and prevent destructive diffusion of the pus. the secondary lesions of the scalp must be treated upon general principles; 196 INJURIES AND DISEASES OF THE HEAD. by incision, and a profuse discharge of matter, if there be great tenderness, of a circumscribed character, depending upon chronic thickening of the peri- osteum; by anti-neuralgic remedies, when the pain is periodical, or of a dull, heavy, aching character; and by emetics, purgatives, and a properly regulated diet, when there is disorder of the digestive organs, with irregular action of the muscles. The cold shower bath, change of air, and, in obstinate cases, slight but persistent ptyalism will be beneficial. 3. TUMORS. The sanguineous tumor, as it is termed, is often met with on the scalp, generally as a consequence of blows, falls, kicks, and other injuries, the blood being extravasated into the subcutaneous cellular tissue, either in the form of fi distinct swelling, or as an infiltration. The accident not unfrequently happens during parturition, from the pressure on the child's head in its descent through the soft parts of the mother. Contusions of the scalp, how- ever slight, or however iuduced, are always followed by sanguineous effusion. The blood may be situated immediately beneath the skin, below the aponeu- rosis of the occipito-frontal muscle, or beneath the pericranium, in direct con- tact with the bone. Varying in quantity from a few drachms to several ounces, it is of a fluid, semi-fluid, or solid consistence, and of a dark purple color, according to the period at which it is examined, or the circumstances under which it is extravasated. The most abundant accumulations of this kind usually occur at the sides of the head and the superior part of the occiput, in consequence, apparently, of the greater laxity and vascularity of the tissues there than elsewhere. Immense bags of blood are occasionally formed in both these situations, especially after falls and blows on the head, attended with the laceration of some of the branches of the temporal and occipital arteries. When the tissues of the scalp have been much contused, the extravasated blood will seldom be found to be fully coagulated, and occasionally, in fact, it is even completely fluid, having apparently been deprived of its vitality at the moment of the accident. The same thing usually happens when the col- lection is very large, although the parts may have suffered comparatively little violence. If the blood be permitted to remain for any length of time, it undergoes changes similar to those witnessed in an apoplectic effusion; that is, it loses its dark color and soft consistence, and is converted into a grayish fibrinous mass, of varying firmness and density. On the other hand, it occasionally happens that all the solid matter is absorbed, and that all that' remains is a pale serous, or oily-looking fluid. During the inflammation which supervenes upon these accidents, pus is sometimes poured out, and, mingling with the blood, imparts to it its peculiar appearance. The tumor formed by the extravasated blood is either circumscribed and of a rounded or conical shape, or it is diffused and irregular, being, perhaps, flattened at one point and elevated at another. It is always soft and fluctuat- ing at the beginning, and sometimes it even retains this feature throughout, though in most cases it soon.becomes comparatively hard and firm, from the coagulation of its contents. When it is caused by external violence, as a blow or fall, it has occasionally a sharp, abrupt, and well-defined margin, and the finger, as it sinks into the centre of the swelling, receives an impression as if there were a fracture of the skull with depression of the bone,.although nothing of the kind is present. The appearance of the skin is variable; but in general it is unchanged, being neither discolored, ecchymosed, nor (Ede- matous. When inflammation arises, the tumor becomes hot, tender, and painful. In cases of. long standing, the blood is sometimes surrounded by a distinct cyst, and, in the sub-pericranial form of the affection the uplifted membrane has been known to undergo extensive ossification. PONCUSSION OF THE BRAIN. 197 Accumulations of blobd of the scalp, whether circumscribed or diffused, usually disappear, either spontaneously, or under very simple treatment, as refrigerant, astringent, and sorbefacient lotions, tincture of iodine, blisters, and leeches, the two latter being particularly indicated when the tumor is hot and inflamed. Mild purgatives will often be useful, and proper attention must be paid to the diet. In children, a very convenient and efficient remedy is a weak solution of hydrochlorate of ammonia in equal parts of vinegar and water. When the -case proves troublesome, as it will be liable to do when the blood is profuse, deep-seated, or deprived of vitality, subcutaneous evacuation will be necessary, followed by systematic compression. Various other kinds of tumors are liable to form on the scalp. The most common are the sebaceous, which sometimes exist in considerable numbers, and which are always easily diagnosticated. The proper remedy is removal by incision and enucleation. . The fibrous tumor is sometimes met with in this situation. Such a growth, • . removed by Professor Pancoast, at the Fig-90. College Clinic,* in 1858, by means of the ecraseur, is represented in fig. 90. The patient was an elderly man.; and the tumor, which occupied the? vertex, and was of the volume of a large orange, had been of several years' standing. Its summit had been in- vaded by ulceration. ■ Fig. 91. Fibrous tumor of the scalp. Malignant ulcer of the scalp. Different kinds of vascular tumors, arterial, venous, or arterio-venous, are liable to form on the scalp, and may in time acquire a large bulk and a very formidable character. Riddance should be effected as early as possible. Malignant tumors of the scalp are infrequent. The most common form is the epithelial, or exedent lupus, which, usually beginning as a warty excre- scence or small shot-like tubercle, in its- progress occasionally involves the cranial bones. The resulting ulcer, fig. 91, is characteristic, having a foul, unhealthy aspect, and being the seat of a sanious, fetid discharge. The only remedy is early and free excision. Surgical interference with tumors of the scalp should never be attempted without due preparation of the system, as it is extremely liable to be followed by-erysipelas and other bad effects, jeoparding life. SECT. II.—CONCUSSION OF THE BRAIN. Concussion of the brain has been variously defined by different writers, hardly any two agreeing in regard to it. The most common idea appears to be that it is a commotion of the nervous fibres, inducing a change, vague . 198 INJURIES AND DISEASES OF THE HEAD. and indefinable, in the relatiorts which they sustain to each other and to their vessels. How far such a view is worthy of adoption it is not easy to deter- mine ; for it is very certain that, notwithstanding all that has been said upon the subject from the earliest period of medicine down to the present, the progress of science has failed to afford us any substantial light respecting the true mechanism of this occurrence. The modern pathologist, in surveying this interesting and important topic, finds that he has no reason to pride him- self upon his knowledge; if he attempts to penetrate beyond the trodden paths of his predecessors, doubts and difficulties meet him at every turn, and soon compel him to retrace his steps. If we reflect upon the pulpy structure of the brain, it is surprising that' any one should ever have seriously entertjiined the idea that, during concus- sion, this organ experienced a diminution of size, from the condensation of its constituents. Such an explanation is certainly not well calculated to give us very correct conceptions of the nature of this lesion. Accurately filling the cranial cavity, it is impossible that the brain could undergo any change of bulk from a mere commotion of its substance. A decrease of size can be effected only by the slow action of the absorbents, -not suddenly, but gradu- ally, in a manner altogether irreconcilable with the production of concussion. The theory of an increase of bulk of the organ is equally absurd, inasmuch as such an occurrence can only take place in consequence either of extrava- sation of blood or of inflammatory exudation. The only idea that I 'can form of the nature of the injury is that it is caused by the jarring of the nervous substance, eventuating, at least in* severe cases, in a loss of its con- sistence, if not in its positive laceration. To show how plausible this view is, it is only necessary to inquire into the character of the exciting causes of concussion. In general, the accident is produced by direct violence, as a blow or fall upon the head. Now, when'this happens, jt is easy to perceive how the brain is influenced by the vibratory movements which are communi- cated to it by the osseous case which incloses it. " The force of the injury, instead of being expended upon the skull, is transmitted to the cerebral sub- stance, which it jars very much as a bow may be supposed to be jarred in discharging an arrow. When the blow is slight, the effect will be propor- tionately mild, the patient being, perhaps, merely stunned ; but when the force is severe or concentrated, the. result will be. different, the substance of the brain being not only shaken but, it may be, even lacerated, the lesion ex- hibiting itself in the form of a fissure, which becomes immediately filled with blood, from the rupture of the small vessels. Similar effects^ occur when the concussion takes place in consequence of violence applied* indirectly, as when a person, falling from a considerable height, alights upon his feet, knees, or buttocks. Here the force of the in- jury is transmitted along the bones of the extremities and of the spine to the base of the skull, where, exploding, it is communicated to the brain, very much in the same manner as when the head is struck with a hard body, as a bludgeon, poker, or brick. The effect of this form of concussion may be illustrated by what occurs in the boyish amusement of killing woodpeckers in countries where cherries abound. To prevent the depredations of these marauders, a slender pole is sunk into the earth, its head protruding at the top of the tree. When the bird alights, the pole is struck with an axe, and the vibratory motiou thus transmitted through the pole to his body kills him in an instant. Now, in this case, death is caused, not by any change of bulk in the brain, nor by any alteration in its consistence, but simply by the jarring of its substance, disqualifying it for the transmission of the vital fluid, and, consequently, also for the maintenance of its circulation. Dissection unfortunately has thrown little, if any, positive light upon the nature of concussion. All that the knife has revealed in the examination of CONCUSSION OF THE BRAIN. 199 those who have perished from the immediate effects of the accident is of a negative character. The most minute inspection, both with and without glasses, has failed, in ordinary cases, to detect the slightest lesion of the cerebral tissues. Even in the worst forms, those which are associated with compression, the most that has been found has been a laceration, commonly sufficiently insignificant, of some portion' of the organ, attended, perhaps, with a trifling extravasation of blood. Sometimes, as when the rent has been more extensive, involving, it may be, the surface of the hemispheres, or the lateral ventricles, the effusion has been more considerable, but such an 'event constitutes the exception and.not the rule. As concussion of the brain may exist in various degrees, so the symptoms which characterize it may present various shades of difference, depending upon the severity of the injury; hence it will be proper to study these symp- toms with reference to their diagnostic and therapeutic value. It will greatly facilitate the comprehension of the subject if we adopt the division of con- cussion into three stages of collapse, reaction, and inflammation, usually recognized by writers and teachers; for, although such an arrangement is altogether arbitrary, and, therefore, unnatural, yet something of the kind is • absolutely necessary for the sake of clearness of description. 1. The stage of collapse is characterized by-symptoms of exhaustion, not unlike those produced by the loss of blood. The system has received a shock, varying from the slightest functional disturbance to complete.insensibility, life being suspended, as it were, merely by a feeble thread.. In the former case there is, perhaps, only slight pallor of the countenance, a confusion of ideas, a disposition to yawn, and a feeling of nausea. The patient rubs his eyes, stares wildly around, and perhaps vomits; but, presently recovering his consciousness, he gets up, and goes about his business as if little or nothing had occurred. This is an example of slight concussion, such as happens when a man is pitched gently off a horse, thrown out of his carriage, or struck upon the head. When the lesion exists in a more aggravated degree, these symptoms will not only be much more distinctly marked, but of longer dura- tion, a number of hours, perhaps, elapsing before reaction will set in. The prostration is profound; the countenance is of a deadly pallor; the breathing is almost extinct; the pulse is soft, feeble, fluttering, and intermittent, some- times hardly perceptible; the loss of strength is complete ; deglutition is impossible ; the stomach, oppressed with nausea, perhaps lazily ejects its con- tents; the bowels are relaxed, and there are occasionally involuntary dis- charges; the pupils are usually contracted and still somewhat sensible to light, or one is diminished and the other dilated, or, finally, one is contracted and the other natural; special sensation is in a state of abeyance ; the mind is prostrated; and the patient, roused with difficulty, answers, if spoken to, in a drawling monosyllable. The surface of the body soon becomes cold, and is often bathed with perspiration. The condition of the bladder varies ; in general the urine dribbles away involuntarily, but sometimes it is retained, and requires to be drawn off with the catheter. The duration of this stage varies from a few minutes to several hours or even days, depending upon the Extent and severity of the lesion. W7hen the functional 'disturbance is slight, it may last only a very short time, but, under opposite circumstances, the prostration will be more persistent, and sinking may occur, without any effort at reaction. lhe symptoms of collapse from concussion are sometimes painfully simu- lated by those of intoxication, or it may be that the two,affections co-exist, thus increasing the embarrassment. The diagnosis is to be deduced from the history of the case, the presence of external injury, particularly upon the scalp, the habits of the patient, and the state of the breath, which, in inebria- tion, will be alcoholic in its character. When doubt exists, the proper plan 200 INJURIES AND DISEASES OF THE HEAD. is to treat the case as one. of concussion, endeavoring, by the means to be presently mentioned, to bring on gradual reaction. A few hours will gene- rally suffice to reveal the true nature of the affection, and this interval is not spent idly by the surgeon, but in a thorough examination of the body, with a view to the prompt detection and rectification of other injuries. The leading indication in the stage of collapse is to establish reaction, or to rouse the enfeebled and, perhaps, flagging energies of life. This object may usually be attained by very simple means, promptly and judiciously exer- cised. The first thing to be done is to place the patient recumbent with his head on a level with the body, or, if the sjmptoms be at all urgent, even con- siderably lower, in order that the heart, exhausted by the shock, maybe enabled to throw the blood with more facility to the exhausted brain. A free access of air is next procured, by opening the doors and windows of the apartment, and by the active use of the fan. If there be any bystanders, or idle spectators, they must immediately be sent away, as their presence cannot fail to be prejudicial to the patient. Any tight garments, especially the collar and pantaloons, must promptly be relaxed, to give full play to the respiratory muscles. Cold water is freely dashed upon the face and chest, smelling bot- tles are held near the nose, not steadily, but intermittently, and sinapisms are applied to the extremities and the precordial region. In the milder forms of concussion, these means are generally amply sufficient for the speedy estab- lishment of reaction; but when the case is very severe it may be necessary, in addition, to place sinapisms along the whole length of the spine, and to employ stimulating injections, as water impregnated with mustard, common salt, brandy, or spirits of hartshorn. If the feet are cold, they may be im- mersed in warm water, or rubbed with hot cloths, and afterwards wrapped up in warm flannel. As soon as the patient is able to swallow, he may take a little cold water, or water and spirits, the latter being more especially indi- cated when the system is long in showing signs of reaction. Spontaneous vomiting sometimes greatly promotes restoration, particularly if'a hearty meal was taken shortly before the occurrence of the accident; a heavy load being thus removed, the diaphragm enjoys greater play, and the pneumo- gastric nerves act with increased vigor. As life returns, color succeeds pallor, warmth coldness, and intelligence confusion of ideas; the' pulse resumes its wonted force and activity, the respiration becomes more natural, the stomach is relieved of nausea, the sphincters recover their proper functions, the special senses are again on the alert, and volition is exercised with its proper freedom. The restoration may be rapid or gradual, temporary or permanent; but once fully established, it rarely recedes, but, on the contrary, steadily advances, with a tendency, not unfrequently, to ovea-action. In treating concussion of the brain, the young practitioner is apt to be led into several serious errors, especially if he is surrounded by officious by- standers, and not perfectly self-possessed. 1st. He may be'foolish enough to draw blood, or, at all events, to attempt to draw blood while his patient is in a state of profound exhaustion, unable, perhaps, to cr«ok a finger or utter a syllable. Nothing is more common immediately after such accidents than for the friends of the patient to insist upon his being bled ; and if the practitioner, in an unguarded moment, yields to the silly request, he may destroy life on the instant, or render the reaction a matter of great difficulty, if not of. impossibility. To bleed a man in such a condition would be as absurd and culpable as to bleed him when he is in a state of syncope from the loss of blood. ■ 2d. Great care should be taken in the use of ammonia, and other pungent articles, not to hold them too near the nose, lest they induce spasm of the CONCUSSION OF.THE BRAIN. 201 glottis, and thus suffocate the patient. Moreover, their employment may give rise' to inflammation of the nares, fauces, larynx, and trachea. 3d. The practice of pouring drinks into the patient's mouth, before he is able to swallow, cannot be too pointedly condemned. It is fraught with great danger, on account-of the liability of the fluid to pass into the wind- pipe, where even a small quantity might induce suffocation. The patient •should, therefore, be sufficiently conscious to know what is being done to him, or, if he cannot be properly roused, and the symptoms are very urgent, the fluid should be placed in contact with the fauces, beyond the reach of the larynx, the act of deglutition being thus excited without any risk of injury. 4th. When stimulants are used, due regard must be had to their quality and quantity, as well as to the period of their administration. Brandy, as a general rule, is- preferable to anything else, but it should be given sparingly, and be suspended the moment reaction has fairly commenced. The object is to rouse the system gradually, not rapidly, to coax, not to force, the jaded powers of life; this wish attained, all artificial excitants are refrained from. In ordinary cases no internal stimulants whatever are required. 5th. The accident may have occurred soon after a hearty meal, and then the question may arise in regard to the propriety of an emetic. Nature sometimes decides this for the practitioner, by the institution of spontaneous vomiting; but when this is not the case, and there is no contra-indication, as there will be when the concussion is complicated with compression, it may- be excited by salt and mustard, ipecacuanha, or sulphate of zinc, aided by large draughts of tepid water. During the act of emesis, whether occurring spontaneously,.or induced artificially, the patient should lie with his head in- clined forwards, otherwise some of the ingesta, as they are lazily ejected, may drop into the air passages, and so caus^ fatal asphyxia. 2. Reaction being established, the surgeon's duty plainly is, not to fold his arms idly, on the one hand, nor to be over-officious, on the other. His business is to stand as a guard over his patient, carefully watching, and mea- suring, as it were, every symptom as it arises, in order, if possible, to form a just appreciation of its pathological import, and to seize the earliest moment to counteract any aberration from the healthy action. The great danger now is from inflammation of the'brain. Usually, after the patient has completely regained his faculties, it is observed that the functions which were suspended are performed with a slight degree of excitement; but this is not to be taken as an evidence for active interference; on the contrary, it generally disap- pears spontaneously in a few hours, the surface becoming moist, and the pulse losing its sharpness and frequency. ' The diet is light and non-stimulant, per- fect quietude of mind and body is enjoined, and the bowels are moved by gentle laxatives. If the shock has been at all severe, the patient is warned against premature exposure,-even if the symptoms have happily passed off; he must consider himself as an invalid for weeks, and avoid everything cal- culated to awaken excitement in the recently shattered organ, now peculiarly prone to take on morbid action from the slightest causes. The head must be sedulously watched, and any pain of which it may be the seat, must be looked upon with suspicion, especially if it be combined with irritable temper, vitiated appetite, and a sharp, frequent pulse. A brisk purgative, and a few leeches to the temple, or the abstraction of a little blood from the arm, may avert the threatened evjl, and prevent it from passing the natural limits, while the delay, even of a day, may enable it to reach a crisis which may speedily prove destructive to life. 3. Over-action of the system, consequent upon the cerebral lesion, con- stitutes the third stage of concussion. The period of its access is variable. In general, it comes on within the first four or five days, sometimes, indeed, within the first twenty-four hoors; but cases not unfrequently occur where it 202 INJURIES AND DISEASES OF THE HEAD. is not developed for weeks and months, the patient considering himself all the while out of danger, and fully competent to attend to his daily occupa- tion. In the former case, the disease is usually bold and undisguised ; in the latter, on the contrary, it is often latent, its approaches being slow and stealthy, and its progress, consequently, often considerable before its true nature is discovered. Such cases are always peculiarly dangerous, on ac- count of theiv liability to be overlooked and mistreated. Traumatic inflammation of the brain, as. it ordinarily exhibits itself, is characterized by high febrile disturbance, intolerance of light and noise, cephalalgia, flushed countenance, suffusion of the eyes, vigilance, excessive thirst and restlessness, heat and dryness of the skin, hurried respiration, coated tongue, loss of appetite, constipation of the bowels, scanty and high- colored urine, and a quick, hard, and frequent pulse. The wind begins to wander at an early, period, and gradually ^muttering delirium, or maniacal excjtement, sets in. The carotid arteries often beat with great force. As the disease advances, the patient is seized with spasm, and finally with coma, paralysis, and convulsions, which soon close the scene, life usually terminating in from three to six days. On dissection, the brain and its envelops are observed to -be in a state of disease, portions of the former being softened, and seemingly mixed with blood and pus, and patches of the latter preter- naturally vascular, and incrusted with lymph. .Seruni, often in considerable quantity, exists in the ventricles, at the base of the skull, and on the top of the hemispheres. The dura mater is usually free from disease, but the pia mater and arachnoid are almost always involved in the morbid action, as is evinced by the injected condition of the vessels of the former, and the opaque appearance of .the substance of the latter. In the treatment of this form of inflammation, the object is to assail the morbid action as early and as vigorously as possible. It will readily be understood that, in an organ-so essential to life as this, there can be no hope of relief if the disease is permitted to obtain the slightest ascendency. Few cases recover when structural lesion has taken place, or when there are inflammatory exudations. Hence, whatever is done must be done promptly and energetically. Th? treatment, too, is sufficiently .simple. Blood is taken liberally from the arm and temples; the bowels are thoroughly evacuated with calomel and jalap, aided, if need be, by enemas; the head, shaved and elevated, is enveloped with a bladder partially filled with ice; light and noise are excluded from the apartment; and the patient is kept upon the smallest possible allowance of food, of the most bland and simple character. Cold water, simple or acidulated, constitutes the proper drink. After the first heat of the conflict is over, the same means are continued, but in a milder form, the antimonial and saline mixture with occasional leeching now taking • the place of the lancet. Sleeplessness and jactitation are relieved by the cautious use of anodynes, combined, if there be dryness of the surface, with antimony. Counter-irritation is sometimes beneficial, but generally much less than has been supposed. My experience does not enable me to say any- thing in its favor. Vesication with croton oil rubbed behind the ears is, perhaps, the least objectionable.'mode.; it is less painful than vesication of the nape of the neck, and is, I think, quite as efficacious. Occasionally, espe- cially when there is much delirium, a blister may advantageously be applied to the innersurface of the thigh. When effusion is threatened, or is already, going on, mercury, in the form of calomel, or the protiodide, properly guarded with opium, and given in full doses, as three grains of the former, or one of the latter, every four hours, is iudicated, and should be rapidly pushed to the extent of decided ptyalism. After the influence of the remedy has been fully established, iodide of potassium may be used as.a substitute, to complete the cure, should nature and art be fortunate enougJi to'accomplish it. CONCUSSION OF THE BRAIN. 203 The more insidious form of inflammation of-the brain, consequent upon concussion, is by no means uncommon, and is particularly dangerous, for the reason, as was previously mentioned, that it is so very liable to be overlooked at a period alone when treatment can be of any avail. The patient, after having suffered from this lesion, has perhaps made a very rapid recovery, and soon goes about his accustomed business, hardly thinking that anything has ailed him. This will be particularly apt to happen if the injury has been very slight, and the effect very transient. Under such circumstances, it may be quite impossible, with all the arguments that the practitioner can adduce, to persuade him to refrain from exercise and food even for a few days. He will not consider himself an invalid. He goes about his business, eats, drinks, and is merry. By and by, he begins to. feel unwell; his head aches," his temper is easily ruffled, his appetite is capricious, his bowels do not act pro- perly, his sleep is interrupted by unpleasant dreams, he has occasional fits of dizziness or vertigo, his pulse is too frequent, and he cannot apply himself with any satisfaction to his pursuits. Such is the usuaT prodrome of an event which has cost many a man his life. Mischief is stealthily going on in the brain, or in the brain and its membranes, which, if not promptly checked, will soon burst forth like the- smothered flame of the incendiary's fire. In a little tjme the system is overwhelmed with.excitement; soon delirium follows ; then come coma and paralysis, and finally convulsions seal the sufferer's doom. Inspection reveals serious lesion of the brain and its envelops, with effusion of lymph and sero-purulent matter on the surface of the latter, and softening and perhaps a'bscess in the substance of the former. The nature of this form of disease is, unfortunately, seldom recognized by the practitioner in time to afford his patient the necessary relief. He is generally disposed to make light of it, or it may be that he overlooks it alto- gether. When at length his suspicions are aroused, he finds to his horror that the case is utterly beyond the reach of his power. Effusion has taken place, and death is inevitable. The treatment of 'this secondary affection does not differ materially from that of the primary. As soon as the symptoms begin to develop themselves, the patient must be restricted to the most scrupulous antiphlogistic regimen, and submit to active and steady purgation, with the liberal use of tartrate of antimony and potassa. If head-symptoms exist, blood is taken from the arm and temple, and counter-irritation is applied to the nape of the neck by seton, issie, or blister, its action being much more advantageous here than in the acute form of the malady. The treatment is continued for some time after all disease has apparently vanished, the patient slowly returning to his former habits and occupation. Other effects, some primary and some secondary, are liable to follow con- cussion of the brain. Among these, the most prominent are a sallow, icterode, and haggard state of the countenance, disturbed sleep and frightful dreams, pain in the head, dizziness, vertigo, loss of memory, partial deafness, impaired vision, contracted or dilated pupil, strabismus, difficulty of articulation, mus- cular twitchings, partial paralysis, nausea and vomiting, constipation of the bowels, irritability of the bladder, and gradual emaciation. The loss of memory is among the most singular of these occurrences. It often exists in a remarkable degree, and may take place by itself or in asso- ciation with other affections. Generally, it refers only to recent events, but in some instances it involves every circumstance in the history of the indivi- dual's life, past and present. The patient is sometimes unable to recollect his own name, the country of his birth, or his present residence. Sometimes, again, he is unable to connect his words, or to pronounce certain letters. Occasionally the mind is in a state bordering upon fatuity, or mental aliena- tion. Epilepsy is another, though, happily, a rare occurrence. Cases are 204 INJURIES AND DISEASES OF THE HEAD. met with in which the sexual powers are seriously impaired; sometimes tem- porarily, sometimes permanently. An albuminous condition of the urine, with or without diminution of urea, is occasionally noticed. What the pathology of these affections is is not known, as dissection has thus far failed to throw any light upon it. It may be supposed, in the ab- sence of positive facts, that they are dependent upon local congestion, irrita- tion, or inflammation of particular parts of the brain, or of the brain and its envelops, upon laceration of the cerebraj substance, or upon the presence of extravasated blood, serum, or lymph. The treatment mHst, of course, be in great measure empirical; but, how- ever this may be, it should always be particularly directed to the head and alimentary canal, consisting mainly in local depletion, quietude of mind and body, the administration of purgatives, an occasional emetic, counter-irrita- tion, especially of the pyogenic kind, and a careful regulation of the diet. \ gentle course of mercury is sometimes beneficial, and in most cases signal advantage will accrue' from moderate country exercise, tonics and the cold shower bath, with dry friction. SECT. III.—COMPRESSION OF THE BRAIN. It is hardly possible to give a more satisfactory definition of compression of the brain than of concussion. Every surgeon knows what import to attach to the expression, but to say what compression is, or how it is produced, are questions that have puzzled and perplexed many of the wisest men "in the profession. The legitimate meaning of the term, and as it is generally under- stood, is that the cerebral substance is pressed, by some eccentric force, into an unnatural space, or, what is the same thing, that the natural volume of the part pressed upon is diminished. But is this really the case? Is it possible to compress an organ composed of so pulpy a structure as the brain ? I can- not myself conceive of such an occurrence, unless we take a portion Of brain and subject it to an amount of artificial pressure such as is altogether incon- sistent with what takes place even in the worst cases of compression within the skull. We can conceive how the different portions of the brain may be changed in their relations ; how one part may be flattened and another part expanded in consequence; how, for instance, the convolutions of the hemi- spheres may be pressed out, and how their furrows may be effaced; howthe lateral ventricles may be encroached upon, and even be obliterated ; how the vessels of the brain may be flattened and destroyed ; but we cannot, I repeat,. conceive how the cerebral tissues can be so condensed and pressed together as to occupy less space than in the natural state. This view of the case, it seems to me, is the only one that is at all admissible, and hence, if we assume it to be correct, it follows that compression of the brain is merely a change of the relative position of the component portions of the organ, and not what the term really signifies in its etymological sense. Dissection affords daily proof of the correctness of this opinion. We sometimes see the greater part of a whole hemisphere flattened by an enormous coagulum, and yet, if the affected portion could be accurately measured, it would be found to occupy as much space as in the normal state, or as it did previously to the accident. The change is observed to depend mainly, if not exclusively, upon the depres- sion of the convolutions and the effacement of the intervening spaces, and not upon any condensation of the cerebral tissues, or any actual reduction of their volume. The pressure exerted by the clot could not act in any other manner, because its force is not sufficient; nor is it possible for a piece of bone to cause any more efficient pressure, for the moment the force thus applied COMPRESSION OF THE BRAIN. 205 exceeds the force of the resistance, the brain gives way, and projects up beyond the edges of the depressed bone. Compression of the brain may arise from various causes, but, surgically considered, they may*all be referred to four classes : first, compression from extravasated blood ; secondly, compression from depressed bone ; thirdly, compression from effused pus; and fourthly, compression from the presence of a foreign body. However induced, the symptoms of compression are always of the same character, and are generally easily recognized, as every organ of the body is affected by the cerebral disorder. The period of their appearance is influ- enced by the nature of the exciting cause. When the compression is depend- ent upon depression of bone, the symptoms are usually immediate, whereas in compression from extravasation of blood some little time often elapses, espe- cially when there is great shock. In compression from effusion of matter, a number of days intervene between the occurrence of the injury and the appear- ance of the symptoms, the parts being obliged to pass through the several stages of inflammation before they can reach the suppurative crisis. A person laboring under compression of the brain is deprived of sensibility and motion ; he is unconscious of what is passing on around him ; if he is spoken to, he makes no reply, not even in a monosyllable ; he cannot hear, nor see, nor taste, nor smell, nor has he any power to articulate, to swallow, or to protrude his tongue. The countenance is ghastly pale and devoid of expression; the eyes are turned up, glassy,* and fixed ; the lids are closed ; the pupils are widely dilated, and insensible to light; the breathing is slow, labored, stertorous, and performed with a peculiar whiff, or blowing sound; there is hemiplegia, or paralysis of the side opposite to the seat of injury, and, as a necessary consequence, the corner of the mouth is drawn over towards the sound side ; the pulse is slow and oppressed ; the stomach and bowels are torpid; and the bladder is incapable of expelling its contents. These symptoms do not, of course, always exist in the same degree, nor are they all equally well marked in every case. The compressing cause being slight, the phenomena will be proportionately mild. Thus, the patient may be only partially insensible ; his intelligence may be weakened, but not abol- ished ; the special senses may still be able to perform their functions, although very imperfectly ; the paralysis may be confined to one limb, or to certain muscles; the pupils, pulse, and respiration may be only slightly altered ; the bowels may be torpid, but only in a moderate degree, and the bladder may still be able to expel a portion of its contents. If the foot be pinched the patient will moan, or draw the limb away, thus showing that he has still some feeling, if not motor power. The paralysis which attends this affection is usually, on the side opposite to that of the compressiug agent, the occurrence being generally supposed to depend upon the decussation of the fibres at the base of the brain. This is doubtless true, but whether it be or not, the fact is of great practical importance in relation to the operations that may be required for the patient's relief. In a few instances, as inexplicable as they are rare, the paralysis exists on the same side as the cause of compression. Much diversity obtains in respect to the state of the pupils. In general, they are observed to be widely dilated, but occasionally they are* contracted, and cases occur in which one is contracted and the other dilated. A dimi- nution of both pupils is extremely uncommon. DIFFERENTIAL DIAGNOSIS OF CONCUSSION AND COMPRESSION. If compression of the brain were always an uncomplicated affection, it would be difficult, if not impossible, to confound it with other diseases'; but such, 206 INJURIES AND DISEASES OF THE HEAD. unfortunately, is not the case. Not unfrequently it is blended with concus- sion, the symptoms of the two lesions being so commingled as to render it doubtful to which they properly belong. As such an occurrence is always exceedingly embarrassing, and must, to a greater or less* extent, influence the nature of the treatment, it is the duty of the surgeon to study the features of each complaint, in it's more simple forms, so that, when he meets with them in combination, he may be the better able to discern their various shades of difference. The subjoined summary of the diagnostic characters of the two affections w'ill serve to aid him in his investigations. Concussion. 1. The symptoms are immediate, com- ing on instantly after the infliction of the injury. 2. The patient is able to answer ques- tions, although with difficulty, and usually only in monosyllables, as yes or no. 3. Special sensation is still going on, the patient being able to hear, see, smell, taste and feel. 4. The respiration is feeble, imperfect, and noiseless. 5. The pulse is weak, tremulous, inter- mittent, and preternaturally frequent. 6. There is nausea, and sometimes vo- miting. 7. The bowels are relaxed, and there are sometimes involuntary evacuations. 8. The power of deglutition is impaired but not abolished. 9. The bladder retains the power of ex- pelling its contents ; but sometimes, owing to the weakness of its sphincter, the water flows off involuntarily. 10. The voluntary muscles, although much weakened, are still able to contract, there being no paralysis. 11. The pupils are usually contracted, and somewhat sensible to light; the lids are open and movable. 12. In concussion, the mind is in a state of abeyance ; it is weak and confused, not abolished. Compression. 1. An interval of a few minutes, or even of a quarter of an hour, sometimes elapses, especially if the compression be caused by extravasation of blood. 2. The power of speech is totally abol- ished ; we may halloo in the patient's e«r as loudly as possible, and yet there will be no response. 3. Special sensation is destroyed. 4. The respiration is slow, labored, and stertorous, being performed with a pecu- liar blowing sound. 5. The pulse is labored, soft, irregular, and unnaturally slow, often beating not more than fifty, fifty-five, or sixty strokes in a minute. 6. The stomach is quiet, and insensible to ordinary impressions, even to emetics. 7. The bowels are torpid, and with diffi- culty excited by the action of purgatives. 8. Deglutition is impossible, and some- times does not return for several days. 9. The bladder is paralyzed, and, there- fore, incapable of relieving itself, the sur- geon being obliged to use the catheter. 10. There is always paralysis on one side of the body, generally opposite to that where the compressing cause is. 11. The pupils are widely dilated, and unaffected by light, the lids being closed and immovable. 12. In compression, the mind is absent, and the patient is comatose. Treatment.—The treatment of compression of the brain must be regulated by the nature of the exciting cause, which it will, therefore, be necessary next to consider. . a. COMPRESSION FROM EXTRAVASATION OF BLOOD. This species of compression is of frequent occurrence, and may exist either with or without fracture of the skull. It is invariably the result of external violence, acting directly or indirectly, upon the vessels of the brain and«its envelops. The extravasated blood may be situated at five- different points: first, between the dura mater and skull; secondly, in the arachnoid sac, on the surface of the brain ; thirdly, beneath the arachnoid membrane, in the furrows of the hemispheres; fourthly, in the substance of the brain; and COMPRESSION FROM EXTRAVASATION OF BLOOD. 207 Fig. 92. rJ -,«■ ■ Extravasation of blood between the skull and dirra mater, from rupture of the middle meningeal arterj at a. fifthly, in the lateral ventricles. The first of these sites, fig. 92, is the most frequent, and, practically speaking, the most important, as it is the only one admitting of surgical interference. The quantity of blood poured out here is some- times very great, especially when it de- pends upon rupture of the middle menin- geal artery. I have seen, I am sure, as many as eight ounces extravasated from this cause; in general, however, the quan- tity is much less, not exceeding, perhaps, one-half that amount. When the effusion is considerable, the blood usually presents itself as an irregular, dark-colored mass, iying in a sac formed by the dura mater and the inner surface of the cranium, the ruptured vessel, it may be, opening directly into it. Large quantities of blood are sometimes observed at the base of the skull and upon the anterolateral aspect of the" cerebral hemispheres, forming broad cake- like clots, from three to six lines in thick- ness. . Copious effusions may also occur in the ventricles; but in the substance and on the surface of the brain they are commonly quite small, though, from the pressure which they exert upon the nervous pulp, they are hardly less dangerous to the cerebral functions. Having already spoken, in general terms, of the symptoms of compression, it only remains, in connection with this subject, that Tshould make some re- marks on the diagnosis between this form of compression and that produced by the depression of bone, and on the distinction between it and apoplexy. In compression from extravasated blood, the symptoms, although some- times immediate, do not generally appear for some little time, the interval being occupied by a state of concussion, during which the lacerated vessels, in cousequence of the exhausted condition of the heart, pour out hardly any blood; but as soon as reaction* begins, the bleeding recommences, and now . proceeds with great vigor, the fluid running into, and filling up, every acces sible space. It is now, perhaps, before the patient has recovered any con- . M'iousness, that compression, for the first time, shows itself, as is evinced by the comatose state of the brain, the stertorous breathing, the slow and labor- ing pulse, the hemiplegia, or general paralysis, and the dilated and insensible pupil. Occasionally the extravasation results from apparently very trifling .causes. A man, for example,, receives what he conceives to be a slight blow upon the head. He is somewhat stunned; but soon recovering his con- sciousness, he gets up, and resumes his work. In a short time; often not exceeding ten, fifteen, or twenty minutes, he is observed to turn deadly pale, to reel, and to fall to the ground in a fit, foaming at the mouth, and appear- ing.as if partially asphyxiated. Such an accident is particularly apt to happen when a large artery has been wounded, as, for example, the middle meningeal; the orifice of the vessel, having been partially closed during the exhausted state of the system consequent upon the injury, now that reaction has ensued, has become re-opened, and lets out its contents in a full and rapid*stream, suddenly overwhelming the brain and heart, and reducing the sufferer literally to the condition of a mere automaton. There js occasionally what may be called secondary extravasation of blood, inducing compression at a more remote period than in the form of the lesion just described. Cases of this kind are, in fact, not uncommon, and, as they 208 INJURIES AND DISEASES OF THE HEAD. ^re always remarkably insidious in their character, they qxe extremely liable to be overlooked. .They are most apt to follow injuries of the skull and brain' attended with concussion. After the symptoms of shock have passed off, the pulse either remains unnaturally slow, or if, as often happens, it becpmes too frequent, it soon sinks again below the normal standard, beating, perhaps, only fifty, fifty-five, or at most sixty-five, in the minute, at the same time that it is full and laboring. The mind is sluggish and fretful; the pupil is torpid and rather dilated; the countenance is more or less flushed, and the patient complains of headache, with ringing noises in the ear. If let alone, he gradu- ally sinks into a comatose condition, followed by squinting and convulsions, and finally dies under symptouas denotive of cerebritis and hemorrhagic effu- sion. The blood often exists in large quantity, and in various degrees of consistence, much of it being quite soft and of a dark color, thus showing that it was poured out only a short time before death, in consequenee, appa- rently, of the softened and lacerate'd condition of the cerebral tissues at the site of injury, and the inability of the vessels to protect themselves by the formation of firm clots. In compression from depression of bone, the symptoms are immediate. • The only exception to this rule is in slight depression, incapable, of itself, of producing compression, but, where this occurrence ensues in consequence of injury done to the soft parts, eventuating in effusion of blood, the two causes thus co-operating in bringing about the result. Moreover, extrava- sation may take place without fracture, or with fracture unattended with depression. Compression of the brain from extravasation of blood may be mistaken for apoplexy. Such an error may readily occur, simply from a want of proper knowledge of the history of the case. Thus, a man may be found in a state of insensibility in the street, with all the ordinary symptoms of compression; no one knows anything of the nature of his affection, and Ihe most thorough examination of the body fails to throw any light upon it: There may not be even a scratch upon the scalp. The man dies, and inspection reveals the existence of a fracture with a large extravasation of blood. The symptoms of'the two affections are, in fact, forcibly alike, and the error is really, prac- tically, of no consequence, unless, in the case of compression from external violence, the effusion should happen to be accessible to the trephine. • The treatment of this affection will depend upon the site of the effused blood,-and the absence or presence of fracture of the skull. When the blood is accessible, it is obvious enough that it should be evacuated; but how is the practitioner to know this? How can he determine whether it is situated immediately beneath the cranial bones, upon the hemispheres of the brain, at the base of the skull, in the cerebral substance, or within the ventricles? Are there any symptoms, any grand landmarks, which will serve to point out the spot where the compressing agent is lodged ? The most subtle pathologist and diagnostician must be at fault here. Especially must this be true when there is no fracture, or outward evidence of injury. Indeed, even when there •is a fracture, we cannot always be certain. To illustrate: A person has com- pression, and the symptoms render it pretty clear that it has been caused by extravasation of blood; there is no visible fracture, but a contusion on the scalp denotes where the injury has been inflicted, and hemiplegia exists on the opposite side. Taking these facts in connection, the presumption is that the effusion, is on the side of the brain where the head has been hurt, and, acting upon this view, the surgeon, especially if he is fond of operating, may feel inclined to perforate the bone. But is he right in doing so ? He may, if he embark upon the enterprise, find the object of his search; but he is groping in the dark, and there is quite as much likelihood that he will fail. The blood may be far beyond his reach, and thus the patient may have been COMPRESSION FROM EXTRAVASATION OF BLOOD. 209 subjected to a fruitless and dangerous operation. Besides, it must not be forgotten that the blood may be at a point opposite to that upon which the blow has been inflicted. A surgeon makes occasionally a fortunate hit. Dr. Physick, in a case of this kind, boldly perforated the skull at the site of injury, and, extracting the clotted blood, cured his patient. But how often has the operation failed ? Where one surgeon has succeeded, twenty have been dis- appointed. A judicious practitioner should have something more than con- jecture to guide him in such an undertaking. The truth is, the only case in which such a procedure is really warrantable is where the extravasation is associated with, or dependent upon, fracture of the skull, complicated with depression, or serious injury of the soft pa#ts, or where the fracture is situated directly over the course of the middle meningeal artery. But even here the operation does not always succeed, as I know from personal observation. A boy, ten years old, was thrown off a heavy log, which, rolling over him, broke his skull directly over the right temple. The fracture, although not compound, was comminuted, and, as the symptoms were urgent, I made an incision through the scalp, raised a loose and slightly depressed piece of bone, and extracted a large coagulum. No relief followed; for, as fast as I removed the blood, the osteo-matral cavity, which was quite capacious, filled up again, and I was finally compelled to close the wound, as best I could, with a' compress and a tight roller. If this had not been done, the boy, I am sure, would speedily have bled to death. As it was, he died unrelieved in less than forty-eight hours. Cases are occasionally met with where, after the skull has been perforated, the blood is observed to be seated in the arachnoid sac, inside of the dura mater, lifting up this membrane in the form of a small, bluish swelling, beat- ing-synchronously with the left ventricle of the heart. "Under such* circum- stances, the proper operation, it has been alleged, is to make an opening into the tumor, and let out its contents. But such a procedure must, it is obvious, seriously complicate the case, exposing the patient to the occurrence of in- flammation and fungous protrusion, to leave out of the question the possi- bility, even in a respectable number of cases, of removing the clotted blood, or, after this has been effected, of preventing a new hemorrhage, perhaps quite as copious as the original one. My opinion is that little advantage is to be gained from such an undertaking, and that it-would be well, in view of its hazards, to refrain from it altogether. Since, then, so little is'to be accomplished by operation, how is the treat- ment of this affection to be conducted ? Obviously, upon the same general principles as that of ordinary apoplexy, from which, as we have already seen, compression from traumatic extravasation differs only in the absence of ex- ternal injury, as lesion of the scalp and fracture of the cranial bones. The object is twofold : first, to enable the brain to accommodate itself to the effused blood; and secondly, to promote the speedy absorption of this fluid. The first indication is fulfilled, after reaction has taken place, by copious general and local depletion, by the frequent use of active and rather drastic purga- tives, and by the administration of the saline and antimonial mixture, along with the use of light diet, cold applications to the head, and perfect quietude' both of mind and body. By these means, properly employed, the quantity of the blood is materially reduced both in the brain and general system, and, while the danger of inflammation is lessened, the organ is gradually brought to bear with the extraneous substance, no longer resenting its presence. Blood must not, however, be taken- heedlessly or causelessly. No surgeon, in his senses, would think of bleeding a patient before reaction has been estab- lished. But it is unnecessary to repeat here what has already* been set forth, in regard to this subject, in speaking of concussion of the brain. The same rules must govern us here, in the use of the lancet, as in exhaustion of the VOL. n._14 210 INJURIES AND DISEASES OF THE HEAD. system from other causes. Premature bleeding, in this form of compression and in apoplexy, has slain its thousands of subjects, or compelled the poor and crippled patient to drag out a miserable state of existence. Mercury should be freely used at an early stage of the disease, as soon, indeed, as possible after thorough evacuation by the lancet and purgatives. It should be given in the form of calomel, in doses of three grains every six or eight hours, its action being assisted by inunction of the groins and inside of the'thighs and arms with blue ointment. The gums must not merely be touched, but they must be maintained in a tender condition for a number of weeks. When the case has become chronic, the iodide of potassium takes the p]^ce of the mercurial, as there is now less need of hurry. Throughout the treatment, the greatest vigilance is exercised over the suf- fering organ, lest, in resenting the encroachment of the coagulum, it should take on inflammation, the slightest approach to which must be instantly met by the resumption of antiphlogistic measures. Infants occasionally suffer from compression of the brain, in consequence of an effusion of blood beneath the dura mater, before the completion of the ossific process, caused by blows upon the head. The little patient lies in a state of insensibility, and is usually affected with convulsions or spasmodic twitches, and, perhaps, some degree of stertor. Considerable contusion of the scalp generally exists, but there is no fracture of the sku]l, because the bones are too yielding for such an occurrence, and the fontanel appears to be elevated somewhat above its proper level. Pressure made with the'finger discovers unusual tension, and may aggravate the symptoms, especially the disposition to convulsions. Such a case is to be treated on general princi- ples ; with leeches and cold applications to the head, and stimulating injec- tions, followed by a brisk purgative as soon as the power of deglutition returns; but if it be very menacing, the duty of the surgeon plainly is to make a crucial incision through the scalp, and dissecting up the angles of the flap, to puncture the distended, and, perhaps, purple-looking membrane with the bistoury, taking care to make the aperture as small as may be consistent with the state of the extravasated blood, and to protect the parts, imme- diately-after the evacuation has been effected, with adhesive strips, a com- press, and a roller. b. COMPRESSION FROM THE DEPRESSION OF BONE. Depression of bone may exist .to a considerable extent without compres- sion ; but when it gives rise to this state, the symptoms come on immediately, and continue until the brain has either accommodated itself to its new rela- tions, until the offending portion of bone has been removed, or until the patient dies from the effects of.the injury. The lesion may be one purely of compression from the depression of bone, or the accident may, as was pre- viously intimated, be combined with extravasation of blood, caused by the laceration of the cerebral or meningeal vessels, either by the depressed bone or by the vulnerating body. In the latter case, the compression may be very violent, although the depression itself may be slight. The symptoms, in this case, too, may, in the first instance, be imperfectly marked, those of concus- sion perhaps predominating over those of compression, but being speedily succeeded by the latter. In the treatment of this form of compression, which will again come up for discussion in the remarks on fractures of the skull, no very definite rules can be laid down for the guidance of the surgeon.' Every case must, so to speak, make its own rules. Practitioners are generally agreed that, when the com- pression is produced by depression of bone, attended with compound fracture, immediate recourse should be had to trephining, and such a procedure is COMPRESSION FROM EFFUSION OF PUS. 211 certainly, it seems to me, the only one lhat ought to be thought of under the circumstances. In this way we not only remove the cause of compression, but we place the parts in a much more favorable condition for speedy repa- ration. The question is still an open one as it respects the treatment of compression from depression, attended with simple fracture. I am fully sen- sible of the difficulties that invest this subject, surrounded as it is by doubt and contradiction; but, after the best consideration that I can bestow upon it, I am disposed to regard operative interference as justifiable only in the event of extensive depression, and I should adopt this plan whether the symptoms of compression were urgent or not, on the ground that the patient would be much less likely to suffer from subsequent cerebral disorder. When the depression is comparatively slight, and especially when there is no com- minution of the bone, or great irregularity of its edges, giving them a rough, spiculated character, it would be well to let the bone alone, and to treat the case upon general principles, hoping thereby to prevent inflammatory mis- chief, and ultimate nervous irritation, which are so much to be dreaded in the more severe forms of the accident. There is a species of compression of the brain in children caused by extensive depression of bone without fracture, of which I have .witnessed several remarkable examples, and which never requires operative interference. The bone is simply bent or indented, and usually, by its own resiliency, regains its natural level in a few days under the use of a little purgative medicine, light diet, and cold applications to the head. C COMPRESSION FROM THE PRESENCE OF FOREIGN BODIES. Compression of the brain by a foreign body is an unusual occurrence, and could hardly take place without some concomitant depression of the skull. A large ball, a piece of iron, or a splinter of wood lodging in the cranial cavity, in the cerebral substance, or in the ventricles, might produce the effect, accompanied, probably, by a pretty copious hemorrhage, thereby seriously complicating the lesion. The symptoms would be likely to be im- mediate, as in compression from depression of bone, and the treatment would manifestly resolve itself simply into the extraction of the extraneous body, care being taken, in doing this, to inflict as little injury as possible upon the surrounding structures, and to guard the brain and its membranes afterwards against inflammation. Such lesions must necessarily be fraught with danger, and will rarely be recovered from, however judiciously managed. d. COMPRESSION FROM EFFUSION OF PUS. Compression of the brain from effusion of pus can occur only as a second- ary effect, coming on at a period varying', on an average, from a week to a fortnight from the commencement of the inflammation which precedes its development. Every practitioner, however, meets with cases where the in- terval is much longer, and to which we may, therefore, apply the term chronic. In general, the characteristic symptoms set in gradually, the disease bearing a great resemblance, in this respect, to the compression of the brain which follows arachnitis. There can, therefore, be no difficulty in discriminating between it and the other forms of compression already described, where the symptoms appear either immediately, or, at.farthest, within a few minutes after the occurrence of the injury giving rise to the compression. At first there is evidence merely of inflammation; by and by, as the disease advances, effusion takes place, and now the chain of morbid action is completed by the supervention of coma, -paralysis, convulsions, and death. This steady, pro- gressive movement, from one point to another, can.leave no reasonable doubt 212 INJURIES AND DISEASES OF THE HEAD. respecting the true nature of the lesion, especially if it be coupled with a con- sideration of the history of the case. The pus may Ire situated at the same localities as the extravasated blood; but, in general, it will be observed to be either between the dura mater and the inner surface of the skull, or in the anterior and middle lobes of tho hemispheres. It is frequently formed, it is true, in the arachnoid sac at the antero-lateral parts of the brain, but rarely in sufficient quantity to produce, of itself, any active compression. When it exists here, it is usually associated vyith serous effusion, which, being most abundant, becomes in reality the im- mediate cause of the cerebral trouble. Matter also is seldom effused, at least not to any considerable extent, in the lateral ventricles, whereas an effusion of serum is quite common there. In the majority of instances, it will be found, when the compression depends upon the presence of pus, that the fluid is situated in the anterior and middle lobes of the brain, which, if I may be permitted to judge from my own experience, have a greater aptitude for this kind of action than any other portion of the organ. When matter forms in the substance of the brain, it is usually'collected into an abscess, which, espe- cially in chronic cases, is sometimes inclosed by a distinct cyst, thick, pulpy, aud vascular, and containing a greenish, yellowish, or dark-colored pus, the cerebral tissues around being softened and disorganized. In regard to the precise situation which the matter occupies, the same difficulty exists, in forming an opinion, as in compression from extravasation of blood. It is only, as a general rule, when the matter lies immediately beneath the skull, and when the scalp or bone has-sustained considerable injury, that even an approach can be made to anything like a correct diag- nosis. When the pus is deeply buried in the substance of the brain, or lodged in the ventricles, we know of no means by which we can determine its pre- sence. We may, it is true, usually form a tolerably correct idea as to the side on which the effusion exists, by the hemiplegic condition of the body, the right side, for example, beiug paralyzed when the matter is seated on the left side, and conversely; but to say whether it is situated in the substance of the brain or in its cavities, is an impossibility. In general, it may be assumed that the matter lies immediately beneath the skull when the compression arises from inflammation caused by a bruise or wound of the scalp ; when, on the other hand, it follows concussion or fracture of the skull, it will be more likely to occupy the interior of the brain. To this statement, however, there are, of course, many exceptions. The effusion of matter which induces this species of compression may be the result of concussion, sometimes so slight as hardly to attract any atten- tion ; of fracture of the skull, with or without extravasation of blood, and with or without depression of bone; and, finally, of injury of the scalp, in the form, perhaps, merely of a slight contusion or wound, yet sufficient to jar the skull, and detach the pericranium and the dura mater. It is amazing how an apparently trifling accident may sometimes give rise to the most serious consequences, destined to sweep everything before them. A man re- ceives concussion of the brain ; his suffering is altogether momentary, and he soon goes about his business ; by and by, he begins to feel unwell, his head aches, he has no appetite, his bowels do not act properly, and he sleeps badly at night. Soon symptoms of inflammation of the brain set in, and thus the case progresses, from bad to worse, until effusion of pus takes place, followed by compression. Or, he has met with a fracture, perhaps quite insignificant; he gives himself no trouble about it, and may even entirely disregard the in- junctions of his medical adviser. By and by, cerebral symptoms come on; the disease advances insidiously; treatment fails to relieve; matter forms, and the patient perishes from compression* Or, a little bruise has been in- flicted upon #the scalp, hardly perceptible to the eye, but still sufficient to FRACTURES OF THE SKULL. 213 injure the pericranium ; in a few days erysipelas appears ; gradually a small puffy tumor forms; rigors, delirium, coma, and paralysis supervene, and the patient finally dies from a collection of pus between the skull and the dura mater, or beneath the dura mater, the inflammation having extended across the bone along the vessels and cellulo-fibrous connections. Or, lastly, the mischief may have been produced by a small wound of the scalp, the blow by which it was inflicted having, perhaps, detached both the pericranium and the dura mater. Again the case advances insidiously ; the ill-boding rigor, delirium,, stupor, and paralysis soon appear, and but too clearly indicate the formation of pus. The treatment of abscess of the brain is necessarily most unsatisfactory. When there is reason to believe from the state of the scalp, and the appear- ance of the skull at the site of injury, that the matter lies immediately beneath the bone, or within the arachnoid sac on the surface of the brain, the removal of a disk of bone by the trephine will, of course, be indicated, but even sup- posing that the operation is well performed, and the fluid evacuated, the chances are that the patient will ultimately perish from the mischief sustained by the brain and its envelops during the inflammatory crisis. If, as occa- sionally happens, a case recovers, it must certainly be regarded merely in the light of a rare exception, and nothing more. When the abscess is deep-seated, whether in the substance of the brain or in the lateral ventricles, and there are satisfactory evidences of its existence, as indicated by a sense of fluctuation, or by the continuance of deep coma after the removal, perhaps, of a large portion of depressed bone, the surgeon should not hesitate to make a free incision through the superimposed cerebral tissues, in order to afford free vent to the pent-up fluid. Desperate as such a procedure must necessarily be, it is clear that it holds out the only pos- sible hope of relief. In a remarkable case of this kind, Dr. Detmold, of New York, succeeded, by means of repeated incisions, some of them fully an inch and a half in depth, in preserving the life of his patient for seven weeks. An enormous quantity of pus followed the first operation, the patient immediately recovering his consciousness and power of- speech. SECT. IV.—FRACTURES OF THE SKULL. Fracture of the skull is a frequent occurrence, and is liable, even in com- paratively slight cases, to be followed by the worst consequences. It may happen at any portion of the bony case, and may exhibit itself in a great variety of forms, from the merest fissure in the osseous surface to the most extensive loss of substance. In its character, the accident may be simple, compound, comminuted, depressed, or complicated. The import of these terms will be fully understood from what has been said respecting them in the chapter on fractures in general. All fractures of the skull are the result of external violence, applied either directly to the part, or through the medium of the spinal column. It is re- markable how slight a blow will sometimes produce this injury. Several circumstances may be supposed to contribute to this result, of which the principal are the unusual thinness and brittleness of the cranial bones. It is by no means uncommon to see skulls which are so exceedingly thin as to be quite translucent, not at one point merely, but nearly through their entire ex- tent. My collection contains several specimens, the walls of which are hardly half'a line in thickness at the thickest part; they are, in fact, mere shells, composed of compact tissue, with hardly any trace of diploe. Such skulls are also, for the reason just stated, generally very brittle, although this pro- perty is by no means peculiar to them, but ^s often witnessed in compara- 214 INJURIES AND DISEASES OF THE nEAD. tively thick crania. "When unusual thinness and fragility co-exist in a bone, it requires very little force to break it, either at the point struck, or at some opposite one. The fracture will, moreover, be likely to be uncommonly ex- tensive, comminuted, and depressed. On the other hand, the skull may he so thick and hard as to be almost proof against any force, however severe. In one of my specimens, the average thickness of the cranium is at least half an inch, its density is nearly equal to that of ivory, and hardly a trace is to be seen of a suture. To break such a skull, even in a comparatively slight degree, would require an amount of violence which is rarely inflicted under any circumstances. A very frightful fractur&is sometimes produced by indirect violence. It occurs when a person, in falling from a considerable height, alights upon the top of the head, and thus receives the whole weight of the body upon the base of the skull. The atlas, being powerfully pressed against the occipital bone, not only breaks it in pieces, but often also the sphenoid, temporal, and frontal bones, as well. Theolder writers have much to say about fracture of the skull by centre- coup; and in reading their works one cannot fail to be impressed with the conviction that they considered it as an accident of frequent occurrence. Modern research, however, has pointed out the fallacy of this conclusion, by showing that this kind of fracture ranks among the rarest lesions of this portion of the skeleton. The most common site of fracture of the cranium by contre-coup is the base of the skull, from blows upon the vertex. Here the force, instead of being expended upon the part struck, is diffused over the cranium, being finally concentrated upon the sphenoid, temporal, and occipital bones, which are either separated along the line of suture, or broken in their continuity. A similar effect is sometimes witnessed in the occipital bone from blows upon the frontal, and in the parietal bone of one side from force applied to that of the other side. The subject of fracture of the skull is an exceedingly complex one, and cannot possibly be understood by the young practitioner without the most careful and attentive study. The following arrangement will, it is believed, facilitate his inquiries and lighten his labors : 1. Simple fracture of the skull, without depression : 2. Simple fracture, with depression : 3. Simple fracture, with displacement, and compression of the brain: 4. Compound fracture: 5. Fracture of the base of the skull: 6. Punctured fracture : 1. Fracture of the external table alone : and, 8. Fracture of the internal table alone. Finally, there may be depression of the skull, sometimes, indeed, of a very marked character, without fracture, the cranial bones being bent rather than broken.• 1. SIMPLE FRACTURE WITHOUT DEPRESSION. The term simple, as applied to fracture of the skull, implies that the bone alone is involved, or that, if there be any injury of the soft parts, it does not present itself in the form of an open wound. Some contusion of the scalp must, of necessity, always exist, however trifling or insignificant the osseous lesion. Such an occurrence constitutes a complication, but it is very different from a wound communicating with the seat of the fracture, and which, when present, renders rtie fracture compound. The most simple form in which fracture of the skull occurs is that of a crack or fissure, as in fig. 93, similar to what is observed in a broken pot. It is a mere solution of con- tinuity of the osseous tissue, comparable, in many respects, to a simple incised wound. It is unattended with depression or the separation of any pieces of bone. The fissure may involve the substance of the bone, or it may run along the course of tlje sutures, its extent varying from a few lines SIMPLE FRACTURE WITH DEPRESSION OF BONE. 215 to several inches. It may be caused by direct violence, or, as occasionally happens, by contre-coup. Such a fracture, • provided . Fig- 93. there is no serious lesion of the soft parts, or of the brain, re- quires none but the most simple treatment. Rest for a short time in bed, the use of an occa- sional purgative, rigid absti- nence, and the avoidance of / mental excitement, constitute \ the principal means of cure. The brain, of course, is carefully watched; for the shock produced . simple fracture of the skuii. by the accident, causing more or less functional disturbance, may be followed by serious inflammation, and that, too, when, perhaps, it is least apprehended. Operative inter- ference is not thought of; there being no depression of bone and no extra- vasated blood to remove. The fissure gradually closes up by bony matter, without encroachment upon the inner table of the skull, arid, consequently, without injury to its contents. In these cases, the older surgeons used to trephine, sometimes taking away large portions of the skull, and thus seriously complicating an injury which,, at the preseht day, often gets well under the mildest means. 2. SIMPLE FRACTURE WITH DEPRESSION OF BONE. This form of fracture is not at all uncommon ; the integuments are more or less contused, and the patient is usually severely stunned by the blow or fall by which he has been hurt. The bone is found to be de- pressed, as in fig. 94, or driven beyond the surrounding level, but not sufficiently far to be productive of compression. If the injury has been very violent, the bone may be comminuted, and some of the pieces may be partially detached, pressing, perhaps, against the dura mater. The great danger from such an accident, after reaction has taken place, is inflammation of the cranial consents, and, remotely, nervous irritation, followed by epilepsy. The question then arises, how shall it be treated ? Upon this subject, surgeons have been much divided in opinion, some Tavoring, otners conaemning, ope- rative interference; favoring, because of the dreaded primary and secondary effects; condemning, because a simple fracture is thus converted into a com- .. pound one. Avoiding both these extremes, as calculated, if fully carried out, to be followed by mischievous consequences, the judicious practitioner will be governed, in the choice of his remedies, by the circumstances of each indi- vidual case. When the fracture is of small extent, free from comminution, and without much depression, the best plan will be not to attempt elevation, Fig. 94. Fracture with depression. 216 INJURIES AND DISEASES OF THE HEAD. but to treat the patient upon general principles, using depletion by the lancet and other means, with a view to the prevention of inflammation and other evil consequences. If, on the other hand, the bone be forced down consider- ably, so as to impinge very decidedly upon the brain, or if it be comminuted, or jagged at the edges, the sooner it be raised or removed the better; since, if it be allowed to remain, it cannot fail to become a source of trouble, either by exciting inflammation, or by causing unpleasant secondary effects.. I am fully, indeed I may say painfully, sensible of the responsibility which I incur in giving this advice ; but I feel satisfied, after mature consideration, aided by the light of experience, that it is the best, if not the only, proper course to be pursued under the circumstances. A man laboring under such an affection is never free from danger; he may get well, or be well to all appear- ance, and yet be only half cured ; for he is subject, at any moment, to have his mind and life imperilled by the broken bone. It is like the sword of the tyrant suspended over the head of his subject. 3. SIMPLE FRACTURE WITH DEPRESSION, AND SYMPTOMS OF COMPRESSION. In this variety of fracture, the bone is not only-displaced, but sunk so far below its natural level as to produce compression of the brain. The patient lies in a comatose condition, breathing heavily and stertorously, with dilated pupil, and a slow, laboring pulse, the side opposite to the seat of injury being paralyzed. The-symptoms are unmistakable. The fractured and de- pressed bone, with, perhaps, slight sanguineous effusion, is the cause of trouble. The case, although different from the preceding, has yet much in common with it, the cerebral compression constituting the main feature in the dissimilarity. ■ Here, too, the treatment is not settled, some contending for delay, others for immediate action ; the former hoping, by depletion'and other means for cere- bral accommodation and prevention of inflammation ; the latter trusting, by operative measures, to prevent both present and future evil. Unfortunately, experience, always the best guide in such matters, has not yet fully decided the question as to which of these two plans is to be preferred. Much has been said on both sides ; but the tendency, if I mistake not, is. decidedly in favor of immediate trephining on the ground that, while the operation adds but little to the risk of the casefc the patient has a much better chance of prompt and permanent recovery. As long as the bone is depressed, even supposing that the compression is removed, there is danger of inflammation of the brain and its envelops, to say nothing of the occurrence of epilepsy and other nervous affections, as distressing to the patient as they are embar- rassing to the practitioner. My opinion, then, is that operative'interference,. early and efficient, is, as a general rule, the only proper plan to be pursued under such circumstances. I am sure I should prefer such a course in my own case, if, after all the facts on both sides of the question had been fairly stated to me, I had sufficient judgment left to determine my choice. 4. COMPOUND FRACTURE. A fracture of the skull is said to be compound when the injury of the bone is associated with a wound in the scalp, communicating with the fissure in the bone. Such a fracture may be comminuted or depressed, or both com- minuted and depressed, and attended with or without compression pf the brain. The scalp is frequently much contused and ecchymosed, and a good deal of swelling generally arises soon after the occurrence of the injury. The symptoms may be those merely of shock, perhaps severe and protracted, or concussion and compression may co-exist, commencing simultaneously, and running on, step by step, until reaction ensues, or until the case terminates COMPOUND FRACTURE. 21? in sinking. Hemorrhage, occasionally quite copious and protracted, may attend the accident, adding to the exhaustion of the already enfeebled frame. The danger of compound fracture of the skull is threefold: from shock, from inflammation, and from fungus of the brain. When the violence to the bone and soft parts has been unusually severe, death may occur without 're- action, or after a feeble and unsuccessful show at restoration; or, the first symptoms having passed off, life may be assailed by inflammation; or, this being happily surmounted, the patient may perish from fungus of the brain. When the fracture is very extensive, and is accompanied with considerable- loss of substance and laceration of the dura-mater, death may occur from loss of cerebral substance, as in a case which came under my observation in 1852. The patient, a little girl, nearly three years of age, had received a blow from a brick, which literally mashed the top of the cranium, causing extensive laceration of the dura mater, through which the disorganized brain escaped in immense quantity, despite my efforts to prevent it. The proper treatment iu compound fracture is to elevate the depressed bone, and to remove any loose or partially detached pieces, this plan being adopted whether there be any compression or not. The case, being a compound one, cannot be aggravated by operation, though it is not to be forgotten that this should be executed with the greatest care and gentleness. The operation is done at once, while the parts are still fresh from the first effects of the injury, and, consequently, prior to the supervention of inflammation. Elevation and retention of the depressed fragments are effected whenever this is practicable, but all loose pieces are removed, as well as such as are nearly detached, lest they should become a source of irritation, either present or future, by acting as foreign bodies. In the compound, comminuted fracture, I have, on seve- ral occasions, been compelled to take away an extraordinary quantity of bone, fully equal in size to that of the palm of the hand, and yet recovery followed in almost every instance. The danger of such a procedure is probably not as great as is generally imagined, provided there is no lesion of the brain and its envelops. When these structures are wounded, the case assumes at once a grave character, as there is risk then not only of violent inflammation, but also of loss of cerebral substance and of the ultimate formation of fungus ; two circumstances which cannot be too much dreaded. I am averse to the retention of any piece of bone, however large, that has lost all connection with the surrounding parts, believing that its reunion, even if it were possible, which, however, it rarely is, would, from the irregularity of the provisional ' callus, almost inevitably become a source of mischief, leading perhaps, at length, to the necessity of trephining. Whenever such a procedure is re- quired, due'support must be given to the now unprotected brain by sheet lead, compress and bandage, otherwise there may be extensive protrusion of the cerebral pulp before the surgeon is aware of it, the brain rising and tend- ing to escape at every pulsation of the heart. I have found it extremely difficult, in several instances, successfully to counteract this tendency, by any means that I could adopt; the consequence was that the patient soon fell into convulsions, and speedily perished. The offending bone having been raised, or removed, the edges of the wound are gently approximated by suture and plaster, the whole being supported by a compress and roller. The head, previously well shaved, is maintained in an elevated position, and kept constantly wet with cold w^ter, or, what is hetter, a bladder partially filled with pounded ice, or some refrigerant lotion. If the patient is young and plethoric, and there has been no serious hemor- rhage, blood is taken freely from the arm, and by leeches from the temple, the bowels are thoroughlyjnoved by drastic purgatives, and the heart's action is equalized by the antimo'nial and saline mixture, aided by the moderate use of opiates and veratrum viride. Light and noise are excluded from the pa- 218 INJURIES AND DISEASES OF THE HEAD. tient's apartment, and the diet is of the mildest and simplest character, con- sisting of a little panada, thin gruel, or arrowroot, along with acidulated drinks. Great prejudice exists in the minds of practitioners against the employ- ment of anodynes in fracture of the skull, even in its worst forms, on account of their supposed tendency to cause congestion of the brain, thereby increas- ing the danger of inflammation. I "believe that this opinion is not only groundless, but fraught with mischief. In the first place, it is by no means established that opiates, judiciously administered, produce cerebral conges- tion ; and secondly, even supposing that they did, the occurrence would be no contra-indication to their exhibition. If they produce congestion at all, the congestion is of a passive, and not of an active character, and, therefore, comparatively harmless. But I do not look upon the matter in this light; on the contrary, I believe that anodynes, by controlling the heart's action, exert a direct and positive influence in controlling inflammation of the brain, by placing the organ in q, state of repose, so essential in every case of disease and injury, no matter how induced., or where occurring. The brain, in the normal state, rises and descends with every movement of the left ventricle of the heart; in injury, this action is greatly increased, becoming often quite tumultuous and overwhelming; the nervous pulp receives a shock at each pulsation ; it is never at rest, and has, therefore, no opportunity to repair the mischief that has been inflicted upon it. Now the object of. the anodyne is to insure this result by paralyzing the heart, and thus rendering it unable to send to the brain the accustomed quantity of blood. If this mode of reason- ing be correct, it follows that the wounded organ, receiving less blood than usual, will be less prone to inflammation. We can secure repose for it in no other way. "We may carry the inflamed hand in a sling, and apply splints to the inflamed leg, but we can insure tranquillity to the brain, heart, lungs, stomach, bowels, and peritoneum only by the use of anodynes. But these remedies do good in another capacity under these circumstances. They in- duce sleep, allay pain, and quiet the mind, effects which cannot fail to pro- mote recovery, when, from the frightful nature of the injury, recovery is not impossible. 5. FRACTURE OF THE BASE OF THE SKULL. Fracture at the base of the skull may be perfectly simple; mild symptoms characterizing the affection, and mild remedies sufficing for its relief. But it is far otherwise when the fissure is extensive, owing to the lesion sustained by the brain and its envelops, the former being often severely concussed, and the latter freely detached, large quantities of blood being at the same time frequently extravasated at the site of injury, either in the arachnoid sac or beneath the dura mater. The accident is usually caused by falls upon the vertex, or by the head being crushed laterally, as by the passage of the wheel of a carriage, or by the head being jammed in between two hard and resist- ing bodies, as a post and a railroad car. A fall upon the buttocks, knees, or feet may also produce this fracture, but such an occurrence must be extremely rare, and will be likely to happen only when the cranial bones are uncom- monly thin or brittle. In most of the cases of this fracture that have come under my observation, the injury was occasioned by the person pitching head foremost from a second story wjndow or a high scaffolding down upon the pavement, the weight of the body being received upon the vertex. In a re- markable instance of this kind, which was treated in 1846 by Professor T. G. Richardson, in the Louisville Hospital, and which I had an opportunity of seeing soon after the occurrence of the accident, the fracture extended in a circle around the occipital, sphenoid, temporal, and frontal bones, separat- FRACTURE OF THE BASE OF THE SKULL. 219 ing them completely from the rest of the skull. The man had been pushed down a high flight of stairs, and in the fall had struck his head violently against the floor. He was picked up immediately in a state of insensibility, in which he continued, without any successful attempt at reaction, until he died, about forty-eight hours afterwards. Dissection showed not only the frightful extent of fracture above described, but an immense coagulum at the base of the skull. The adjoining cut, fig. 95, affords" an excellent illustration of the form of fracture now described. It will.be ob- served that the occipital, temporal, and sphenoid bones are most extensively fis- sured, the injury having been occasioned by a fall upon the vertex. It is, then, not so much in consequence of the fracture, as of the great mischief inflicted upon the soft parts, .the brain in particular, that this injury is so much dreaded by the intelligent surgeon. The moment he sees his patient, he is fully impressed with the critical nature of his condition. The symptoms are always of the worst possible description. They are invariably those of concussion and compression, the latter coming on early, and usually continuing, with little or no mitigation, until the close of life. The countenance is deadly pale, the pulse is fe.eble and hardly perceptible, the respi- ration %is nearly extinct, the pupils are widely dilated, and there is not the slightest sign of sensibility of any kind. Blood often issues from the ears, the nose, and the mouth, from some of the vessels in.these parts having given way, in consequence of the severity of the blow or fall inflicting the injury. Occasionally the bleeding from the ears is quite copious, especially when there is fracture of the petrous portion of the temporal bone, and sometimes even when there is merely a rupture of the tympanum. Now and then the blood proceeds from the interior of the skull, through a crack in the cranium communicating with the nose or mouth. An escape of serosity from the ears is occasionally observed, and great stress has been laid upon it by recent writers on account of its supposed diag- nostic value. The discharge generally appears within a short time after the accident, and after having continued, often quite profusely, for several days, gradually vanishes. As many as three, four, and even five ounces are lost in the twenty-four hours, the fluid dropping upon, and saturating the patient's pillow. It is strongly saline in its taste, of a clear watery aspect and con- sistence, and entirely destitute of coagulability, containing merely a trace of albumen, and differing, therefore, essentially from ordinary serum. The source of this discharge has been variously explained, but the most plausible theory is that it consists of the cephalo-spinal liquid, and that its evacuation through the ear is effected by the rupture of the cul-de-sac of the arachnoid membrane which surrounds the auditory nerve as it passes along the auditory canal in the petrous portion of the temporal bone. This view of the case is certainly very strongly favored by the similarity in the physical and chemical properties of the two fluids, and by the fact that the serous investment of the braiu has been found to be torn completely across, opposite the outlet at Fissure at the base of the skull. 220 INJURIES AND DISEASES OF THE HEAD. which the escape has been observed to take place. The discharge is usually most abundant, as well as most common, in young subjects. The diagnosis of fracture at the base of the skull is not, I think, as diffi- cult as is generally supposed. The history of the case, the coexistence of violent concussion and compressiqn, the profound coma and insensibility, the absence of fracture at the more accessible portions of the cranium, and the obstinate persistence of the symptoms, are sufficiently declarative, in most cases, of the nature of the accident. The inferences derived from these sources will be materially strengthened, if there be at the same time a discharge of blood from the ears, profuse, and continued, as it will be likely to be when there is fracture of the petrous portion of the temporal bone. A flow of serosity from these passages is an infrequent, but, diagnostically considered, a most valuable occurrence, as it always affords indubitable evidence of the lesion in question. Bleeding from the nose and mouth may proceed from other causes, and cannot, therefore, be rendered available in the discrimina- tion of the present affection. Fracture at the base of the skull is one of the most serious of accidents. If it does not always terminate fatally, the number of recoveries is so few as to form merely an exception to a law which is by many regarded as general. I have, myself, out of at least a dozen cases of the kind, witnessed only one restoration. That the injury should usually end in this way is not surprising, when we reflect upon its violent and complicated character, and upon the fact that under any circumstances, hardly anything is to be effected by treat- ment, which is obliged to be altogether expectant. Operative interference. is, of course, wholly out of the question. The only thing to be done, in the first instance, is to endeavor to establish reaction, and, if this should fortu- nately take place, afterwards to employ means for averting inflammation. In most of the cases that have .come under my observation, the patient never recovered from the unconscious and exhausted condition consequent upon the first blow, death having usually occurred before the end of the third day. 6. PUNCTURED FRACTURE. A punctured fracture is a small, circumscribed opening in the skull, attended with depression of both tables, the inner, however, being always more dis- placed, as well as more badly broken,-than the outer. It derives its name from its size, which is often quite insignificant, and from the circumstance that.it is always produced by a narrow weapon, as a poker, bayonet, or dirk. It is sometimes caused by a fall upon a nail, a sharp stone, or the top of an iron rail; and I have seen several cases where it was produced by a blow with a brick, the angle striking the bone. From the manner in which the injury is inflicted, there is always necessarily severe contusion of the scalp, if not laceration of its entire thickness, con- Fig-96. stituting, in the latter case, a compound fracture. The annexed drawing, fig. 96, from a pre- paration in my collection, affords an excel- lent idea of the nature of this variety of fracture. The case was neglected, or mis- managed, and the man died in three weeks, from abscess of the anterior lobe of the brain, caused by the pressure of the depressed bone. Punctured fracture is not often attended with compression ; for, although the inner table of the cranium may be considerably Punctured fracture of the skuii. depressed, there are few cases where it causes FRACTURE OF THE EXTERNAL TABLE ALONE. 221 such an amount of pressure as to produce this effect. Sometimes a sh-arp spicule of bone dips down into the membranes of the brain, and even into its substance, seriously complicating the case. The accident is always easily recognized by inspection and digital exploration, aided, if necessary, by the probe, the latter often affording important information relative to the nature and extent of the depression. However simple, a punctured fracture of the skull should always be regarded as an occurrence of the most serious character, from which, unless it be properly understood and treated, few per- sons ever make a happy escape. The great danger is inflammation of the brain and its membranes, frequently coming on within a few days after the accident, and sure to terminate fatally, if the case have been neglected or mismanaged. Should the patient be so fortunate as to escape with his life, he can scarcely fail to suffer afterwards from cerebral irritation, especially epilepsy and mental imbecility. In view Of these occurrences, practitioners have long been agreed that the proper treatment is trephining, performed at the earliest possible moment, and without the slightest regard whatever to the character of the head symptoms ; or, in other words, as to whether there be compression or not. It is sometimes extremely difficult to persuade a patient, when he has merely a little hole in his cranium, without pain, headache, or any other symptom of consequence, to submit to "what he regards as so serious an operation as that of boring the skull. I recollect a memorable instance where a man lost his life from this cause. He had been struck, early one morning, with a brick upon the head, resulting in a punctured fracture over the middle of jbe left parietal bone. He was stunned for a few minutes by the blow, but soon recovering, he cursed the fellow who had played him the shabby trick, and immediately set out for my office, a distance of nearly two miles, on horseback. Upon his arrival, he was in every respect comfortable, except that he complained of a little soreness of the scalp. Discovering the nature of the fracture, I pointed out to him very fully its dangers, and begged him to submit without delay to an operation for his relief. To this, however, he would not consent, and I accordingly dismissed him, having previously enjoined upon him absolute rest, light diet, and constant elevation of the head, with the use of the cold water-dressing. Two days afterwards I was sent for, having been informed that he was very unwell. I found him quite feverish, with a tendency to delirium. Again an operation was urged, and again declined. He grew gradually worse, and on the seventh day, when he was in a comatose condition, his wife permitted me to use the trephine. No relief followed the operation, and he died in thirty-six hours after. Pus and lymph were found at the seat of the injury, the brain was slightly softened beneath, and the lateral ventricles contained several ounces of serum. Who can doubt that this man lost his life by his obstinacy and folly ? Could he have been immediately trephined, there is reason to believe that he would have made a speedy and perfect recovery. X. FRACTURE OF THE EXTERNAL TABLE ALONE. This species of fracture is extremely rare, and can occur only in the adult, or in persons whose cranial bones have a distinct diploe. Moreover, its occurrence implies unusual brittleness of the outer table, and inordinate firm- ness of the inner. The fracture is generally of small extent, and the depres- sion inconsiderable. The most common cause is a blow from a narrow, blunt- pointed body. Besides being momentarily stunned, the patient suffers no particular inconvenience, save what results from the scalp-lesion. The diag- nosis of such a fracture must necessarily be obscure, and, unless great care 222 INJURIES AND DISEASES OF THE HEAD. be taken, it might easily be confounded with the punctured fracture just de- scribed. Mistake will best be avoided, in case of wound, by a careful use of a fine probe, carried around the edge of the depressed bone, by the pressure of the finger, and by filling the artificial hollow with water. If the probe enter any side crevices, the finger cause motion, or the water disappear, there will be strong reason to conclude that the fracture involves both tables of the bone, and that it is of a punctured nature. The injury requires no particular treatment, apart from that which may be necessary on account of the lesion of the scalp and brain. • .A fracture of the outer table of the frontal sinus is 'sometimes met with. I saw a singular case of this description a few years ago, along with Dr. Bo- nalds, in a lad, eight years old, from a blow with a piece of brick. The outer table of the left sinus was broken at several points, and knocked considerably below the natural level. A wound, one inch long, existed on the left eye- brow. In attempting to raise the depressed bone, which I succeeded in • doing with a delicate and slightly curved awl, the boy had a violent convul- sion, but from this he soon recovered, and he had no bad symptoms after- wards. 8. FRACTURE OF THE INTERNAL TABLE ALONE. This fracture, fig. 91, is still more rare than the preceding; indeed, it is so uncommon that many surgeons of large experience have denied the possi- bility of its occurrence. I have, myself, FlS- 9^- never seen an instance of it; but that it has been met. with by others, although very seldom, is indisputable. 'In the few cases of it upon record, the fracture was caused by the blow of a bullet, or some outer con- centrated violence, sufficient to break the inner table without cracking the other. The lesion is seldom discovered until after death, and then, perhaps, only accidentally, as it does not give rise to any marked, much less characteristic, symptoms. When Fracture of the inner table of the skull. ifc is Suspected to exist, and especially when there is concomitant compression, the pro- per remedy would be the trephine, for the same reason that that operation is performed in punctured fracture. 9. DEPRESSION WITHOUT FRACTURE. Depression of the cranial bones without fracture can take -place only in very young subjects, before the completion of the ossific process. It is a bending rather than a fracture of the osseous fibres, and is confined chiefly, if not entirely, to the frontal, parietal, and occipital bones.. It is usually produced by a fall from a considerable height, in which the child alights upon the top of the skull, which is sometimes flattened'in a most grotesque manner, and in a most extraordinary degree. I have seen only two instances of this occurrence, one of which made a great impression upon me at the time, on account of its novelty and extent. It happened in a child two years and a few months old, who, in falling down a long flight of stairs, struck its head violently against the floor. It was picked up in a state of insensibility, and, for a few minutes, it was supposed to be dead. Signs' of reanimation, how- ever, soon appeared, and in a few hours the reaction was perfect. The ante- rior and upper portion of the skull was completely flattened, the frontal and APPARENT DEPRESSION. 223 parietal bones being pressed out in such a manner as to give the head a most singularly deformed appearance. The child lay for the -better part of a day in a comatose condition, with frequent spasmodic twitches, but no decided convulsions; both pupils were dilated, but not altogether insensible to light, and the pulse, after the subsidence of the shock consequent upon the fall, was slow and labored. Under mild treatment, these symptoms gradually disap- peared as the depressed bones regained their natural level, which they did in less than a week from the time of the accident. In the other case, the depres- sion was much less, and the effects proportionably milder. In the American Journal of the Medical Sciences for August, 1840, a very extraordinary case of this accident is related by one of my former pupils, Dr. Burt, now of the United States Navy. A child, three years old, .fell out of a second story window, head-foremost, upon the pavement below, a distance of sixteen feet, knocking the skull as flat as a board, the frontal bone projecting two inches over the eyebrows. For an hour the child had symptoms of violent concus- sion ; then slight convulsions came on, followed by vomiting, which afforded great relief. The treatment consisted of cold applications to the head, and of gentle cathartics. No fracture could be detected. The bone speedily began to resume its natural position, and in a short time the skull had re- gained its former shape. In cases similar to those now mentioned, the treatment resolves itself into the adoption of the most gentle measures, as leeches and cold applications to the head, purgatives, and stimulating enemata. If the patient is very plethoric, blood may be taken fromthe arm, but in general this will be un- necessary. The bone will gradually resume its natural position, by its own resilient powers and the pulsatory movements of the brain. All interference with the trephine is, of course, avoided. If the child be very young, an attempt may be made to raise the bone by suction with a cupping-glass, as recommended by Heldanus, and as was done successfully in one case, in 1849, by Dr. W. L. Moultrie, of Charleston. The depression occupied the parietal bone; and was large enough to contain with ease the bowl of a common tablespoon. The instrument having been pro- perly adjusted, and exhausted of air, traction was made upon it with the effect of rapid and complete restoration of the entire surface to its natural level. The child, which was five months old; recovered without an untoward symp- tom. A case of a similar nature has been reported by Dr. Nicolls, in the Dublin Medical Press for September, 1853. The depression, which was deep, narrow, and about three inches in length, was promptly.raised by a cupping- glass placed upon an embankment of common glaziers' putty, in order to afford the instrument a proper purchase. The child was two years old. 10. APPARENT DEPRESSION. The practitioner is sometimes sorely puzzled to determine whether what he sees and feels upon the skull is really a depression of the bone, or merely a deceptive appearance. Of this occurrence I have seen several well-marked instances, and, as it is by no means uncommon, it is very important that we should be acquainted with its true character, lest we be tempted to use the trephine in cases which will either yield to very slight treatment,*or where, from the injury'done to the brain, treatment of every description is hopeless. The manner in which it is produced is easily understood, A man receives a blow or fall upon the head, severely contusing the scalp, and perhaps inflict- ing serious injury upon the cranial contents. Upon examination, a tumor is found, having a depressed centre and elevated edges, its size perhaps equal- ling the palm of a small hand. The depression indicating the spot upon which the violence was concentrated, is due solely to the condensation of the 224 INJURIES AND DISEASES OF THE HEAD. tissues of the part; while the tumor itself is caused by the blood that is ex- travasated at the time of the accident, and which now distends the cells of the adjacent structures. The first case in which I noticed this occurrence was that of- an elderly man, who was brought into the Louisville Hospital in a state of coma from a fall which he had received a short time previously from a second-story window upon the pavement below. The tumor, which was uncommonly large, existed upon the right side of the head, over the parietal protuber- ance ; its edges were remarkably prominent and well defined, and the central cavity felt precisely as if it had been caused by a fracture with depression of the bone. A careful examination, however, satisfied me that the appearance was altogether deceptive, and the death of the man, occurring nine hours afterwards, confirmed the accuracy of my diagnosis. The parietal bone was perfectly sound, but one of the most extensive fractures that I have ever known, existed at the base of the skull, along with immense effusion of blood. A'boy, aged sixteen, in riding "rapidly round a race-course, was pitched; head-foremost, off his horse against the earth, the animal being at the time under full speed. He was picked up in a state of utter insensibility, and a large tumor was discovered just above the left eyebrow, with a well-marked central hollow. Although convinced that the bone beneath was sound, I was iuduced, at the request of Dr. Knight and Dr. Wakefield, to cut through the part, but found no fracture. The lad never recovered his consciousness, and died in a few days after the receipt of the injury. An extensive fracture existed at the base of the skull. A mulatto boy, aged eleven years, a patient of Dr. O'Reilly, was thrown off his horse, striking his head violently against a fence. On the right side of the head, just in front of the temple, was a severe contusion,- feeling very soft, and readily permitting the finger to sink down into it at the centre, thus imparting the sensation of a badly-depressed fracture. The lad had been somewhat stunned, but soon regained his consciousness. Being in doubt whether the appearance was real or not, I made a small incision across the swelling, down to the bone, but there was no fracture. Recovery occurred without an unpleasant symptom. " ... To the above cases I might add several others, but as they are sufficiently typical of the occurrence in question this will be unnecessary. What in- creases the embarrassment in such cases is the fact that the deceptive appear- ance of the scalp is often associated with symptoms of compression of the brain, inducing the idea that the cerebral affection might be caused by de- pression of the skull. Doubt may sometimes be thrown upon our diagnosis by malformation of the skull. A man, aged thirty-two, was admitted into the Louisville Hos- pital in 1849, on account of a wound upon the posterior part of the head, received a week previously by being struck with a piece of iron. He was stunned by the blow, and was hardly able to walk across the room for several days after. The wound, which was about two inches and a half in length, extended down to the bone, and was situated over a ridge just behind the lambdoidal suture. On passing my finger around the wound, I found, imme- diately in front of it, a broad, deep hollow, reaching forwards towards the sagittal suture, and looking very much like a depression from a fracture. Upon inquiry, however, I ascertained that it had always existed there, hav- ing been the result of malformation. The patient, on his entrance, had vio- lent headache, along with considerable fever, for which he was" bled and purged, and from the effects of which he soon recovered. Had he labored under compression of the brain, the deceptive appearance caused by this state of the bone might have induced an incautious surgeon to apply the tre- phine. DISEASES OF THE CRANIAL BONES. 225 It is hardly probable that any surgeon, at the present day, would mistake a suture of the skull for a fracture. Such an error is said to have been com- mitted by Hippocrates, who actually applied the trephine for the relief of his patient. An accident like this could only be excused in a case where symp- toms of compression are superadded to a depressed appearance of a bone from malformation, the suture running across its surface, and the scalp being more or less contused from the injury. SECT. V.—DISEASES OF THE CRANIAL BONES. The cranial bones now and then suffer from exostosis, of which there are two distinct kinds, the ordinary and the syphilitic. The former, which is often caused by external injury, is most common about the fore- Pig. 98. head, and may, in time, acquire a considerable bulk, although in general it is small. Its struc- ture is either comparatively soft and spongy, or hard and dense, like ivory. It seldom extends beyond the outer table of the skull, and has usually a tole- rably broad base. Occasionally several such growths occur on the same bone, as seen in fig. 98. The proper remedy* is removal. When the exostosis exteuds in- wards, or grows from the inner surface of the cranium, inducing neuralgia or epilepsy, and the diagnosis is sufficiently obvious, the offending structure should be removed with the trephine. The syphilitic form of exostosis is occasionally met with as a tertiary symp- tom, being most common in persons whose system has been injured by the conjoined effects of the syphilitic poison and of mercury. The forehead is the most common site of the morbid growth, which is often multiple, and not unfre- Fig. 99. Ivory-like exostoses of the skutl. Syphilitic exostoses of the skull, both external and internal. quently appears simultaneously on both surfaces of the cranial bones. Its base is broad or diffused; its structure soft and porous. The disease is always ac- companied by tenderness on pressure, and by fixed pain, liable to nocturnal exa- cerbations, which, together with the history of the case, generally readily dis- tinguish it from the ordinary affection. When a tumor of this kind forms on the inner surface of ihe skull, it must necessarily cause more or less cerebral VOL. II.—15 226 INJURIES AND DISEASES OF THE HEAD. Syphilitic exostosis of the inner surface of the skull. disturbance. The treatment is similar to that of tertiary syphilis in other parts of the body. The annexed sketches, figs. 99 and 100, exhibit these formations on both surfaces of the skull. Fig. 100. A species of general hypertrophy of the bones of the skull is sometimes met with, either as the result of exter- nal injury, as a blow on the head, or, as more frequently happens, as an ef- fect of the syphilitic virus. It is cha- racterized by extraordinary density of structure, by complete effacement of the diploe, and by great increase of weight and thickness of substance. The treatment must be regulated ac- cording to the nature of. the exciting cause. Caries of the skull, fig. 101, is usually the result of constitutional taint, and sometimes attacks every bone, completely riddling both tables, and causing the most fright- Fig. 101. • ful suffering; the scalp is studded with ulcers, the discharge is foul and fetid, and the general health is sadly under- mined. The affected bone often perishes, seldom, however, in its entire thickness, the external table being much more frequently involved than the internal. The treat- ment must be in strict conformity with the na- ture of the exciting cause. Great attention must be paid to cleanliness, fetor is allayed with the chlo- rides, and dead bone is removed as soon as it is sufficiently detached. . " Caries and necrosis of the cranium from ordinary causes are uncommon. Serious mischief of this kind may arise from a simple blow upon the head, with or without scalp- wound, provoking inflammation and suppuration of the pericranium, which, becoming detached, occasions destruction of the osseous tissues. The effect may be limited or diffused, attacking one'or both tables of the bones, and sometimes, although very rarely, involving almost the entire calvaria, as in the remarkable case of Saviard, in which, two years after a blow on the head, the whole skull-cap came away in one mass. Injury inflicted upon the diploe, in which this substance is more or less severely bruised and shaken, if not completely broken down and disorganized, is liable to be followed by grave inflammation, acute or chronic, eventuating in the formation of pus, either in its own structure, beneath the pericranium, or between the dura mater and skull, considerable portions of which some- times perish from the destruction of their vascular connections. The treatment of these affections is to be conducted upon strictly antiphlo- gistic principles, copious leeching, vesication, and free incisions being among Syphilitic caries of the skull; at a the bone is necrosed. OPERATION OF TREPHINING. 227 the more important measures. Matter must be promptly evacuated, and dead bone removed as soon as it is sufficiently loose. The brain and its membranes are carefully watched, that they may not suffer from secondary involvement. The diploe is occasionally the seat of aneurism by anastomosis, arising either as a congenital defect, or as a consequence of external injury. As the morbid growth advances, it causes absorption of the tables of the bones, and in this way a large tumor may ultimately be formed, pulsating synchronously with the heart's action, diminishing by pressure, and augmenting when the patient cries or makes any violent exertion. Very little can be done for this disease, in the way of treatment, beyond keeping the patient quiet, and obviating all sources of mental excitement. In its earlier stages trial may be made of gentle pressure or of subcutaneous ligation. The common carotid artery has been tied for it in a number of cases, but not, so far as I know, in a solitary one with any marked benefit. SECT. VI.—OPERATION OF TREPHINING. The circumstances which require this operation are : 1. Compound frac- ture with depression of the bone, with or without symptoms of compression. 2. Simple fracture with depression and symptoms of compression after a fair trial of ordinary means. 3. Punctured fracture, no matter what may be the condition of the brain. 4. Extravasation of blood between the skull and dura mater, or in the arachnoid sac on the cerebral hemispheres. 5. The existence of pus in the same situations. 6. Foreign bodies. 7. Epilepsy, and other secondary effects. In performing the operation, the patient is placed upon a narrow dining- table, or lounge, the head and shoulders being properly elevated by pillows, covered with a sheet and a piece of oil-cloth. If he is faint, the less the head is raised the better. The scalp being extensively shaved, the bone is ex- posed by a suitable incision, of which the semilunar, T-shaped, V-like, or crucial, are the most common. Sometimes the bone is sufficiently denuded by the accident, or so nearly so as to- render but little dissection necessary. In no event should any portion of the scalp, however severely it may be lace- rated or contused, be cut away. The bleeding which follows the use of the knife usually ceases in a few minutes of its own accord; should it not do so, it is easily arrested by the ligature, which, however, should always, if possible, be avoided, as it has a tendency to interfere with the Adhesive process. The peri- osteum, upon the integrity of which the welfare of the bone so essentially depends, is cautiously dealt with, the flaps being, if practicable, drawn towards the sides of the wound, and carefully held there until the operation is completed. I am sure that if more attention were paid to this subject than there is, there would be much less danger of exfoliation of the bone ; an occur- rence which often greatly retards the cicatriza- tion of the parts, and leads to much pain and inconvenience. All scraping is inadmissible. The -crown of the trephine, of which there should be several sizes, is planted upon a sound portion of the bone, as in fig, 102, to a degree just sufficient for the accommodation of the cen- , Application of the trephine. Fig. 102. 228 INJURIES AND DISEASES OF THE HEAD. tre-pin, which is always protruded at the -moment of the application. The instrument is then moved by semicircular sweeps from left to right and right to left, until it has formed a groove deep enough to maintain its place, when the pin is permanently retracted, lest, upon reaching the inner table,'it pierce the cranial contents. The saw-dust is removed from time* to time from the trephine with the brush, or, what is preferable, a wet sponge, and from the track in the bone with the toothpick. Approach to the diploe, if any be present, is indicated by greater freedom of motion, a more abundant flow of blood, and a less grating sound. The instrument is now turned with more and more caution, and in such a way as to divide the inner table simulta- neously at every point. There is no necessity for any hurry; the patient is frequently insensible from the accident, or is rendered so 'by chloroform, and hence the whole proceeding is conducted in the most deliberate manner, the operator constantly bearing in mind that any injury, however slight, which he may inflict upon the brain and its membranes, may seriously com- promise the patient's safety. The- disk of bone frequently comes away in the saw; but where this does not occur, it is readily raised with the finger, forceps, or elevator. All depressed pieces of bone are next elevated, and all loose pieces removed. The edges of the osseous orifice are then smoothed with the raspatory, blood and other extraneous matter are carefully cleared away, bleeding vessels are tied, and the wound in the scalp is accurately secured by suture and plaster, a small interspace being left for drainage, unless there is the strongest reason to believe, from the appearance of the parts, that they will unite by the first intention. Over this dressing is ap- plied a tolerably stout compress, confined by a roller, to support the beating brain, and prevent the occurrence of fungus. The annexed cut, fig. 103, represents the trephine which, from long habit Fig. 103. Fig. 104. Different forms of elevators. Different forms of saws. in its use, I prefer to any other. It is a very beautiful instrument, and such is the facility with which it may be worked that, unless the skull is of extra- OPERATION OF TREPHINING. 229 ordinary density, the operation may generally be accomplished in a very short time.' The other instruments which usually accompany the trephine are a pair of Hey's saws, fig. 104 (or, more properly speaking, the saws of Scul- tetus), an elevator, fig. 105, a lenticular, fig. 106, and a raspatory. Fig. 106. Lenticular. Yery recently the old conical trephine, depicted in the works of Heister, was reintroduced to the notice of the profession by Dr. Gait, of Virginia, in a short paper in the New York Journal of Medicine and Surgery for May, 1860. It consists, as is seen in fig. 107, of a truncated cone, the surface of which is furnished with numerous sharp spiral teeth, which thus greatly facilitate the perforation of the bone, while the instrument, from its peculiar shape, ceases to act the moment the penetration is effected, and so prevents all risk of injury to the brain and its membranes. There are certain points of the skull where, if it be possible to avoid it, the trephine is never applied. These points are the frontal sinus, the anterior inferior angle of the parietal bone, the course of the longitudinal sinus, the - occipital protuberance, and the different sutures. The reasons for this injunction are sufficiently obvious. Ex- posure of the frontal sinus might lead to a fistulous orifice, attended with a constant escape of air and mucus ; at the second point indicated is the middle artery of the dura mater, running sometimes in a deep furrow of the bone; at the top of the skull is the longitudinal sinus ; and in the occipital region there is not only inordinate thickness of bone, but danger of interfering with the lateral sinus. Should an operation at any of these situations become imperative, the greatest caution should be employed in its execution. When the frontal sinus is obliged to be penetrated, two trephines must be used, a large one for the external table, and a smaller one for the internal. The operation being over, the patient is placed in bed with his head and shoulders well elevated, and subjected to the most rigid antiphlogistic regi- men. The great danger, of course,, is inflammation of the brain and its meninges, and hence the head should be most diligently watched, in order that the earliest moment may be seized to counteract the slightest untoward occurrence. The dressings are removed from time to time, as they become soiled, or a source of irritation, and great care is taken that the formation of pus beneath the replaced scalp does not become a cause of cerebral oppres- sion. Should this be found to be the case, the dressings must immediately be removed, and, if necessary, a puncture must be made through the super- imposed parts, to afford a proper outlet to the pent-up fluid. The opening left by the trephine is generally closed by fibrous tissue; sometimes by fibro-cartilage, and occasionally, though very rarely, by a thin stratum of osseous substance. The site of the injury is ever afterwards indi- cated by a depression in the skull, and for a long time the pulsations of the brain are perceptible across the adventitious structure. As this matter remains weak and thin for years, and, consequently, affords but a veryimper- Conical screw tre- phine. 230 INJURIES AND DISEASES OF THE HEAD. feet protection to the brain, the opening should be kept constantly covered with some suitable contrivance, as a piece of leather, silver, or gutta percha. For want of this precaution, fatal accidents have occasionally occurred. The operation of trephining has been followed By different results in the hands of different surgeons. In general, they are anything but flattering. In the hospitals of Paris and Yienna the operation is nearly always fatal; in London, Dublin, Edinburgh, Glasgow, and other large cities of Great Britain, the mortality, although also very high, is much le*ss; and in the United States, the number of recoveries in proportion to the number of deaths is, as nearly as we can arrive at the matter, as one to four. From the statistical accounts, by Dr. Lente, of fractures of the skull, occurring in the New York Hospital, it appears that eleven out of forty-five who were sub- jected to "this operation recovered. There is reason to believe that the greatest success of the trephine is to be found in private practice. My own experience has furnished me with a number of excellent recoveries, and some of my friends have been equally fortunate. The mortality of the operation will, of course, be materially influenced by the. nature of the case, the cha- racter of the existing complication, the habits of the patient, and various other circumstances, which will readily suggest themselves to the mind of the reader. The operation itself is not free from danger, as is proved by the fact that it is often fatal when it is performed for the relief of epilepsy and other severe nervous symptoms. Trephining in Epilepsy.—The operation of trephining is occasionally per- formed for the relief of epilepsy consequent upon neglected cases of depressed fracture of the skull. The first attempt of this kind was made by La Mjtte, in 1705, but with only partial success. In 1804, Mr. Cline of London re- called attention to it by the publication of a successful case ; and since then it has repeatedly been performed for this purpose both in Europe and in this country. Dr. Dudley, of Kentucky, in 1828 published a valuable paper upon the subject in the first volume of the Transylvania Journal of Medicine, in which he detailed the particulars of five cases of epilepsy treated with the trephine, of which three were successful. The results of the practice of other surgeons have not, however, I think, been so flattering. I have myself had occasion to perform the operation four times, with the effect of one cure and three deaths; and I have witnessed its execution in three other cases, all of which terminated fatally. In nearly all of these cases death occurred within the first week from inflammation of the brain and its envelops, evi- dently induced, not by any direct injury inflicted upon them in the operation, but by the disturbance of the cerebral circulation consequent upon the removal of the depressed bone. In all these cases, the event in question occurred, notwithstanding the most thorough preparation of the system, and the most assiduous attention during the after-treatment. In one of my own cases, that of a man aged thirty-three, whom I trephined at the Clinic of the Jefferson Medical College, in 1857, the cause of death was quite unique. The depression, which had existed ever since he was eight years old, involved the upper portion of the parietal and frontal bones, and was nearly two inches in diameter, by upwards of half an inch in depth at its centre. At the age Of twenty-two epileptic convulsions set in, and continued to recur, with increased severity and frequency, up to the time of the operation. Lat- terly his speech, memory, and general health had become so much impaired as to render him unfit for business. A large disk of the depressed bone being removed, the case seemed to progress favorably for forty-eight hours, when, stupor and spasms coming on, he gradually lapsed into a state of unconsciousness, and died five days afterwards. The dissection revealed the existence of extensive softening of the cerebral hemisphere at the site of the depression and an enormous effusion of black CONTUSIONS OF THE BRAIN. 231 blood, with an opening in the membranes of the brain large enough to receive the end of the index finger. This opening, which was noticed at the time of the operation, was produced by the pressure of a small exostosis on the inner surface of the injured bone, and permitted a free escape of the cephalo-spinal fluid, both during and after the operation. The pressure upon the brain being thus removed, the diseased vessels at the seat of the soften- ing gave way, thereby causing fatal apoplexy. In a paper on the surgical treatment of epilepsy by Dr. John S. Billings, in the Cincinnati Lancet and Observer for June, 1861, there is an analysis of 72 cases of this disease, subjected to trephining, of which 16 proved fatal, or 22§ per cent.; 42 cases are set down as cured, 4 as unchanged, and the remainder as improved, but not entirely relieved. Finally, trephining is occasionally required for the removal of necrosed ' bone, perhaps incarcerated by an overlapping ledge of the cranium. In a case of this kind, under my charge at the Louisville Hospital in 1842, the sequester was not only prevented from escaping, in consequence of the nar- now state of the opening in the skull, but the irritation which its pressure exerted upon the brain and its membranes was such as to cause repeated attacks of epilepsy, which promptly and permanently disappeared upon the extrusion of the offending substance. SECT. VII__-CONTUSIONS OF. THE BRAIN. Contusion of the brain may be defined to be a sudden and violent attrition of a portion of its substance, attended with more or less laceration, and an effusion of blood, generally in the form of minute specks or little clots. It may present itself in two distinct varieties of form, the circumscribed and the diffused, the latter, which sometimes involves a large extent of tissue, being by far the less common. Resulting from the same causes as concussion of the brain, with which it is, in fact, almost constantly associated, the more serious cases are commonly the consequence of concentrated force, or of force applied with a pointed weapon. To produce it, however, there need not necessarily be a fracture of the skull, nor, indeed, any injury whatever of the calvaria; a fall upon the feet, knees or nates is, at times, quite sufficient to give rise to it. Instances have been known where it followed apparently very slight blows upon the head. However this may be,, the bruise is ordi- narily direct, that is, at the part struck, although it may also be indirect, or at a considerable distance off, especially when it has been caused by contre- coup. In the latter case, indeed, it is often immediately opposite the seat of the blow. The most common situation of the lesion is the cerebrum, in its under part, owing, doubtless, to the intimate relation of this portion of the organ with the sharp edges of bone at the base of the skull. The cerebellum, pons, crura and medulla are comparatively seldom affected. The extent of the injury varies, being sometimes limited to a few small patches, so slight, perhaps, as to be hardly distinguishable, while at other' times it may occupy the greater portion of an entire lobe, or even a large portion of one of the hemispheres. The most severe cases are usually con- nected with fracture of the cranium, with or without depression. Marked evidences of it almost invariably exist in fracture of the base of the skull, caused by blows or falls upon the-vertex. Occasionally the lesion occurs at several points,' more or less remote from each other, as the cerebrum, cere- bellum, pons and fornix, or tlje cerebrum,, fornix and medulla. The contusion varies also in regard to its degree. In the circumscribed variety, the patches, in the milder cases, are confined exclusively to the gray 232 INJURIES AND DISEASES OF THE HEAD. substance, and are frequently not more than a few lines in diameter; they are of a dark-purplish hue, and are interspersed with minute specks of blood, not larger than pin-points, and more or less closely grouped together, a sec- tion strongly resembling the appearances produced iii capillary apoplexy, When the injury has been unusually violent, the discoloration is much deeper, as well as more uniform, and the affected part, torn, softened, and disorgan- ized, is thoroughly infiltrated with blood, small clots of which, generally not exceeding the volume of a pea, are at the same time imbedded iu its sub- stance. Both the gray and white tissues-are implicated, often to a great extent and in a high degree. The slight and severe forms frequently co- exist in the same brain. In the diffused variety of brain-bruise the extravasations are more or less widely disseminated; their size varies from that of the smallest pin-point to that of a millet-seed or a split pea, and they often exist in considerable num- bers, though cases occur in which there are so few that, unless a very careful dissection be made, they may altogether elude detection. The cerebral sub- stance around these clots is generally somewhat softened, and, occasionally, though not generally, a good deal discolored. If death occurs soon after such an accident, the extravasated blood, whether appearing in the form of pin-point specks or in that of small clots, will usually be found to be quite soft and of a dark color; but, after the lapse of a few days, it is generally solid, and often a few shades lighter. At a still, later period, it is either partially or completely absorbed, its place being occupied by a minute yellowish spot, containing, not unfrequently, a little serous fluid, precisely as in ordinary apoplexy. The membranes of the brain are variously affected in this injury. In the slighter forms, there may be simply an infiltrated, ecchymosed condition of the pia mater in the vicinity of the lesion, but in the more severe cases there is nearly always, in addition to this, more or less laceration of this membrane and of the arachnoid, with extravasation of blood into the sac of the latter, and occasionally also extensive detachment of the dura mater. Mr. Prescott Hewett, who has studied this subject with great care and attention, states that out of sixty-nine cases of more or less severe contusion of the brain, independently of compound fracture, he found blood poured out in this situa- tion in not less than fifty-two, the quantity in thirty-one being so large as to cap the brain. The symptoms of brain-bruise are, in general, vague and ill-defined; hence it is not surprising tha't the nature of the lesion should often be overlooked. Its recognition is the more difficult because it is nearly always accompanied with concussion, the symptoms of which, running into those of contusion, thus occasion an inextricable blending of the characteristics of the two affec- tions. Then, again, it must be recollected that there must necessarily be many cases in which the lesion is associated with, and masked by, compression of the brain, the result either of more or less copious extravasation of blood or of fracture of the skull with depression of bone. Hence, if an attempt be made to separate the more simple cases of this affection from the compli- cated ones, the number will be found to be exceedingly'limited. Dupuytren, who was the first to call attention to this lesion, came to the conclusion, in formulating the results of his experience, that the earliest re- liable phenomena did not appear until about the fifth day, or the usual period for the supervention of cerebral inflammation. Observations, however, made since his time have led to a different result. Tn general, it may be inferred, especially.in the absence of fracture, that the lesion is one of contusion, wbe\ the first symptoms of shock having, passed awaj, the disturbance of the brain more or less obstinately persists. This conclusion will be rendered so much the more probable when there is pretty complete loss of consciousness, along WOUNDS OF THE BRAIN AND ITS MEMBRANES. 233 with an uncommon degree of somnolency, but no stertorous respiration ; when there is extreme agitation and restlessness, the patient tossing continu- allytabout in bed ; when there is rigid contraction of one or more of the limbs, especially of the fingers; and, finally, when there is more or less delirium during the first few days after the accident, with a gradual but steady aggravation of all the symptoms. In the milder cases of contusion there may be merely some contraction of one of the pupils, partial paralysis of an eyelid, impaired vision, indistinctness of articulation, slight spasmodic twitching of the muscles of the face, partial loss of memory, pain in the head, especially at the seat of the part struck, and defective sensation, or want of control over the action of the sphinc- ters. When the lesion is complicated with fracture of the cranium, whether with or without fracture, all effort at discrimination must necessarily be abor- tive. Finally, it must not be forgotten that, in the milder cases of contusion, the symptoms must necessarily be proportionately insignificant and evanescent, cerebral accommodation occurring within a short time after the accident. The prognosis of contusion of the brain must necessarily vary with the extent of the lesion, the presence or absence of complications, and the con- dition of the patient at the time of the accident. The milder cases will gene- rally recover with little or no treatment, the effused blood being more or less rapidly absorbed, and the lacerated tissues gradually undergoing reparation. When, on the contrary, the contusion is very severe, the worst consequences are to-be apprehended, death happening either soon after the infliction of the injury from structural disorganization, or secondarily from the effects of in- flammation of the brain and its envelops. The treatment of this affection must be regulated according to the general principles of practice applicable to other injuries of the brain and its mem- branes. The earlier symptoms are usually those of coucussion or shock, and should, therefore, be combated by such means as may be calculated to favor gradual reaction, as recumbency, access of cold air, the use of the smelling bottle, and the administration of ammonia, or, in the more severe cases, of some stronger stimulant. When this object has been accomplished, the chief duty of the attendant is to watch the patient that he may not, by overfeeding, neglect of his bowels, or premature exertion and exposure, bring on inflam- mation, the great source of danger after such an occurrence. The period when this may be looked for is, on an average, from the fourth to the sixth day; up to this period, therefore, as well as for some time after, his vigilance should rather increase than relax; every avenue should be guarded with the greatest care, and the slightest approaches of the enemy be met with the most vigorous measures. -The hard, frequent, quick, and jerking pulse, the intolerance of light and noise, the excessive restlessness and thirst, the suffused eye and flushed, cheek, and the wandering intellect, with a tendency to coma, paralysis, and convulsions, are signs of evil import, which it is generally much easier to prevent than to control successfully after they have made their appearance. If the patient be plethoric, he must be bled freely at the arm or by leeches at the temples and behind the ears ; the bowels be moved by active cathartics; the head shaved, elevated, and cooled with pounded ice; in short, no effort must be spared to crush out the disease in its incipiency. The more remote effects of the lesion are combated by tonics and alterants, 'proper regulation oT the diet and bowels, aud change of air. SECT. VIII.—WOUNDS OF THE BRAIN AND ITS MEMBRANES. ^Wounds of the brain and its membranes may be produced in various ways, or by whatever is capable of causing fracture of the skull. From the charac- ter of the weapon by which they are inflicted, they may be incised, punctured, 234 INJURIES AND DISEASES OF THE HEAD. lacerated, contused, or gunshot. They may occur without fracture, as when they are the result of contre-coup, but the most severe varieties of the injury are always associated with fracture and wound or laceration of the meninges of the organ. As stated under the head of concussion, this lesion is not un- frequently complicated with laceration of the cerebral substance, exhibiting itself in the form of a rent or fissure, often several inches in length. Such an occurrence is by no means uncommon at the base of the brain from fracture by contre-coup, as happens when a person falls from a great height and alights upon the top of the head. A severe wound of the brain is sometimes caused by depressed bone, or by a spicule of bone driven down into the substance of the organ. Punctured wounds in the adult are generally confined to the anterior lobes of the brain, and are usually inflicted with narrow, sharp- pointed instruments, such as a fork, pen-knife, stick of wood, dirk, bayonet, and the like, thrust across the orbital plate of the frontal bone. Children, before the completion of the ossific process, may be injured in a similar manner through any portion of the skull. Some years ago a case was com- municated to me of a punctured fracture of the skull, from a long nail pene- trating deeply into the brain, in a lad six years old. The child, in falling from a considerable height, struck the top of his head against the nail, which was thus driven nearly two inches into the left hemisphere. In another case, which came under my own observation, in consultation with Dr. Rogers, a little boy fell, headforemost, upon the point of an iron fence rail, receiving a frightful wound upon the brain, and literally impaling himself. The cranial bones were extensively comminuted, and a large quantity of brain escaped during the removal of the loose fragments. Convulsions soon followed, and recurred, with more or less frequency and violence, up to the time of death, eighteen hours after the accident. The brain is sometimes traversed from one extremity to the other by a ball, bayonet, or tamping-iron, .as in the famous New England case, previously referred to. Occasionally, again, the vulnerating body is retained in the organ. Thus a ball, the but-end of a pistol, pieces of iron, fragments of bone, and various other substances, have been found within the skull, in contact with the surface of the brain, or lodged more or less deeply in the cerebral substance. What is remarkable, in such cases, is that the extraneous matter does not always speedily cause death. A few instances are upon record of balls having become encysted in the brain, so as to be afterwards comparatively harmless. The usual tendency, how- ever, of such bodies is to excite fatal inflammation. . But the most formidable wounds of the brain are those generally which accompany compound fractures of the skull and extensive laceration of the meninges. They are usually of a lacerated and contused nature, are apt to be followed by copious hemorrhage, and are frequently attended with pulpifi- cation and disintegration of the cerebral tissues, which sometimes escape in large quantity. The symptoms and effects of wounds of the brain vary according to the extent of the lesion, and also according to the particular parts implicated. When the wound is comparatively small, and the cerebral substance is not too much mashed or contused, recovery is altogether within the bounds of possibility, and may, under judicious management, take place even readily The great danger to be apprehended, in till cases, is encephalitis, with the formation of fungus, or protrusion of a portion of the brain. The mind is not necessarily affected, and the patient often recovers without any untoward symptoms. When the accident is more severe, the danger will, of course, be greater; but even here it is wonderful what little disturbance sometimes follows in cases apparently the most desperate. We see occasionally large quantities of cerebral substance lost, and yet the patient make a most excel- lent recovery, his intellect not only not being weakened, but, perhaps, im-- WOUNDS OF THE BRAIN AND ITS MEMBRANES. 235 proved by Ihe occurrence. Such cases are, of course, uncommon, and are chiefly interesting as serving to show the extraordinary resources of the system in surmounting the effects of some of the most frightful accidents that can befall the human body. When the wound involves the base of the brain, or the superior portion of the spinal cord, life may be destroyed in an instant by an arrest of the func- tions of the respiratory nerves. Tlie intellectual faculties are also more deeply affected, if not completely annihilated, and ultimate recovery is doubt- ful in any case, however simple. If the patient be so fortunate as to escape with his life, he will afterwards suffer from loss of bodily and mental power; the mind will be permanently crippled, some of the special senses will be weakened, if not abolished, and the limbs will be affected with paralysis and contraction, followed sometimes by the most disgusting deformity. Epileptic convulsions are of frequent occurrence in such cases. Wounds of the cerebellum are often followed by priapism and other evi- dences of inordinate sexual excitement. The*prognosis of wounds of the brain and its membranes is altogether too variable to admit of general specification. While in some cases, indeed in a great many, the slightest injury causes death, in others, attended, perhaps, with excessive shock and the loss of a large quantity of blood and cerebral matter, the most prompt and satisfactory recovery occurs. Thus, in a case which was treated by Dr. Ellerslie Wallace, of 'this city, and the particulars of which have been narrated in the North American Medico-Chirurgical Re- view for January, 1858, the fracture, inflicted by a circular saw, was four inches and a quarter in length by one-sixth of an inch in width, extending horizontally across the skull, along the coronal suture, wounding the brain, and dividing the longitudinal sinus, and yet the patient, a girl ten years of age, rapidly recovered without one untoward symptom. A still more extraordinary case happened in 1848, in the practice of Dr. J. W. Harlow, of Yermont; a case so unique that, if it were not well attested, its occurrence could hardly have been supposed possible. The accident took place while the man, who was twenty-eight years of age, was engaged in blasting rock, and was caused by the propulsion of a tampirtg iron, three feet seven inches in length by one inch and a quarter in diameter, its weight being upwards of thirteen pounds. The iron entered by its narrow extremity, near the angle of the lower jaw, on the left side, passing obliquely upwards behind and below the zygomatic arch, traversing the skull, the anterior lobe of the cerebrum, and the longitudinal sinus, and fracturing, as was supposed, the malar, sphenoid, temporal, and frontal bones, at the latter of which it emerged, just in advance of the coronal suture. Notwithstanding this hor- rible mutilation, enough, one might imagine, to kill a dozen ordinary men, the patient made an excellent recovery, completely regaining his mental and physical faculties, except the loss of the left eye. When last heard from, twelve years after the receipt of the injury, he was perfectly well. An elabo- rate report of this interesting case, illustrated by drawings, has been pub- lished by Professor H. J. Bigelow, in the American Journal of the Medical Sciences for July, 1850. The treatment of wounds of the brain and its envelops must be conducted upon the most rigid'antiphlogistic principles; great care, however, must be taken not to carry this plan too far, for it should be recollected that a certain amount of inflammation is absolutely necessary to insure the restoration of the injured structures. If, therefore, the depletion be pushed to an inordi- nate extent, the system may be so far exhausted by it as to be unable to furnish the parts with the requisite supply of blood and plasma to carry on the work of repair. Besides, it can hardly be doubted that very active mea- sures, tending to add still further to the debility of the patient, can fail to 236 INJURIES AND DISEASES OF THE HEAD. prove prejudicial, by abstracting unduly the nervous influence of the brain, and thereby seriously retarding, if not altogether preventing, recovery. On the other hand, too much forbearance must be equally disadvantageous. Hence, he will best discharge his duty who steers a strictly middle course, neither giving too much freedom to his hands, nor exhibiting too much in- activity. Having removed all extraneous substance, and placed the parts, provided they are accessible, as nearly*as possible in their natural relations, the patient is carefully watched, any tendency to over-action being at once arrested by the lancet, leeches, and other means. Early recourse is had, in all cases, to active purgation, the best articles for the purpose being calomel and jalap, or infusion of senna and sulphate of magnesia. When the patient has difficulty in swallowing", stimulating enemas must take the place of cathar- tics. Yomiting must, of course, be carefully guarded against, but when there is great dryness of skin, conjoined with an active pulse and excessive restless- ness, there is no remedy more likely to promote perspiration, subdue vascular excitement, and tranquillize the system, than tartar emetic in union with morphia. I am never afraid to employ either of these articles in wotfnds of the brain, after the system has been properly reduced by bleeding and purga- tives, or where these means are rendered unnecessary in consequence of previous shock and loss of blood. The head, being well shaved, is thoroughly elevated, and kept constantly wet with a bladder partially filled with pounded ice. Starvation is not carried too'far, lest it should create irritability in the heart and brain ; at the same time great care is taken that the diet is perfectly simple.and non-stimulant. All excitement is avoided, both during the active treatment and for a long time afterwards. SECT. IX.—FUNGUS OF THE BRAIN. This affection, which is sometimes, ridiculously enough, called hernia of the brain, consists in a protrusion of cerebral substance through an opening in the skull, accompauied by a laceration of the brain and its envelops. It occasionally follows caries of the cranial bones and disease of the dura mater. One of the worst cases that I have ever seen was produced by syphilitic ulceration of the skull. "When it supervenes upon external violence, it gene- rally makes its appearance within a few days after the accident, and some- times, indeed, almost immediately, especially when the cerebral lesion is unusually extensive. Its progress is commonly very rapid, the growth often attaining the size of a hen's egg in less Fig. 108. FunguR of the brain after fractur?. than a week. Pressure has a tend- ency to restrain it, and to limit its bulk. The form of the tumor bears a considerable resemblance to that of a mushroom, the expanded portion overhanging the skull, while the nar- row, projecting through the abnor- mal opening, is connected with the brain below. Its surface is rough, incrusted with lymph, and bathed with ichorous matter ; in some cases it is studded with fungous granula- tions. The appearances of cerebral fungus are well illustrated in fig. 108, from one of my patients. The frac- ture was situated at the outer and inferior portion of the frontal bone. GUNSHOT INJURIES OF THE HEAD. 237 If a section be made of the fungus, it will be found to be composed of a mixture of cerebral substance and coagulating lymph, sometimes the one, sometimes the other predominating. When the growth is recent and rapid, it is not unusual for it to contain small masses of clotted blood, similar to apoplectic depots of the brain. Its structure is usually very vascular, and hence it often bleeds quite freely when cut, or even when roughly handled. Destitute of sensibility, it is elastic and compressible, moving synchronously with the pulsations of the brain. That this tumor is not composed entirely, or even in great measure, of cerebral matter, as has sometimes been supposed, is proved by the circumstance that, after death, the loss of brain does not at all correspond with the volume of the morbid growth and the repeated retrenchments to which it was subjected during life: If this were the case, we should often find the greater portion of one entire lobe destroyed, or, at all events, an immense cavern in the affected hemispheres ; but such, except in a few rare instances, is not the fact. The cerebral tissues around the tumor are always softened, discolored, and more or less infiltrated with serosity. It is impossible to confound this morbid growth with any other; its his- tory, the> rapidity of its development, and the peculiarity of its shape, being always sufficient to mark its character. The symptoms which accompany it are variable. The discharge is usually of a thiu, ichorous nature, quite pro- fuse, and excessively fetid. Frequent bleeding occurs. The mind is some- times affected from the very first; at other times it remains perfectly clear and calm for days and weeks. In general, however, there is considerable cerebral disturbance, as is indicated by the delirium and by the incoherent answers of the patient; the countenance has a peculiarly vacant expression ; the skin is dry and harsh ; the pulse, seldom normal, is either too frequent, or, as more commonly happens, too slow ; the secretions are deranged ; the bowels are constipated ; and the sleep is interrupted by frequent starts and twitches.' As the disease nears its close, coma and convulsions set in, and the patient dies, gradually exhausted, from nervous irritation. Recovery is an extremely rare occurrence in any case, however simple. In the early stage of this affection, before the tumor has made much pro- gress at extrusion, well conducted systematic compression constitutes the prominent feature of the treatment. The object is to restrain the growth, and to circumscribe its limits. The pressure is made with a piece of sheer, lead, a compress, and a roller, changed as often as may be necessary to insure firnyiess and cleanliness. As the mass recedes, the compress is gradually pushed into the osseous opening, until it is reduced to the level of the brain. To prevent relapse, the pressure is steadily maintained, now, of course, more gently, up to the very point of cicatrization. When, through neglect or mis- management, the protrusion has attained considerable bulk, the proper plan is to excise all that is accessible, or to destroy it with the Yienna paste, or, what I prefer, the actual cautery, the parts being afterwards protected in the manner just indicated. When the discharge is very offensive, free use must be made of the chlorides. The patient's strength must be supported by tonics and a mild but nutritious diet. The head must be maintained in an elevated position, and all excitement must be carefully avoided. Sometimes the fungous mass, becoming strangulated by the edge of the orifice in the skull, loses its vitality, and sloughs off; rarely, however, with any permanent advantage. SECT. X.—GUNSHOT INJURIES OF THE HEAD. Gunshot injuries of the head constitute an important class of lesions, often difficult of diagnosis, and liable, even when comparatively slight, to be fol- 233 INJURIES AND DISEASES OF THE HEAD. lowed by the most serious consequences. They may be limited exclusively to the scalp, merely grazing, bruising, pr dividing its substance; or they may involve the cranial bones; or, finally, they may embrace all these structures, along with the brain and its envelops. 1. Gunshot Injuries of the Scalp.—Theselesions derive their chief import- ance from their proximity to the brain and their consequent liability to give rise to cerebritis and arachnitis. Erysipelas is also a common occurrence, and occasionally they are followed by jaundice, with or without abscess of the liver. Wrhen the missile penetrates the pericranium, or contuses the skull, the accident may cause suppuration and slight exfoliation of the outer table of the bones. The prognosis after such injuries should, therefore, always be very guarded, the more so when it is recollected that they are not unfre- quently accompanied with serious mischief to the brain and its envelops. The modern military surgeon meets no longer with any of those curious cases of the circuitous route pursued by balls in gunshot injuries of the scalp, so much spoken of by European writers in the early part of the present cen- tury, during the reign of the round missile. The conical missile performs its work much more neatly, rarely glancing, or deviating from the straight line. The treatment of these lesions is similar to that of gunshot injuries in gene- ral. If the ball has lodged, immediate extraction is effected, any foreign matter that may have entered along with it being removed at the same time. Such wounds, which cannot be watched with too much solicitude; often require dilatation and counter-opening, to afford vent to effused fluids. 2. Gunshot Injuries of the Skull.—These injuries may be divided into three classes: 1st, contusions and fractures of the bones without depression; 2dly, fractures with depression ; 3dly, fractures with perforation of the biain and its envelops. a. Contusions and Fractures without Depression.—Grave injury is often inflicted upon the skull by the blow of a ball or shell, the osseous tissues being violently bruised and shaken, but not broken. Such a lesion is gene- rally fraught with danger from the fact that it is nearly always attended with serious disorder of the brain, as concussion, contusion, or laceration, eventu- ating, if the case .be at all severe, or improperly managed, in destructive inflammation. The danger here, however, is not merely in the first instance; the patient may happily survive the primary effects of the accident, but perish from the secondary, death happening, perhaps, weeks, if not months, after the receipt of the blow. Even under the most favorable circumstances, recovery will be tedious and troublesome, if for no other reason than the fact that abscesses under the scalp will be apt to be repeated, with more or less exten- sive exfoliation of the contused bones. Sometimes a ball or shell, in traversing the skull, scoops out a portion of its substance, leaving thus a pretty deep furrow, groove, or gutter, perhaps several inches in length ; or the missile strikes the bone, and breaks it, not unlikely at several points, causing a fissured, stellated, or even a comminuted fracture, without depression. Occasionally, though rarely, a shell carries away bodily a considerable portion of the skull-cap, along with the corre- sponding portion of scalp. The danger of all such injuries is too apparent to require comment. The treatment of these various lesions must be strictly antiphlogistic, blood being taken freely by leeches, or even by the lancet, if the patient be at all plethoric, and the danger from cerebral involvement imminent; the bowels are thoroughly moved by drastic cathartics ; the heart's action is controlled by the antimonial and saline mixture with the addition of a suitable quantity of tincture of veratrum viride ; and the •head, shaved and elevated, is kept constantly covered with pounded ice, or some refrigerant lotion. If the case GUNSHOT INJURIES OF THE HEAD. 239 is obstinate, mercury is employed, in doses of from two to three grains thrice a day, with a view to rapid and decided ptyalism. b. Fractures with Depression.—Gunshot fractures of the skull with depres- sion of- the bone are among the most common and fatal injuries on the field of battle. The bone may be broken without a wound in the scalp, the latter being, perhaps, merely somewhat contused, us when the blow is inflicted by a shell or a partially spent round shot; but, in general, there is also an open- ing in the soft parts, the case thus constituting one of compound fracture. The bone, moreover, may be comminuted, or shattered into numerous frag- ments. The skull is sometimes frightfully broken, and yet the scalp remains literally intact. A case of this kind, referred to by Dr. Macleod, occurred at the battle of the Alma. A round shot, passing in ricochet, struck the scale from an officer's shoulder, and merely grazed his head as it ascended. The result was instant death. The skull was so completely mashed that the fragments rattled under the scalp like so many marbles in a bag. The brain was not examined. The amount of depression in this form of fracture is variable, depending upon the size and force of the missile and the brittleness and thickness of the skull. Occasionally it is extremely slight, but examples occur in which it is of frightful extent, involving the greater portion of the posterior vault of the skull, the vertex, or the frontal bone. In rare cases it is limited to the outer or inner table; probably more frequently to the latter than the former. The possibility of such a fracture was at one time universally rejected, but that it may take place has been satisfactorily shown by modern military surgeons. There are certain rules which, in the treatment of fractures of the skull with depression, are applicable to all cases of the injury, whatever may be its extent. These are, first, to remove foreign matter, so as to place the parts in the best condition for satisfactory reunion, and, secondly, to guard against the supervention of undue inflammation. The disposition of the missile varies. .It seldom lodges, but rebounds, and is lost. When it is arrested, it will generally be found to be much flattened, and very irregular, and to be either imbedded in the bone, or intercepted in a crevice of the fracture. Some- times it is cut in two, one portion being lost, while the other either lies under the scalp or has entered the brain. However this may be, it must, if found, be promptly extracted, along with any fragments of bone that may be very loose, or completely detached. In regard to the depressed bone itself it should undoubtedly be elevated, if this can be done without inflicting serious injury upon the brain and its envelops. To leave it in its unnatural position would be productive only of future mischief. In making this remark, I cer- tainly do not wish to be understood as advocating interference in every case of depressed fracture. When the accident is very slight, and, especially, when it is unaccompanied with a wound of the scalp, the best plan is to let the parts alone, the surgeon restricting himself to the employment of such means as shall tend to favor rapid and permanent cerebral accofamodation. But there are cases in which the propriety of trephining is so self-evident as not to admit of the slightest hesitation. Such cases fall under the same rules as similar injuries in civil practice. If the depressed bone, perhaps terribly shattered, and, to a considerable extent, even thrust into the brain, is not promptly removed, it must either cause fatal inflammation, or, if recovery should occur, eventually lead to epilepsy and other distressing affections, ren- dering life hardly worth the possession. There seems to be a growing disposition on the part of military practitioners to eschew the use of the trephine nearly, if not entirely in depressed fractures of the skull. Thus, Dr. Stromeyer, surgeon-in-chief in the Schleswig-Hol- stein war, pointedly condemns the operation in every case, on the ground that, independently of the mischief inflicted upon the tissues during its per- 240 INJURIES AND DISEASES OF THE HEAD. formance, the admission of air to the contused portion of the brain and its membranes greatly augments the danger of inflammation. Of forty-one cases of gunshot fractures of the skull with depression, reported by him, seven died, and thirty-four recovered. Among the latter was one which had been tre- phined, aud this was the only instance of the kind throughout the war which gave a favorable issue. The results furnished in the Crimean war strongly corroborate the views of Dr. Stromeyer. The English surgeons applied the trephine successfully only in four cases, and in those not on.account of rifle-ball wounds, during the entire campaign ; and the operation does not seem to have been any more favorable in the French army, Dr. Scrive asserting that it was for the most part fatal. Dr. Macleod concludes, from the result of his experience, that interference is admissible only when the bone is very deeply .depressed on the brain, and the patient is comatose, with stertorous breathing, a slow pulse and a dilated pupil. In all other cases, in which these phenomena are not very decidedly marked, or where they do not continue for any considerable length of time, trephining should, he thinks, be avoided. The above views, although emanating from men of large experience, should, I think, be received with great caution when applied as rules of practice. Every surgeon knows that there are injuries of the skull which must neces- sarily be fatal under any mode of treatment, however judiciously conducted, and the very fact that the use of the trephine is required, is of itself an evi- dence that the case will be one of doubtful issue, not merely as a consequence of the injury inflicted upon the parts during the operation, or, as Larrey and Stromeyer suppose, of the admission of air, but from the intrinsic mischief done to the brain and its membranes by the primary blow. As a proof of the great mortality of such lesions, it may be stated that, in the Crimean war, they invariably ended fatally whenever they were at all severe. Of seventy- six cases of depressed fractures unattended with penetration or perforation, fifty-five perished, twelve were invalided, and nine only were discharged as fit for duty. In the twenty-one who survived, the amount of depression was very slight, and all these, excepting one, recovered without a bad symptom. Of eighty-six cases, in which the skull was perforated, not one was saved. Moreover, it must be remembered that there is a great difference between gunshot lesions of the skull as inflicted with the conical and tlie round ball, the former making, as a general rule, an incomparably worse wound than the latter. In former times, men injured with the round ball often made excel- lent recoveries, with hardly any treatment at all, or perhaps even after the most severe exposure and fatigue, evidently because, although the cranium was apparently badly hurt, the brain and its membranes had sustained little, or no injury. Thus, after the battle of Talavera, of fourteen men with wounds of the head, involving the skull, not one died, notwithstanding they were com- pelled to march for sixteen consecutive days under the influence of a burning sun, with no other treatment than simple water-dressing. In several of these cases both tables of the skull were broken, and in two fracture of the frontal bone co-existed with destruction of the globe of one eye. Now, no one will presume to assert that these met would have fared so well if they had been wounded with the sharp and heavy Miuie ball, instead of the old round hall, used in the Peninsular war. Finally, in compression of the brain from blood or pus, consequent upon gunshot injuries, the same rules of practice are to be pursued as in ordinary cases. The great difficulty here will be, not in performing the operation, but in knowing when it is necessary. In general, the formation of matter, under such circumstances, does not occur under several weeks. c. Fractures with Perforation of the Brain___These injuries are nearly always promptly fatal, the patient dying either on the spot from shock and GUNSHOT INJURIES OF THE HEAD. 241 hemorrhage, or, at all events, witllin the first eight days, from the effects o inflammation. The danger in these cases is not from the ball alone, although this is generally very great, but also from the presence of pieces of bone, hair, and other extraneous matter which are forced in with it, and which are often 'much more destructive than the missile itself, contusing, tearing and pulpi- fying the cerebral tissues in the most frightful manner. A ball, lodged in the brain, is sometimes encysted, and may then become a comparatively harmless tenant, the functions of the mind and body being performed with their accustomed vigor"; in general, however, it acts as an irritant, even when jt is thus isolated, exciting inflammation, which is certain to be followed, by abscess and death. Bone and other foreign matter are never encysted ; the lymph effused around them is incapable of organization, and the consequence is that they soon produce fatal, disturbance. * Although gunshot wounds of the skull and brain nearly always prove fatal, yet a remarkable exception occasionally occurs, the patient getting well, as it were, despite the injury, and in defiance of all the laws of prognosis. This was happily exemplified in the case of a youth, aged eighteen, the particulars of which have been kindly communicated to me by Professor May, of Wash- ington City. The ball, an ounce one, entered the upper and back part of the skull, making ah opening capable of receiving the index finger, and penetrating the brain, as was proved by the fact that some of it had escaped at the wound. Where the-ball lodged could not be ascertained. Rapid and complete recovery followed without a solitary untoward symptom. The treatment of these accidents resolves itself into the removal of foreign matter, the elevation of depressed bone, and an effort to sustain the brain-in its attempts at repair. • The finger is, of course, the best probe, but all officious interference is-to be avoided, it being far better to let the missile and even detached pieces of bone remain where they are than to search for them at the risk of severe additional injury. A counter-opening with the trephine, with a view of facilitating the extraction of the ball, is hardly to be thought of in any case, although two instances have been recorded, one by Larrey and the other by Charles Bell, in which such a procedure was followed by the most happy result. The antiphlogistic measures must be strictly guaged by the exigencies of each partfcular case: depletion must not be carried to excess; if the shock and loss of blood have been great, stimulants and even anodynes may be required from the start, to support the system and quiet the heart's action. Fungus, so apt to arise during the progress of the treatment, should be repressed in the usual manner. Gunshot Injuries of the Orbitar Plate of the Frontal Bone___Experience has shown that a ball, entering the orbit, and passing directly backwards and upwafds, generally destroys life by the violence which it inflicts upon the brain and its envelops, the patient dying either on the spot or from shock and hemorrhage, or within a few days after the accident from the inflammation. If, on the contrary, it pursues a downward course, the brain may entirely escape, or suffer merely in a slight degree. The eye is often seriously implicated in gunshot injuries in this situation ; in some instances it is totally annihilated, while in others it is so severely wounded as to be destroyed by the resulting inflammation. Occasionally the globe of the organ escapes, but the optic nerve is cut off, the lesion being- followed by immediate and permanent blindness. . _ It is well known that the orbitar plate may be severely shattered, and yet, if the case be properly treated, the pieces may ultimately perfectly reunite ; for such is the abundant supply of vessels and nerves of the soft parts of the face and eye that they impart to this portion of the skeleton a much greater conservative power than is possessed by the osseous system in general. . VOL. ii._ 16 242 INJURIES AND DISEASES OF THE HEAD. A ball sometimes passes across the skull from one temple to the other, without inflicting any serious injury upon the brain or other soft parts, the patient ultimately making a good recovery. Such an occurrence, however, is much less common now than formerly, during the use of the round ball. After the battle of Waterloo a number of cases of this kind were treated successfully by the British surgeons. Sword and Sabre Cuts of the Head:—Fractures of the skull inflicted by tlje sword, sabre, or Indian arrow, are generally of a.very grave character, usually proving fatal, either from shock, hemorrhage, or inflammation. A sharp arrow, as I am informed by Dr. T. C. Henry, of the army, will cut a'hole into the skull, owing to the great force and velocity with which it is pro- pelled, without apparently any fracture whatever, producing a kind of incised wound, which, however, is very liable to "be followed by death. A portion of the outer table of the skull, or even of its entire thickness, is sometimes sliced off by the sabre or sword, hanging, perhaps, merely by a narrow flap of scalp. When this is the case, the parts should immediately be replaced, and secured by suture, in the hope of their speedy reunion. Wounds of this kind, apparently of the most desperate character, are some- times happily recovered from. A case related by Ambrose Pare admirably illustrates the truth of this remark. " A party," says he, ".had gone out to attack a church where the peasants of the country had fortified themselves, hoping to get some booty of provisions; but they came back very soundly beaten' and one especially, a captain-lieutenant of the company of the Duke de Rohan, returned with seven gashes on his head, the least of which pene- trated through both tables of the sknll, besides four sabre wounds in the arm, and one across the shoulder, which divided one-half of the shoulder blade. When he was brought to the quarters, his master, the duke, judged him to be so desperately wounded that he absolutely proposed, as they were to march by daylight, to dig a ditch for him, and throw him into it, saying that it was as well that the peasants should finish him. But being moved with pity, I told him," says Pare, "that the captain might get cured. Many gentlemen of the company joined with me in begging that he might be allowed to go along with the baggage, since I was willing to dress and cure him. This was accordingly granted. I dressed him, and put him into a small, well-covered bed, in a cart drawn by one horse. I was at once "physician, surgeon, apothecary, and cook to him, and, thank God, I did cure him to the admiration of all the troops, and out of the first booty the men-at arms gave me a crown a piece, and the archers half a crown each." SECT. XI.—CHRONIC HYDROCEPHALUS AND TAPPING OF THE SKULL. The surgeon is occasionally called upon to give his opinion respecting the treatment of chronic accumulations of water in.the head, technically denomi- nated hydrocephalus, or dropsy of the brain. The disease is fortunately a rare one, for it is nearly always fatal, whatever mode of management may be adopted for its relief. In regard to its pathology, there has been much diversity of opinion ; my own belief, founded upon .a careful observation of a considerable number of cases, is that the disease essentially consists in subacute, or chronic arachnitis, commencing generally some time before birth, and going on gradually increasing until the head attains an enormous volume, causing hideous deformity. It would, perhaps, be wrong altogether to deny that the affection may occasionally commence after birth, but if such an event does happen, it must be very uncommon. For, even when a child thus affected is apparently healthy when ushered into the world, well-marked signs of the disease usually manifest themselves so soon afterwards as to lead HYDROCEPHALUS AND TAPPING OF THE SKULL. 243 to the conviction that its origin was laid during intra-uterine life, probably in some inscrutable vice of the constitution. The fluid, which consists almost wholly of water, with some of the earthy salts, but hardly any albumen, usually occupies the ventricles of the brain, which, as the accumulation augments, becomes at length completely unfolded, forming a layer perhaps not more than from three to six lines in thickness, in which it is difficult, if not impossible, to distinguish the white and gray sub- stance. In some instances, it is situated in the arachnoid sac, on the surface of the brain, and when, this is the case, the organ, in consequence of the severe and long-continued pressure of the water, is generally very much atrophied and distorted. I have not met with any examples in which the fluid was lodged between the cranium and the dura mater, and doubt very much whether it ever occurs here. Indeed, how could it get here, if we assume, as we cer- tainly must, that the water is furnished by the arachnoid membrane ? The dura mater has no such power, any more than any. other fibrous tissue. The quantity of water varies from a few ounces to several quarts. Cases have been reported in which upwards of fifty ounces were drawn off in one operation during life, and more than twice that amount has occasionally been found on dissection. The disease is always chronic, and, if permitted to proceed, often continues for a number of years before it proves fatal. The general health, however, usually begins to suffer at an early period ; the child becomes thin and emaci- ated', loses its control over its muscles, and requires to be fed, although the appetite may be quite voracious. Convulsive twitchings are of common occurrence, the eyes roll constantly about in their sockets, the pupils are dilated, speech is absent, and the urine and feces commonly flow off involun- tarily. The head, in the more advanced stages of the disease, is sadly mis- shapen, and altogether too heavy for the weakened body. The fontanels are wide open, the cranial bones are abnormally thin and expanded, almost like parchment, and the subcutaneous veins of the scalp are enormously enlarged. Fig. 109. Fig. 110. Chronic hydrocephalus. Skull of a hydrocephalic child. In general, the mind is idiotic, and existence purely vegetative. The pecu- liar appearances of the head in hydrocephalus are well seen in fig. 109, from one of my clinical cases. Fig. 110 exhibits the state of the bones and fonta- nels, divested of their soft parts. 244 INJURIES AND DISEASES OF THE HEAD. 'The-treatment of this disease could not possibly be more discouraging. A cure, it is true, occasionally occurs, sometimes spontaneously," as after a violent attack of diarrhoea, or a course of active purgation, but the event is so uncommon as only to prove the exception to the great law which, at no distant period, inevitably consigns the patient to his grave. In such a work as this, it is not worth while to give even an outline of the leading plans of treatment that have been proposed for the relief of this affection, inasmuch as there is not a solitary one deserving of the slightest confidence. In the milder cases, especially in their earlier stages, some benefit may sometimes be derived from the steady use of sorbefacient applications to the head, as iodin- ized unguents or lotions, and the exhibition of iodide of potassium and bichloride of mercury, aided by au occasional- laxative, and a properly regu- lated diet. Shaving the scalp, and afterwards vesicating it with cantharides, has sometimes seemed to prove beneficial. No advantage could reasonably be expected from counter-irritation by a seton, or issue in the nape of the neck. Regular, systematic compression has repeatedly been tried, either with adhesive strips, or the roller, or both together, and a few cases have been reported of its supposed efficacy. Usually, however, the cure is but tempo- rary, and it is proper to add that the treatment is often followed by convul- sions, thus necessitating its abandonment. Puncture of the cranium, first proposed by Dr. Yose, of New York, has often been practised, and, if we were to credit the statements that have been published on the subject by certain physicians, we could hardly fail to award to it the praise of extraordinary merit. Thus, one gentleman, Dr. Conquest, asserts that he has cured not less than ten cases out of nineteen. Dr. West has collected sixty-three cases in which the head was tapped by different sur- geons, of which eighteen, or two out of seven, are said to have terminated successfully. I must confess, however, my disbelief in all these statistics, convinced that they are unreliable, not because of any wilful misrepresenta- tion on the part of the reporters of the cases, but simply because they either deceived themselves, or allowed themselves to be deceived by others. I have myself never heard of a radical cure effected in this way. In the only two cases in which I have performed the operation, death in each ensued in less than'four days from convulsions; and such must, I am satisfied, generally be the result, especially when the accumulation is at all considerable, however carefully the treatment may. be conducted after the evacuation of the fluid. It requires no argument to show that life cannot be long supported when such an amount of pressure as attends confirmed dropsy of the brain, is sud- denly taken off from so important an organ. The puncture is made with a very delicate trocar, fig. Ill, introduced some Fig. 111. ^-'""-4' s Trocar for puncture of the cranium. distance from the longitudinal sinus, and closed as soon as about two-thirds of the water have been evacuated, with collodion and adhesive plaster, which should be extensively applied with a view of compressing the skull. The operation may be repeated once a week. BANDAGING OF THE HEAD. 245 SECT. XII.—BANDAGING THE HEAD. For simply retaining dressings, cataplasms, and lotions upon the head, the best contrivance generally is a light handkerchief, arranged in the form of a nightcap, or a nightcap itself. The handkerchief being folded into a tri- angle, the centre of the base is applied to the forehead, and the body to the vertex, the tail hanging back over the neck. The side ends, lying upon the cheeks, are then, carried backwards over the ears, crossed at the occiput and tied in front, an inch above the nose, as represented in fig. 112. Where Fig. 112. , Fig. 113. « Handkerchief bandage. Recurrent bandage. greater nicety is required, as when the object is to make moderate, but equa- ble compression, a double-headed roller should be used, after the fashion shown in fig. 113. Its application is thus described by Mr. Lonsdale.- " The Fig. 114. Fig. 115. Four-tailed bandage for the head. centre of the roller is placed low down on the forehead, and the two heads are carried back and made-to cross low down beneath the occiput. One 246 INJURIES OF THE HEAD. head is then brought over the vertex, while the other is carried horizontally round to lap its extremity; and this, turned up over the horizontal one, is carried back to the occiput, slightly overlapping the former vertical band. At the occiput, the heads are again crossed, the surgeon shifting his hands for the purpose, and a third turn is made on the other side of the vertical band, while a third horizontal round secures it as before. This is continued until the whole head has been uniformly invested." The four-tailed bandage also answers a very useful purpose, especially for retaining dressings. Its application is shown in figs. 114 and 115. It con- sists of a piece of soft muslin, linen or calico, of the requisite length, split up nearly to the centre, in such a manner as to form four strips, the anterior of which are carried back and tied under the occiput, while the posterior are fastened under the chin. In some case's the position of the tail is reversed, according as the middle portion of the bandage rests on the forehead, chin, or occiput. DISEASES OF THE SPINAL CORD AND COLUMN. 247 CHAPTER III. DISEASES AND INJURIES OF THE SPINAL CORD AND COLUMN. The most important surgical affections of the spinal cord are concussion, compression, sprains, inflammation, and wounds. The vertebras are subject to curvature, tuberculosis, and congenital clefts, attended with protrusion of the arachnoid membrane, and constituting what is called hydrorachitis. CONCUSSION. Concussion of the cord is produced by accidents similar to those which occasion concussion of the brain, as blows or falls upon the back, head, feet, or nates. The severity of the effect is usually in direct proportion to the . directness of the injury; but the most violent and protracted case of concus- sion of the spine I have ever seen was caused by a fall, in an elderly gentle- man, upon the buttock, from a height of about ten feet, down upon the floor. The affection exists in various degrees, and probably does not always affect the entire cord, being limited to particular tracts of it, or concentrated with special force at particular points. However this may be, the symptoms are commonly quite characteristic. The patient feels sick at the stomach, looks excessively pale, and is altogether helpless, his body being more or less para- lyzed. A sense of formication, stinging, or prickling, is experienced along the spine and in the extremities; the sphincters are relaxed, and, in the more severe cases, there are apt to be involuntary discharges from the bladder and howels. Death may occur from the severity of the injury within a short time after its infliction; or, reaction taking place, the effects of the concussion may . gradually pass off, the limbs regaining their functions and the sphincters their power of action. In some cases, however-, the mind remains bewildered for a number of days, the patient being partially delirious, but yet not sufficiently so to prevent him from washing and shaving himself, or even, perhaps, attending to business. Another remarkable symptom, which I have occa- sionally witnessed, after recovery from the more immediate effects of the injury, is excessive irritability of the bladder, attended with an almost inces- sant desire to pass water, which is generally greatly increased in quantity. The treatment of concussion of the spinal cord must be conducted upon the same general principles as that of concussion of the brain ; by recumbency and cordials, or mild stimulants, during the stage of depression, and by great vigilance during the period of reaction, lest it should transcend the healthy limits and pass into inflammation. Should this untoward circumstance arise, it must be promptly met by the usual antiphlogistic means. A full anodyne, with the addition of a little tartrate of antimony and potassa, will generally speedily arrest the irritability of the bladder and the tendency to inordinate renal secretion. SPRAINS. Ihe spine is composed of a series of joints, which, from the peculiar mode of their connection, admit of comparatively little motion, except in the cer- 248 DISEASES OF THE SPINAL CORD AND COLUMN. vical and lumbar regions. The ligaments are, for the most part, very short and strong, and the column, as a whole, is still further strengthened by the large muscles and firm aponeuroses which cover them in at the sides behind. Owing to these circumstances, it is impossible for a sprain to occur here with- out the application of great force, either directly to the part itself or indirectly through some neighboring part, as when a person falls from a considerable height and alights upon the buttocks or shoulders. Now and then, a severe sprain of the back is produced by a sudden twist of the body, such as occa- sionally happens when the trunk is forcibly rotated upon its axis, the lower extremkies being at the moment implanted in a hole in the ground. The extent of the injury varies. In some cases there is merely a stretch- ing of the ligaments, whereas in others not only some of these structures hut also the muscles and aponeuroses of the back are more or less contused and perhaps even partially lacerated. In the more severe forms of the accident, sudi, for example, as happen when a man receives a blow from the caving in of a sand-bank, a portion of the spine may be bent forcibly forward or to one side, almost to such a degree as to cause it to break. Mor.e or less blood is then generally poured out, and the muscles often present a very bruised, ecchymosed appearance. Severe, however, as the sprain usually is under such circumstances, the spinal cord always escapes serious injury, the principal effect being concussion. The symptoms of this accident are generally well marked, if not positively diagnostic. Not unfrequently there is excessive shock, attended with partial paralysis of the lower extremities. The pain at the seat of the injury is more or less violent, and is always materially augmented by motion, pressure, and change of posture. The patient.cannot raise himself up without resting his hands firmly upon his knees, nor can he walk without being supported by assistants. As he lies in bed, his body inclines forward, and he is unable to extend his limbs or turn upon his back. A good deal of swelling occasionally occurs, and, when there has been much extravasation of blood, Ihe skin, after a few days, will be apt to exhibit a dark, mottled appearance. Sometimes there is bloody urine, from injury inflicted upon the kidneys. .Sprains of the spine, if at all severe, are always serious accidents. Death may be produced by mere shock, as in concussion of the spine, or it may be a consequence of the secondary effects of the injury, such as a deep-seated abscess, inflammation of the cord and its coverings, or organic disease of the kidneys. A lesion of this kind has occasionally been followed by stone in the bladder. In the treatment of this class of injuries, the first indication is to relieve shock, and the second to prevent undue inflammation. Recumbency and the use of cordials will generally readily fulfil the former; the lancet, leeches, fomentations, aud active purgation, the latter. If the patient be plethoric, blood should be freely taken as soon as«reaction is established; the parts should be kept constantly covered with cloths wrung out of hot water, medi- cated with laudanum and acetate of lead ; and Dover's power, or morphia and tartar-emetic, should be administered in full doses, to relieve pain and promote perspiration. If the suffering is excessive, a large blister may be applied, followed by the endermic use of morphia. After the severity of the injury has abated, the most suitable topical remedies will be sorbefacient and anodyne liniments, aided, if need be, by occasional dry cupping. • When the* patient is able to walk about, benefit will accrue from the use of an opium plaster. WOUNDS. Wounds of the spinal cord may be of various kinds, and are extremely apt, even when of small size, to eventuate fatally, in consequence of their liability WOUNDS. 249 to be followed by inflammation and softening of the proper nerve-substance. Copious hemorrhage sometimes attends them, still further, complicating the case, by inducing severe, if not irremediable, compression. Yery terrible .effects are also frequently caused when the accident is accompanied by frac- ture of the vertebrae, with depression of the bone, which is sometimes driven across the cord in such a manner as to divide it as completely as if it had been done with a knife. At other times, small fragments of bone ar# buried in the substance of the cord. Paralysis, partial or complete, tempo- rary or permanent, necessarily attends all lesions of this description. If the injury is very considerable, it may destroy life on the instant, especially when it occurs above the origin of the phrenic nerves. Gunshot wounds of the vertebras, with lesion of the. spinal cord, are nearly always, if not invariably, fatal. Of 22 cases of this kind which occurred in the English army in the Crimea, not one recovered. Even when the bones alone are injured, the danger is generally very imminent, most of the patients thus affected dying in a short time from inflammation of the cord arid its mem- branes. When men fight behind trenches, terrible wounds, attended with excessive contusion and laceration of the muscles, are apt to be inflicted upon the back by shells, in consequence of the practice which they have, under such circumstances, of lying on the face while waiting for the explo- sion ; such a position being regarded as the most safe. Of 157 severe cases of this description observed by the British surgeons in the Crimea, 20 died, 87 were sent to duty, and 50 were invalided. The. following case of gunshot wound of the spinal cord, which I attended with Dr. Thomson, in 1854, affords an excellent illustration of this class of injuries: A gentleman, aged 29, was shot in the back with a pistol, the ball entering the left shoulder about two inches and a half below its top, and four inches and a half from the middle line. The man instantly fell, as if he had been struck upon the head, and for a moment it was thought that he was dead. It was ascertained, however, that he had merely sustained a violent shock; there was but little bleeding, and reaction soon followed. Intoxica- tion existing at the time of the accident, it was impossible to make out a satisfactory diagnosis. The hands could be moved, but the lower extremities were completely useless. The next morning, when the effects of the liquor had passed off, it was found that his body and legs were completely paralyzed, and that he was deprived of sensation all the way down from near the top of the sternum to the soles of the feet. The pulse was remarkably slow, and the breathing heavy and laborious. The bowels were costive, and the bladder had to be relieved with the catheter. The mind was clear and composed. These symptoms continued until he died, at the end of three days and a half. On dissection, it was discovered that the ball had entered the spine, between the last cervical and first dorsal vertebras, penetrating and pulpifying the cord, and cutting it in two by projecting across it-a fragment from the injured bones. It was found loose in the vertebral canal. In another case, of which I have the particulars but which I did not see, the ball entered near the right axilla, and, passing across the upper lobe of the corresponding lung, between the fourth and fifth ribs, cut the spinal cord ui two, except a mere thread, and lodged in the body of the seventh dorsal vertebra. Immediate loss of motion and sensation ensued, and the patient, a man aged 30, perished on the eighth day. In regard to the treatment of wounds of the spinal cord, nothing of a defi- nite character can be suggested; every case must be managed according to its owu peculiar nature. The great object, of course, should be to moderate inflammation, and to preyent effusion and other ill effects. If foreign matter is present, pressing upon the cord, it should, if possible, be removed, though in attempting to do this there is great risk of increasing the original mischief. 250 DISEASES OF THE SPINAL CORD AND COLUMN. Trephining will not be likely to be of any service; the operation has been tried in a number of cases in depressed fracture of the vertebras, but in none has it ever been productive of any benefit. Inflammation of the spinal cord, technically called myelitis, is rather a medical than a surgical subject, and may, therefore, very properly be passed over in a work' of this kind. ■ LATERAL CURVATURE. Lateral curvature of the spine is a very different affection from curvature produced by caries of the vertebras; in the latter, the distortion is antero- posterior, and is essentially dependent upon organic disease of the osseous tissue; in the former, it is sideward, and is caused by irregular muscular contraction, acting upon weakened bones, fibro-cartilages, and ligaments, dragging them out of their natural position, and so inducing more or less deformity. The causes which give rise to this irregular action on the part of the mus- cles, enabling those of one side of the middle line to overpower those of the opposite side, and so establishing a tendency in the spine to deviate from the straight position towards the side of the stronger muscles, are of a diversified character, and possessing, as they dOj important therapeutic relations, are deserving of attentive consideration. These causes may be conveniently arranged under the following heads : 1. Affections of the muscles, as hyper- trophy, atrophy, inflammation, and spasmodic contraction. 2. Debility, either general or local. 3. Obliquity of the pelvis, from injury or disease of the inferior extremities. 4. Altered capacity of one side of the chest, causing increased action of the muscles of the opposite side. 5. Rachitic softening of the bones. 6. Defective development of the.vertebras. Hypertrophy of the muscles, as a cause of spinal curvature, may be induced in a variety of ways; often simply by excessive use of one arm, in the exercise of a particular avocation. Blacksmiths, compositors, tailors, seamstresses, and dragoons are remarkably prone to this form of spinal disease. It is a law of the animal economy that muscles grow and expand in proportion as they are exercised. Henc.e, if, for example, the muscles of one arm are more developed than those of the other, the necessary result will be a loss of equi- librium, on the principle that the stronger always overpower the weaker, and, therefore, just in. proportion as this preponderance of action exists on one side will the spine, if the muscles so affected are attached to it, be drawn over towards that side. The muscles which are most liable to inordinate develop- ment from this cause, are the trapezius and rhomboid, which, acting directly upon the spine, completely overpower their fellows of the opposite side, causing thus a marked curvature, the convexity of which corresponds to the hypertrophied limb. An effect similar to the above is sometimes produced when the muscles of one side of the spine become atrophied while those of the opposite side retain their healthy condition. The balance between them being thus destroyed, it is easy for the muscles which possess the preponderance of power so to act upon the vertebral column.as to induce more or less lateral displacement. . Similar consequences ensue when the muscles become disabled by inflam- mation, as occasionally happens in rheumatism ; or by paralysis, as in severe contusions, and in failure of nervous influence ; or by spasmodic contraction, as in wry-neck, which, whenever it exists in a high degree, is always accom- panied by curvature of the cervical portion of the spine, occasionally in a very high and distressing degree. Debility of the muscles is a very frequent cause of spinal curvature; un- doubtedly the most frequent of all. It may be general,, or local; in the LATERAL CURVATURE. 251 former case, affecting all the muscles, not only of the back, but of the rest of the body; in the latter, chiefly the spinal muscles. Any circumstance that depresses the vital powers must necessarily weaken the muscular system, and lead to irregularity of action, disqualifying it for the due performance of its functions. Lateral curvature of the spine may often readily be traced to the debility occasioned by protracted fever and exhausting discharges. The patient, on recovering from his attack, finds that the muscles of the back are too feeble to sustain the spinal column in the erect position, and that, conse- quently, when he begins to walk, it is drawn towards one side, which is always in the direction of the muscles having the preponderating influence. Effects of a like character are produced by the use of unwholesome food, starvation, and inadequate clothing, eventuating in an impoverished and anemic state of the system. Among the more common exciting causes of local debility, considered in its relation to, spinal curvature, are''fatigue of the muscles of the back from the protracted maintenance of the erect posture, and arrested growth from tight lacing. The evil effects produced by sitting daily for a number of con- secutive hours, without any support for the spine, are well exemplified in young ladies at fashionable boarding-schools, and in young female operatives in crowded factories. The erector muscles of the spine, being continually kept upon the stretch, soon become exhausted, and by the constant repetition of the abuse are ultimately entirely disqualified for their task. If the child happen to be naturally feeble, or if she have become so by disease, the con- sequences of this practice are frequently most pernicious, the vertebral column heing not only distorted laterally, but twisted more or less upon its axis. . The effects of tight lacing are known to every surgeon, not merely in their relation to spinal curvature, but in their influence upon the general health. There is not an organ of the body that is not injuriously affected by the cor- set, or that does not resent the "vile encroachment." Circulation, respiration, digestion, and secretion are all brought under its dominion. The muscles of the back are seriously restrained by it. Hence, if the practice be continued for any length of time, they must necessarily become stunted in their growth, and irregular in their action, unfitting them for the healthful discharge of their respective functions, those of one side being rendered stronger than their fellows of the opposite side, and so dragging the spinal column out of place. Obliquity of the pelvis is invariably followed, if long continued, by lateral distortion of the spine, particularly in the lumbar region. A good illustra- tion of this coincidence is afforded in diseases and accidents of the hip-joint, in which, in order to throw the weight of the body upon the sound limb, the pelvis of the affected side is elevated, and a curve is formed in the loins, by the constant strain upon the spinal muscles. Affections of the knee-joint give rise to similar effects. The effect of *an altered state of the chest in producing spinal curvature is well exemplified iu what occurs in empyema and chronic pleurisy, where, in consequence of the compression and obliteration of the bronchial tubes, and the extensive morbid adhesions between the pulmonary and costal pleuras, the ribs sink in and lie almost in contact with each other, thus greatly diminish- ing the capacity of the thorax of the affected side, while that of the opposite side is proportionately increased. The shoulder corresponding with the seat of the disease is notably depressed,and its muscles are so much weakened as to permit their fellows on the other side to draw the spine over in that direction. Rachitis is a common cause of lateral-curvature of the spine, the bones being so weak as to be incapable of withstanding the action of its several muscles. This disease, which is essentially of an inflammatory nature, and which is almost peculiar to early childhood, is characterized by a great defi- ciency of earthy salts, in consequence of which the different pieces of the 252 DISEASES OF THE SPINAL CORD AND COLUMN. skeleton are rendered so soft and flexible as to permit themselves to be cut and benfrin almost every direction. The vertebral column, of course, parti- cipates in the morbid action, and hence it is easy to perceive how it must'be affected by the various muscles which naturally influence and control its move- ments. Some of the very worst examples of curvature that we meet with are produced in this manner, the spine being drawn not only sidewards but backwards. Finally, lateral curvature may be caused by defective development or mal- formation of the vertebras, some of the individual pieces being either too small or too large, or so" united as to meet only at particular portions instead of at their entire surface, as in the natural state. The consequence of this arrangement is that the muscles of the spine, intent upon regaining their equilibrium, soon act unequally, those on one side overpowering those of the opposite side ; not uniformly, but at different points, so as to induce, perhaps, the yery worst form of distortion. The extent of the curvature produced by these different causes is variable. Thus, it may be limited to one particular region, or it may involve one-half, two-thirds, three-fourths, or even the entire length of the spine. When the affection is very extensive, the curvature presents itself in the form of an Italic f compensating curves being formed on the opposite sides. In the more common cases of lateral curvature the deformity begins in the upper dorsal vertebras, on the right side, in an abnormal development of the deltoid, spi- nate, trapezius, and rhomboid muscles, which, overpowering their congeners of the opposite side, gradually drag the bones and everything that is con- nected with them over in the contrary direction, thus forming the first or middle curve of the series. The equilibrium between the muscles being thus destroyed, nature is not slow in her efforts at restoring it; but the only way in which she can accomplish this is by forming compensating curves, of which Fig. 116. . Fig. 117. Different forms of lateral curvature of the spine. there are generally two, one in the lumbar region and the other in the cervi- cal, their development usually occurring simultaneously, and, of course, in a LATERAL CURVATURE. • 253 Fie. 118. direction opposite to the primary. There are instances, however, although they are rare, in which one continuous curve exists on one side, evidently de- pending upon paralysis of the muscles on the opposite side. A sigmoid curve can never rectify itself, and hence such cases are often irremediable, simply because it is impossible to establish a counterbalancing power in the congenerous muscles. The external characters of lateral curvature of the spine are well displayed in figs. 116 and 117. Lateral curvature, in its more aggravated states, is always attended with marked rotation of the spine, the rotation existing in the direction of the convexity of the curvature; the vertebral column is diminished in length in a degree proportionate to the lateral deviation, and the chest is materially altered in its figure, the ribs being flattened, elongated, and twisted, and the sternum and costal cartilages tilted prominently forwards, and depressed to- wards the pelvis. The scapula on the side corresponding to the convexity of the thoracic curve is unnaturally large and elevated; its upper border is directed forwards and inwards, while the inferior angle is carried outwards, and hangs off in a very unseemly manner from the side of the chest, in con- sequence either of the elongation of the latissimus muscle, or on account of the escape of the bono from beneath its surface. A lumbar curve always gives rise to obliquity of the pelvis, and a cervical one, to obliquity of the head; so that there is occasionally, in reality, a quintuple curve. In the earlier stages of the affection, the curvature is effected chiefly at the expense of the intervertebral cartilages and liga- ments; but as it advances, the bones themselves become involved in the disor- der, some portions being absorbed, and others strengthened, by the addition of new osseous matter. The annexed drawing, fig. 118, from a preparation in my collection, affords an excellent exhibition of the vertebras and ribs in the milder forms of lateral curva- ture. The symptoms of lateral curvature of the spine are subject to considerable diversity, depending mainly upon the ex- tent and duration of the lesion. In gene- ral, they are such only as are denotive of functional disturbance of the thoracic and abdominal viscera. In the milder cases,. the patient experiences merely some de- gree of inconvenience in walking, becom- ing easily fatigued during exercise, and suffering from occasional palpitation of the heart, with, perhaps, some degree of uneasiness in breathing. Gradually, however, the general health begins to fail; progression, and the maintenance of the semi-erect posture become more and more irksome ; gastric and intestinal derangement supervene ; the bowels are apt to be constipated; pains are com- plained of in the side and back ; dys- menorrhea is often present; and the countenance exhibits a pale, care-worn, and chlorotic appearance, indicative Of Lateral curvature of the spine. 254 DISEASES OF THE SPINAL CORD AND COLUMN. the crowded and compressed condition of the thoracic, abdominal, and pelvic organs. Lateral curvature of the spine, to a slight degree, exists in almost all persons on the right side,.owing to the fact that nearly every one naturally uses the right arm more than the left. Hence, the corresponding muscles are always more developed, and, acting with more vigor than their con- geners, usually draw the dorsal, or dorso-cervical region, a little over to the rio-ht • hardly, however, to an extent sufficient to deserve the name of disease. Considered as a morbid affection', it is most commonly observed in young girls, from the age of five to fifteen or eighteen, especially in such as are naturally of a feeble constitution, or whose health has become early impaired by'want, exposure, and imperfect nutrition. The prognosis of lateral curvature is geuerally favorable when the affection is recent, of slight extent, and met with in a person of comparatively healthy constitution. Proper management, under such circumstances, will usually effect complete restoration, although the treatment will require time and per- severance. Not unfrequently the mere rectification of a bad habit, causing an unnatural strain upon a particular set of muscles, will remove the com- plaint. When the affection depends upon extensive paralysis of the spinal muscles, organic disease of the vertebras or their cartilages and ligaments, or serious lesion of the pelvis, hip, or knee, great improvement may be effected, but a complete cure will be difficult, and probably impracticable. The prog- nosis is also unfavorable in cases of long standing. The treatment of lateral curvature must be governed, in great degree, by the nature of the exciting cause ; hence, before any measures are instituted for its relief, the most careful inquiry should always be made with reference to this particular circumstance. So long as the cause under whose influence the disease has been developed is permitted to continue in operation, so long, it is obvious, will it be impossible to make any favorable progress towards a cure. A primary object, therefore, in every case, is to ascertain, if practi- cable, what has given rise to the affection, and then to shape our conduct accordingly. The mere discontinuance, temporary or permanent, of a particular avoca- tion, will often speedily overcome-the affection, by enabling the muscles of the two sides of the vertebral column to regain their equilibrium, upon the loss of which the trouble depends. Thus, the lateral curvature which results from hypertrophy of the muscles of the right shoulder and arm of the black- smith, from a,disproportionate use of the other limb, may eventually be com- pletely removed, if early Attended to, before there is any structural change in the bones, cartilages, and ligaments, simply by transferring the hammer to the left hand. The steady, daily exercise of the left limb will soon bring out the full strength of its muscles, while those of the right arm, now compara- tively quiet and inactive, will gradually be reduted in volume and force, and so in time permit a restoration of the balance of power, and, along with it, a return of the spine to the straight position. The lateral curvature of the spine, contracted by girls at school and by children at factories, in consequence of a vicious habit of sitting, standing, or reclining, by which the vertebral muscles lose their equilibrium, can he successfully cured only by a reference to the nature of the exciting cause. The awkward and constrained position must be promptly rectified, and means adopted to improve the general h.ealth, when this has been suffering, by gentle exercise in the open air, sea-bathing, the cold shower bath, and a properly regulated diet. Great attention must be paid to the gait in walking, so as to bring into full play the enfeebled and faulty muscles; the spine should be well supported while in the erect position by a light and well adjusted brace; and the child should be requested to lie down frequently during the day, in LATERAL CURVATURE. 255 order to afford complete relaxation and rest to the entire system, so condu- cive to comfort and the restoration of vigor. When the affection is manifestly dependent upon debility, or want of tone in the general system, tonics will be indicated, and should be of such quality and given in such quantity as may be calculated to improve rapidly the con- dition of the blood and solids. The various chalybeate preparations, either alone or in union with quinine or Huxhanj's tincture of bark, generally produce an excellent effect^ and should be administered, steadily and persistently, for several successive months; the dose being occasionally varied, or a new arti- cle added, to relieve the monotony of the treatment. When marked emacia- tion exists, cod-liver oil will come in play, and will often rapidly improve both flesh and strength. The diet should* be judiciously regulated; it should be perfectly plain and simple, but at the same time sufficiently nutritious in the smallest compass, so as not to crowd the stomach and bowels, and so interfere with the movements of the diaphragm and the expansion of the lungs. Fresh milk and sweet cream should be freely used, together with an allowance of brandy, wine, porter, or ale, suitable to the age and condition of the patient. Frequent ablutions with strong soap and water, or some other alkaline solution, followed by dry friction, the occasional employment of the shower bath, and gentle exercise in the open air, or, when this is im- practicable, swinging in a hammock, the body being in a perfectly passive condition, will be valuable adjuvants, and should be diligently enforced. Shampooing the back, practised twice daily for thirty minutes at a time, is often of signal benefit in imparting tone and energy to the weakened muscles, and seems to me to be deserving of more attention in this particular class of cases than it has hitherto received. When the muscles are exhausted by paralysis, the cold douche, the electric current, and gentle flagellation will prove useful, and may be employed conjointly with tonics and minute doses of strychnine. Lateral curvature depending upon obliquity of the pelvis is not always curable, inasmuch as the cause itself does not invariably admit of removal. When this is the case, the weakened spine may be supported by appropriate stays, and by attention to the position of the body in progression, standing, sitting, and reclining. Similar means must be adopted when the fault lies in the chest, as in retrocession of its walls in consequence of empyema and pleuritic adhesions. The treatment of rachitis, considered as a cause of spinal curvature, need not be particularly discussed here, inasmuch as it has received sufficient atten- tion elsewhere. It is essentially an inflammatory affection, associated with, if not directly dependent upon, impaired nutritive action of the osseous tissue, attended with a deficiency of earthy matter, and consequent softening of the skeleton. The treatment must be alterant and tonic, and the spine must be mechanically supported until the bones have acquired a sufficient degree of solidity to enable them to resist effectually the influence of the muscles of the back. Lateral curvature, dependent upon defective development of the vertebras, requires early and persistent mechanical treatment,, to sustain the weakened spine, and afford the affected parts an opportunity of being moulded into a more suitable shape for the due performance of their functions. The occur- rence, which is, fortunately, very rare, is apt to be overlooked until it is too late to benefit the patient. _ The treatment of lateral curvature, however induced, derives important aid, in almost every case, from mechanical support of the spine, and much inge- nuity has been expended of late years in the invention of suitable apparatus, of which there is, consequently,, a vast amount before the profession, all con- structed upon the same principles, although possessing different degrees of 256 DISEASES OF THE SPINAL CORD AND COLUMN. merit. It may be stated, as a general rule, that the more light, airy, and simple such apparatus is, the more comfortable it is for the patient, and the better adapted to the removal of the distortion. It should consist of five principal pieces, as the necessary framework, of which two are horizontal and three vertical, connected together by screws and hinges. Of the former, one corresponds with the hips and the other with the shoulders; of the latter, two extend up along the sides of the trunk into the axillas,. their superior extremity being crutch-shaped for the more easy support of the arms, while the third, or intermediate one, rests upon the spine. The whole apparatus is well cushioned to ward off pressure, and is kept in place by straps and buckles. Counter-pressure may be made, if deemed advisable, upon the convexity of the thoracic curve, by means of an appropriate pad secured to the middle upright piece of the apparatus; and, when there is considerable displacement of the cervical vertebras, a head-piece may be added. The apparatus may be worn day and night; and, although it may at first prove irksome, yet such is the comfort derived from its use that the patient will soon be loth to be without it. The bed upon which the patient lies should be furnished with a smooth and elastic mattress, in order that his body may not sink into any hollows or depressions, at the same time that it should be sufficiently soft to insure the requisite comfort. The object, however, of this arrangement is not to con- fine the sufferer to her bed beyond the hours which are necessary for a due supply of sleep and repose after exercise. In.the antero-posterior displace- ment of the spine, or Pott's disease, rest and recumbency, absolute and uncon- ditional, are enforced, and scrupulously maintained for many months; here, on the contrary, rest and recumbency, although highly important, are not trusted to alone, but are wisely conjoined with gentle exercise in the open air, either on foot, in a carriage, or on horseback, as may be found most con- venient or suitable to the patient. The body, in short, must be invigorated, and the faulty muscles set in action by their appropriate stimulus, namely, motion, varied, diversified, and frequently repeated. With out-door exercise is often advantageously combined a gentle course of gymnastics; but to derive full benefit from it, it should be conducted under the immediate superintendence of a regular master of the art, well acquainted with-the exigencies of the case; otherwise immense harm instead of benefit" will be likely to ensue. A great deal has been said of late years respecting the beneficial effects of myotomy as a remedy for the cure of lateral curvature of the spine; and if the reports that have appeared in some of the periodicals of the day are to be trusted, it would seem that almost every muscle of the back, large and small, has been divided for this purpose. The exploits of Mons. Querin upon this field have been quite of a Napoleonic character, and they would, doubtless, have conferred upon him immortal honors, had it not been discovered that such universal havoc was rather an injury than a benefit to his victims. What the result of a more calm and rational myotomy may ultimately accom- plish for this class of patients, time alone can determine. Judging from the happy effects which have followed the procedure in wry-neck and strabismus, it might reasonably be concluded that it would also confer important service in lateral curvature of the spine, and such is certainly the opinion, at this moment, of some of the best surgeons in this and other countries. TUBERCULOSIS OF THE SPINE. The bodies of the vertebras being composed, in great measure, of areolar tissue, invested by a thin layer of compact substance, are liable to tubercular deposits, similar to those which are so frequently met with in the carpal and TUBERCULOSIS OF THE SPINE. 257 tarsal bones, and in the articular extremities of the long bones. The affec- tion, from its destructive character, is one of very grave import, and has, therefore, always engaged the earnest attention of surgeons. It has been only, however, within a comparatively recent period that its true nature has been properly understood. It was reserved for Mr. Pott, towards the latter part of the last century, by a series of masterly observations and dissections, to point out its etiology, pathology, and treatment, and so completely did he exhaust the subject that nothing of any real importance has been added to our knowledge of it since his death. Indeed, so graphic is his account of the disease that it is now generally known by his name. Although the disease may occur in any portion of the spine, yet it is much more common in the dorsal region than in either the cervical or lumbar, the second, third, and fourth pieces being especially prone to suffer. It is gene- rally stated that the lumbar vertebras are more frequently affected than the cervical, but this I believe to be an error ; at all events, my own practice has supplied me with a greater number of cases of the lesion in the latter than in the former. It is impossible to assign any reason why caries of the vertebras should be so much more common in the dorsal region of the spine than else- where ; but such is unquestionably the fact, and the circumstance is one of great importance, both in a diagnostic and practical point of view. Pott's disease occurs in both sexes, in all classes of society, and at different periods of life, although it is much more common in children from the age of three to twelve years than at any other time. I have met with it as early as the fifteenth month, and cases are occasionally observed as late as the thirtie'th, or thirty-fifth year, but these are rare, and must, therefore, be regarded as exceptions to a general law, which constitutes this a disease of early childhood. It is most common in the lower walks of life, among the ill-fed and half-starved occupants of the crowded lanes and alleys of large cities, and always recognizes, as its essential cause, a strumous state of the system. Like tubercular disease of the lungs, it is, in fact, merely a local manifestation of a constitutional vice, or a general dyscrasia of the blood and of the solids. This, therefore, constitutes the great and fundamental principle of the disease; the indispensable condition of the system which precedes the outbreak of the local affection. External injury, exposure to cold, and various other depressing inflaences, may excite the disease into action, but no such occurrence could possibly happen from these or any similar causes, if no tendency to the disease existed in the constitution at the time of their application. The tubercular matter, which is the immediate cause of caries of the spine, is deposited in the areolar structure of the bodies of the vertebras, either as an infiltration or in the form of distinct, rounded masses, from the size of a millet seed to that of a pea, a few of which are sometimes encysted. It is not improbable that more or less is also occasionally deposited upon the sur- face of these bones, beneath the periosteum, in the substance of the perios- teum, or in the interior of the intervertebral cartilages, or perhaps in all of these situations simultaneously or successively. How long it exists before it becomes softened and disintegrated, we have no means of knowing; the period, doubtless, varies in different cases and under different circumstances, but, on an average, it probably does not exceed five or six months, the sub- stance obeying the same laws here as in other parts of the body. Be this as it may, when the process has once fairly commenced it generally proceeds very rapidly, so that it often produces very serious havoc in the course of four or fiveweeks, completely annihilating the affected structures, and causing great and irremediable deformity. If a dissection be made at this stage of the malady, a gap, fig. 119, the size of which corresponds with the number of vertebras affected, will be-found to exist in front of the spine, occupied by VOL. n.—17 258 DISEASES OF THE SPINAL CORD AND COLUMN. unhealthy, strumous matter, the debris of disintegrated bone, and fragments of fibro-cartilage and thickened periosteum. The spinal cord and the roots of the spinal nerves will be observed to be more or less denuded, and the remnants of the diseased vertebras to be thrust backwards in such a manner as to cause an antero-posterior curvature, very marked behind, in conse- quence of the unnatural projection of the spinous processes, as in fig. 120. Fig. 119. Fig. 120. Caries of the vertebrae (macerated); Angular curvature from caries. the bodies extensively destroyed. When the lesion is seated in the dorsal region, the adjoining ribs often par- ticipate in its ruinous effects, and the matter is sometimes extensively diffused over their internal surface, as well as over the anterior and lateral aspect of the spinal column. The number of vertebras involved in this disease is variable; sometimes it is limited to a single piece, but most generally it attacks two or three, the spongy substance of which, together with the intervening fibro-cartilages and the contiguous periosteum, is eventually completely destroyed. Symptoms.—The affection usually comes on in a slow and stealthy manner, and hence it often makes very serious inroads, both upon the part and system, before its true character is even suspected by any one. Among the earlier symptoms is an appearance of gradually declining health ; the patient looks pale and feeble ; his appetite and bowels are irregular; the gait is vacillating and tottering ; the strength easily gives way under exercise ; the lower ex- tremities are the seat of numbness and occasional spasmodic twitching; a sense of pain and discomfort is felt along the spine, particularly at the affected part; the urine is alkaline and scanty; the sleep is disturbed by moans and restlessness ; and there is not unfrequently a good deal of fever at night, fol- lowed, perhaps, by considerable perspiration towards morning. By and by the symptoms assume a more decided character. The pain in the back in- creases, and pressure upon the part generally causes a peculiar sickening sen- sation; a feeling of constriction is experienced in the chest, as if it were girded by a tight cord ; the difficulty of walking rapidly augments; the general debility becomes more and more marked ; and the numbness in the lower extremities, steadily advancing, is now generally conjoined with a dis- agreeable prickling feeling, evidently the result of pressure on the spinal cord. The paralysis accompanying the disease exists in various degrees; in TUBERCULOSIS OF THE SPINE. 259 some cases it is extremely slight, and hardly attracts attention ; in others, on the contrary, it is so great as to deprive the patient completely of the power of progression. Usually motion is impaired before sensation. The deformity of the spine is always characteristic; it is angular back- wards, fig. 121, and varies in extent according to the number of vertebras affected, and the duration of the disease. It is limited to the seat of the disease, and is often associated with a kind of knob-like enlargement of the neighboring parts, especially conspicuous when there is serious involvement of the ribs. In the more aggravated cases, the spine is bent back many inches beyond its natural level, the chest is singularly elongated in the antero- posterior direction, the sternum is pushed out in front, and the head is sunk down between the shoulders, causing that peculiar hump-backed appearance which forms so striking a feature in the symptoms of this disease in its con- firmed stages. If the body be viewed in profile, the chest will be found to represent the outline of a triangle, the apex corresponding with the affected part, and the base with the sternum and costal cartilages. These appear- ances are well represented in fig. 122, from a preparation in the Mutter collection. Fig. 121. Fig. 122. Posterior curvature of the spine. The matter which forms in this disease may be absorbed ; or it may accu- mulate, and ultimately seek.an outlet, either through the back near the seat of the disease, or it may gravitate along the front and sides of the spine, as ih fig. 123, and eventually point in the groin, the lumbar region, or the upper part of the thigh. A disease which makes such sad inroads upon the part and system as this is necessarily a grave disorder under any circumstances ; but when it occurs, aS it generally does, in children of a broken-down, miserable constitution, ill-fed and half-naked, or whose bodies are completely saturated with the strumous diathesis,,the prospect of an ultimate cure must be very limited in- deed. Many of such patients perish from hectic irritation, while the majority of those who recover are doomed to a wretched existence, permanently dwarfed, and hump-backed. In the better class of subjects restoration is 260 DISEASES OF THE SPINAL CORD AND COLUMN. Fig. 123. Abscess of the spine from caries of the vertebras, the cyst in which the matter is confined beinginterposed be- tween the bone and the aorta. the rule, death the exception ; and it is well to know that, if the case be pro- perly managed, excellent cures, with little or no deformity, may be made even when the disease has already produced consider- able structural change. When the disease is located in the cervical region, the prognosis is generally less favorable than when it affects the dorsal or lumbar; yet most extraordinary recoveries are now and then witnessed, the patient getting well apparently in despite of the malady. One of the most remarkable instances of this kind that I have ever seen occurred recently in a young man, a private patient of mine, who, notwithstanding a most severe attack of caries of the superior cervical vertebras, has got a very good use of the neck, although the upper portion is so completely anchylosed that, in attempting to look sideways, he is obliged to turn his whole body round. A great exuberance of callus has formed over the affected pieces, giving the neck a very full, heavy appearance. When the cervical vertebras are extensively affected, the disease not unfrequently proves fatal, death occur- ring in one of several ways. First, an abscess may form, and destroy life, either by bursting into the larynx, or into the spinal canal; in the one case in- stantly suffocating the patient, and in the other not less certainly killing him by inducing compression of the spinal cord. Secondly, dislocation of the odontoid process may occur in consequence of ulceration of the transverse ligament; and, lastly, life may be suddenly extinguished by injury inflicted upon the spinal cord, by the accidental giving way of some of the diseased vertebras. The manner in which the gap is filled up, when a cure is effected in this disease, constitutes one of the most interesting features in its history. As soon as the morbid action is arrested, nature sets up a process of repair, con- sisting, in the first instance, in an effusion of plastic matter. This often begins at one part, while the disease is still going on in another; a circum- stance which greatly conduces to recovery, as much time is thus saved. The restorative process advancing, the plasma is gradually organized, and thus becomes the nidus of the new bone by which the breach in the bodies of the vertebras is finally closed up, the develop- ment of the osseous tissue taking place in strict conformity with the laws of ossifica- tion in the foetus. The new substance is extended like a bridge, across the spinal canal, and does not, therefore, encroach at all upon its contents ; it is more solid than natural bone, and is usually several shades whiter. It connects together not only the contiguous bodies of the vertebras, but also the remnants of the arches and spinous pro- cesses, soldering them into one solid, immov- able mass, as in fig. 124. The heads of the adjoining ribs generally experience a simi- lar fate. It will thus, be seen that the cure of this disease is by anchylosis. Treatment.—Caries of the vertebras being merely, as already stated, a local manifestation of a general strumous vice, its treatment necessarily resolves Fig. 124. Remarkable example of angular curvature and anchylosis, with spontaneous cure. TUBERCULOSIS OF THE SPINE. 261 itself into topical and constitutional, the latter holding the chief rank. I include, of course, among the constitutional means rest in the recumbent posture, one of the.most important elements of success in the management of every case of this kind, as an absolute, indispensable condition, not to be violated or departed from, on any consideration whatever. If any one feels inclined to doubt the value of this precept, it will only be necessary for him to look around and behold the many hump-backed persons that everywhere meet his eye, to be satisfied of his error. Every object of this kind is a standing, living monument of the miserable treatment that is so generally pursued by the practitioners of this country. The very nature of the case suggests the propriety of absolute rest and recumbency. One need only observe the havoc committed by the disease to be convinced how utterly im- possible it is for the weakened and crippled spine to support the superincum- bent head and shoulders; it must inevitably yield under the heavy weight, * and the distortion thence resulting must necessarily be in direct proportion to the amount of pressure thus maintained, and the extent of the gap left by the destruction of the bodies of the vertebras. The reason why the curvature is posterior, is because the spinous processes, preserving their integrity, tend to drag the affected parts in that direction. Now all this may be effectually obviated by the observance simply of the recumbent posture, maintained faithfully and steadily, not for a few weeks or months, but, if necessary, for more than a year ; in short, until nature has succeeded in bridging over the gap with new bone, capable of supporting the superincumbent weight. Until this is accomplished, the patient must on no account be permitted to rise off his couch for any purpose whatever. When this period has arrived, the sur- geon will generally be made aware of it by the solidity and firmness of the affected parts, and the indurated and enlarged condition of the structures immediately around the seat of curvature, as well as by the subsidence of the more important functional symptoms. It is a mistaken notion to suppose that a person laboring under caries of the spine will not brook confinement, or that it will tend to impair the general health; those who have the largest experience in this matter know better. A child may be taught obedience to anything, especially when it is designed to relieve pain and suffering; he may resist at first, but a few days are generally sufficient to break him in, and to make him docile and contented, if not perfectly happy. It is not necessary that he should lie all the time in one posture; the prone position is undoubtedly the best, as it relieves the parts of congestion and pressure, but he may lie on his back, side, or belly, as he may find it most agreeable, and generally he manages this matter of his own accord, without any prompting from any one. No pillow should be placed under the head, as it is important that the occiput should be on a line with the spine, in order that no pressure whatever should be made upon the affected parts. The bed may be a common trundle one, with a good hair, moss, or cotton mattress. Rest and recumbency, then, are of paramount importance in every case of caries of the spine, and the earlier they are employed the less danger will there be of ultimate deformity. It is the very first injunction that should be delivered by the surgeon when he prescribes for such a disease. The constitutional remedies, properly so called, must depend upon circum- stances. In general, the patient will be benefited by a course of chalybeate tonics, cod-liver oil, and a light but nutritious diet, with an occasional dose of blue mass. If fever be present, or if there be marked disorder of the bowels and secretions, an active purgative may sometimes be required; but, in general, it will be most judicious to avoid the employment of all kinds of depressants. The pain may be such as to demand, now and then, an ano- dyne, especially if it be so great as to interfere with sleep. Night-sweats are 262 DISEASES OF THE SPINAL CORD AND COLUMN. best relieved by quinine and aromatic sulphuric acid, and ablutions with tepid alum water, assisted by dry frictions and exposure of the body to the fresh air. Milk punch, ale, porter, and wine may be used if there be much debility. The principal local remedy is an issue made with the actual cautery, which' is incomparably superior, so far as my experience enables me to judge, to all other modes of counter-irritation of which I have any knowledge. It should be placed either on one side of the affected part, or immediately below or above, as may be deemed most convenient, and should be at least as large, when the eschar has dropped off, as half a dollar. Such a sore will not only yield an abundant discharge bf pus, easily maintained for several months, but afford an excellent surface for the endermic application of morphia, if this should be considered necessary, on account of the severity of the pain. The * ordinary pea issue is of no use in such a case, while that made with Yienna paste is altogether inferior to one made with the hot iron; for this instru- ment, besides destroying the integument, makes a powerful impression both upon the part and system, which is not the case with any other material. As to the seton, Mr. Pott long ago stigmatized it, in speaking of it in connection with this disease, as "painful and nasty," and I am sure that every sensible surgeon will concur with him in opinion. If the discharge from the issue flag, it must be promoted by the application of stimulating unguents, a small blister for a few hours, or a little Yienna paste. A second application of the cautery is seldom necessary in any case. When there is reason to suppose that the parts have been sufficiently repaired to enable them to sustain the weight of the head, the patient may be permitted to rise, not, however, without having been previously provided with a suitable supporter. Such an instrument, to answer fully the object which it is intended to subserve, should combine lightness with strength, and should be constructed in such a manner as to come well up under the arms, at the same time that it makes gentle yet efficient pressure against the weak- ened spine, in the greater portion of its length. A hollow pad may be adapted to the angular projection behind. No mechanical support should be used during the progress of the ulcerative action, except when it involves the cervical region, in which cas.e some appli- cation of the kind is imperatively demanded, lest, in an unguarded moment, the affected pieces should suddenly cave in, and thus fatally crush the cord. PSOAS ABSCESS. In consequence of disease of the vertebras, pus not unfrequently forms at the anterior and lateral aspect of the spine, which, as it accumulates, gradu- ally descends towards the lower part of the trunk, where it ultimately points and is discharged, the event being preceded by the appearance of a fluctuat- ing swelling. When the fluid passes down in front of the psoas muscle, the disease takes the name of psoas abscess, whereas, when it proceeds backwards towards the loins, it is called lumbar abscess ; a distinction which, although topographically correct, must not be regarded as implying any difference in the nature of the two affections, inasmuch as observation has proved them to be perfectly identical in character. Pathology.—An abscess of the kind now under consideration is essentially a strumous disease, which, according to my observation, can occur only in persons of a strumous predisposition. Hence it is often associated with tubercular disease in other parts of the body, especially of the lymphatic ganglions, lungs, and mucous follicles of the large bowel. The disease is rarely met with before the age of puberty, being most common between that period and thirty-five. I have never seen it in very young or in very old PSOAS ABSCESS. 263 subjects. Both sexes are liable to it; males suffer, however, more frequently than females, but in what ratio is not known. It generally comes on without any assignable cause, although the patient is very apt to attribute it to the effects of cold, sprains, blows, or sudden twists of the body. Its march is always essentially chronic. Structure.—Dissection shows that these abscesses always take their rise in strumous disease of the bodies of the vertebras, commencing either upon their outer surface or in their cancellated structure. Occasionally there is reason to believe that it begins in the intervening fibro-cartilages, if not also in the neighboring periosteum. I have never seen an instance whose origin was not fairly traceable to spinal disease. The affection is sometimes double, an abscess occurring on each side, either simultaneously or within a short time of each other. The contents of a psoas abscess are of a tubercular character, precisely like those of a chronic abscess in the soft parts or of a strumous joint. They are usually intermixed with flakes of lymph, and cases occur in which they contain small particles of bone, or of bone and fibro-cartilage. The fluid, which varies in quantity from a few ounces to several quarts, is always inclosed by a distinct cyst, rough or villous internally, and firmly con- nected to the neighboring structures; it is of a dense, fibrous texture, and ranges in thickness from the fourth of a line to the sixth of an inch. In cases of long standing its length sometimes reaches an extent of from eighteen inches to two feet; occasionally it forms one continuous pouch, but more frequently it exhibits a sinuous arrangement, branches being sent off laterally. The psoas and iliac muscles are always atrophied, inflamed, discolored, and partially degenerated into fatty matter. Progress and Symptoms.—As the disease progresses, the matter manifests a tendency to point, but without any uniformity in regard to the precise spot, although this is generally just above Poupart's ligament, external to the iliac vessels. Sometimes the matter gravitates down in front of the thigh, beneath Poupart's ligament; and I have observed cases where it showed itself on the outside of the limb, upon the nates as low down as the tuberosity of the ischium, in the iliac region above the anterior superior spinous process of the ilium, and in the interior of the pelvis, its contents being finally evacuated into the bowel or bladder. Pointing in the lumbar region is by no means uncommon. In a few instances the matter has been known to pass out of the thyroid foramen, forming a tumor at the upper and inner part of the thigh. The period between the commencement of the disease and the occurrence of ulceration varies, on an average, from four to six months. Spinal abscess, for so this affection should be called, always begins in a stealthy and insidious manner, the patient being entirely unconscious for a long time that he is the subject of so serious a disease ; he feels, perhaps, somewhat unwell, and finds that he is gradually growing weak and losing flesh and appetite; his face looks pallid, his sleep is irregular, and he occasionally has slight attacks of fever, followed by perspiration. At a still later period, exercise becomes exceedingly irksome, and.he now begins to limp, especially after walking; he now also finds it difficult to extend his trunk and thigh, so that when he is up or going about, he is obliged to lean forwards a little towards the affected side, in order to relieve the parts of tension. A good deal of soreness is usually complained of in the back and iliac regions, extending along the front of the thigh; but anything like severe pain is seldom felt. After some time, varying from three to six months, a tumor becomes perceptible, soft, com- pressible, and fluctuating distinctly under the finger. When seated in the groin, or in the upper part of the thigh, it generally receives a marked im- pulse on coughing, and recedes more or less on recumbency, especially when conjoined with considerable elevation of the pelvis. In the lumbar and glu- teal regions, on the contrary, coughing and position usually make no impres- 264 DISEASES OF THE SPINAL CORD AND COLUMN. sion upon it. When the abscess points in the groin, a superficial observer might mistake it for an inguinal hernia; but the history of the case, the dis- tinctness of the fluctuation, and the situation of the swelling, which is usually much nearer to the spine of the ilium Jhan in rupture, will always afford just grounds for a correct diagnosis. Wheu the tumor appears at the upper and inner part of the thigh, the only disease with which it is liable to be con- founded,-in its early stages, is femoral hernia. The march of psoas abscess is usually steadily onward ; so long as the sac retains its integrity the general health is often comparatively little affected, but as soon as it is opened, whether spontaneously or artificially, and the air is permitted to mingle with its contents, the constitution manifests at once the most lively sympathy, as is evinced by the rapid supervention of rigors and hectic fever, with all its train of evils. Prognosis.—The prognosis of this disease is generally unfavorable, most patients perishing from its effects in from twelve to eighteen months. Yery few, if any, ever make a good, permanent recovery. In most cases death occurs from hectic irritation, profuse sweats, and colliquative diarrhoea, either as the direct result of the abscess, or of the abscess and of lesion of other organs, especially of the lungs and bowels. Treatment___The treatment of spinal abscess is eminently unsatisfactory. Generally several months elapse before the true nature of the disease is ascer- tained, and when, at length, it is discovered, its ravages will usually be found to be of such a character as to render all efforts at a cure utterly hopeless. If a free, dependent outlet could be formed for the matter early in the disease, the probability is that the patient might occasionally get well; but when it is considered how much the osseous and other structures suffer before the fluid reaches the surface, it is not surprising that these cases should so uni- formly prove fatal. Moreover, it is not to be forgotten that the abscess is merely a symptom of a general tubercular dyscrasia, which is, in itself, an unfavorable omen, as it is always likely to be followed by serious disease in other, and, perhaps, still more important organs. If the affection be left to itself, it will be sure to destroy life, and the event will hardly be any the less certain if it be surgically interfered with. Subcutaneous evacuation of the matter, as proposed by Abernethy, is not of the slightest use as a cura- tive agent; in all the cases, and they have been a good many, in which I have tried it, no benefit whatever resulted, except that it occasionally afforded temporary relief from pain. The operation is always, in a very short time, fol- lowed by hectic fever, and by more or less rapid failure of the health and strength, no matter how carefully it may have been performed. Yery fre- quently not even palliation is derived from it. Sorbefacient applications, in the form of lotions, unguents, or plasters, are of no particular use. When the sac has been opened spontaneously, advantage may sometimes accrue from the injection, twice a day, of tepid water, followed by some slightly astringent and anodyne fluid, or a very weak solution of iodine; but too much caution cannot be observed in the employment of this and similar mea- sures, lest violent local and constitutional irritation be excited, thereby hurry- ing off the patient. Alterants may do good by improving the general health, but not as curative measures. In the latter stages of the disease, tonics and a nutritious diet will be necessary, with aromatic sulphuric acid to allay per- spiration, and anodynes to procure sleep and arrest diarrhoea. HYDRORACHITIS. Hydrorachitis is a congenital defect, consisting in a cleft of the vertebral column, with a protrusion of the lining membranes of the spinal cord. The lesion, which is caused by an arrest of ossification, and consequent deficiency HYDRORACHITIS. 265 Bifid spine, as developed in the neck. of the vertebral rings, is generally situated in the lumbar region, but occa- sionally it affects the dorsal, cervical, or even the sacral. It is frequently associated with hydrocephalus, and is analogous to those malformations which originate from a want of union of the two halves of the foe- tus during utero-gestation, such as hare-lip, cleft-palate, and umbilical hernia. The adjoining drawing, fig. 125, from a clinical case, a boy six weeks old, shows a rare form of this dis- ease. The tumor, which was seven inches and a half in circumference, was quite soft and fluctuating, and tender on pressure, though free from inflammation. The child's health was excellent. The malformations of the spinal column accompanying this affection may be arranged under the following heads: 1, division of the entire vertebra, even of its body; 2, partial or complete absence of the lateral arches; 3, per- fect development of the lateral arches with want of union at the median line. The protrusion of the spinal envelops generally takes place during the latter months of foetal life; occasionally, however, it is not observed until some weeks or months after birth. When the tumor first shows itself, it may not be larger than a pea; but, as the disorder progresses, it gradually in- creases in size, varying in proportion to the deficiency of the vertebras. Although the swelling usually does not exceed the size of an orange, yet occasionally it reaches that of the fist, and even of the patient's head. The skin is commonly very smooth, delicate, and thin ; some- times, however, it retains its normal thickness, or it becomes red, rugose, and horny ; in a few rare cases, it is entirely wanting. The tumor is either soft, flabby, and fluctuating, or it is full, hard, and shining; when pressed upon, it gradu- ally diminishes in volume, or completely recedes; but no sooner is the force re- moved than the fluid reaccumulates, and the part regains its previous bulk. In its form, the swelling is globular, ovoidal, or pear-like^, with a short, narrow neck, by which if reposes upon the cleft bone. Fig. 126, from a preparation in my pos- session, exhibits a tumor of this kind in the lumbar region ; it was about the size of a common orange, and was taken from a child five months old. winch is here laid open, had been exposed by ulceration. The fluid in hydrorachitis is generally of a thin, limpid character, slightly saline in its taste, and'almost uncoagulable. In some instances, it is of the color and consistence of synovia, or it contains flakes of lymph and particles ot pus. These appearances, however, are seldom present until after the swell- Bifid spine, the sac being laid open. Its cavity, 266 DISEASES OF TnE SPINAL CORD AND COLUMN. ing has burst, and discharged its original contents. The tumor usually con- sists of a single cyst; but there may be several, as in the multilocular variety of ovarian dropsy. In such a case it would be difficult, if not impossible, to draw off all the fluid by operation. The contents of the vertebral canal in the immediate neighborhood of the lesion are variously affected. The portion of the spinal cord surrounded by the tumor is often very much softened, or converted into a thin, diffluent sub- stance ; sometimes it has been found abnormally hard; sometimes it is not so large as natural; and sometimes, again, it deviates remarkably from its accustomed route, being forced through the opening in the vertebras, and partially contained in the swelling. The nerves are always more or less dis- placed ; sometimes they are dragged out of the canal, and distributed over the inner surface of the cyst in a beautiful plexiforra manner, not unlike that of the fleshy columns of the heart, as exhibited in fig. 127, from a preparation in my collection. Hydrorachitis is one of the most fatal of dis- eases. Few children survive their birth longer than five or six months, while many perish in a much shorter time, death being caused either by convulsions, or by ulceration of the sac, and the sudden escape of its contents. It is true, life has sometimes been sustained until the age of puberty, and, in one case, until the fifty-fifth year ; but such instances, although encouraging in a practical point of view, are altogether of an exceptional character, and cannot, therefore, be used for the establishment of any general law. If the tumor be ruptured during partu- rition, the infant is nearly always still-born, and if it be opened after birth, either accidentally or designedly, death usually follows in a few hours, the immediate cause of dissolution being convulsions from the pressure being taken off the brain in consequence of the loss of the cephalo-spinal liquid. The case is always likely to have a speedily fatal termination when it is associated with hydrocephalus, paralysis, of the inferior extremities, or in- voluntary discharge of the urine and feces. Moreover, it may generally be regarded as being of a more hopeless character when it affects the cervical region than when it is seated in the dorsal, lumbar, or sacral. The treatment of bifid spine is anything but satisfactory; for modern science, while it has been so suggestive of improvement in almost every other branch of surgery, has made no additions, even of a plausible nature, to what was known respecting the management of this malformation a quarter of a cen- tury ago. When the tumor is small, or of moderate size, a cure may occa- sionally be effected by keeping up constant pressure with collodion, and a common roller, or a cup-shaped truss, lined with a thin air-cushion, so as to diffuse the pressure equally over the entire swelling. The compression should be aided by the occasional evacuation of the contents of the sac by subcuta- neous puncture with a very fine trocar or bistoury, the opening being well closed immediately afterwards to prevent the introduction of the air. Only a portion, however, of the fluid should be drawn off at a time; if the whole be removed at once, convulsions will be inevitable, and from such an attack the child may perish in a few hours, the brain being unable to bear the sud- Bifid spine, showing the distribution of the nerves. * HYDRORACHITIS. 267 den loss of pressure caused by the escape of the cephalo-spinal liquid. Sir Astley Cooper, early in life, treated successfully a case of cleft spine with simple compression alone ; and, in another instance, soon afterwards, he was equally fortunate by combining this method with repeated punctures, as had been previously proposed by Mr. Abernethy. Subsequently, he employed the same measures in two other cases, one of which proved fatal, very unex- pectedly, at the end of forty days, everything having before been in a promis- ing condition, while the other recovered, at the expiration of a year and a half, after the tumor had been punctured thirty times, and the child had been given over as lost. Favorable results have also followed this plan of treat- ment in the hands of other practitioners, both in this country and in Europe, and is, I am satisfied, the only safe one of which we have at present any knowledge. The smaller, of course, the tumor is, the more likely it will be to succeed; if it be of inordinate size, or even if it be comparatively diminu- tive with a broad base, and a large cleft in the vertebras, no treatment of any kind can be expected to be of any but the most transient benefit, and then only in the way of support with a view to the prevention of ulceration and the accidental rupture of the sac. Benjamin Bell and other surgeons have suggested tying the base of the sac with a ligature, with a view of removing the tumor, and preventing further propulsion of the spinal membranes; but the results that have been published in favor of the operation are such as not to warrant a repetition of it. I have myself the particulars of several cases of this kind that have come either under my own immediate observation, or that have been communicated to me by other practitioners, and in every one the effects have been most lamentable, the patient dying either immediately after the operation from convulsions, or a short time afterwards from an extension of the inflammation to the spinal cord and its envelops. The same may be said of the operation of excision after ligation of the pedicle, and the application of the actual or potential cautery for the purpose of exciting adhesion between the opposing surfaces of the sac. All such procedures cannot be too pointedly condemned, as being both unscientific, and certain to prove fatal. The only case in which ligation can ever be proper is where the sac has an uncommonly narrow pedicle, with an exceedingly small aperture of communication, but even under such circumstances, which are extremely infrequent, the safer practice unquestionably would be systematic compression in union with occasional puncture. Dubois, with the hope of gradually diminishing the size of the tumor, and of ultimately agglutinating the serous surfaces at its base, proposed the application of pressure, at this particular point, by means of two narrow steel plates, regulated by two screws, and prevented from slipping by passing two stout needles immediately in front of them, across the swelling. ' He succeeded, in this manner, it is alleged, in curing his patient. I am not aware, however, that it has succeeded in the hands of other surgeons, and I can discover no material difference, either in point of principle or practice, between it and compression with the ligature. Finally, it has been proposed to cure hydrorachitis with injections of iodine; an operation first performed by Dr. Brainard in 1848, and since then repeated by him, up to 1859, in five other cases. In addition to these he has reported five cases that have occurred in the hands of other surgeons, and, it would seein^that neither in these nor in his own have there been any dangerous effects produced. All practitioners, however, have certainly not been equally for- tunate. In,two cases of my own, the particulars of which my limited space will not permit me to give, and in several others reported in the medical jour- nals, the operation was followed by death, either in consequence of the rup- ture of the sac, or the violence of the resulting, inflammation. Whether the 268 DISEASES OF THE SPINAL CORD AND COLUMN. procedure is as free from danger, or as successful, as the facts presented by Dr. Brainard would seem to warrant, is a question which time alone can determine. The most unfavorable cases, of course, will be those in which the disease is complicated with hydrocephalus. Dr. Brainard's rules for performing the operation are as follows :—1st, to make the puncture subcutaneously in the sound skin, by the side of the tumor; 2dly, to evacuate no more serum than the quantity of fluid about to be injected ; 3dly, if symptoms of irritation supervene, to withdraw the con- tents of the sac, and replace them immediately with distilled water; 4thly, the patient should lie on his side or face after the operation, and, if there be much heat, warm evaporating lotions should be applied to the part and head; 5thly, when the tumor becomes flaccid it should be covered with collodion, or be supported by pressure, to be continued for some weeks after the cure has been perfected; and, 6thly, the injection should be repeated as often as may be necessary, care being taken that the previous irritation has always completely subsided. The injection is performed with a very delicate trocar, the puncture being accurately closed with adhesive strips. The active ingredients of the solu- tion are iodine and iodide of potassium, in the proportion of one-fourth of a grain of the former and thrice that quantity of the latter to the ounce of dis- tilled water. When the sac is very thick and pedunculated, the strength of the solution ought, Dr. Brainerd thinks, to be five or six times as great as in ordinary cases ; the sac should be entirely emptied,"then injected, washed out, and immediately re-filled either with its original contents or with distilled water. Pressure is applied during the operation, in such a manner as to prevent any of the solution from entering the spinal canal. INJURIES AND DISEASES OF THE FACE. 269 CHAPTER IV. INJUKIES AND DISEASES OF THE FACE. The face, considered as an independent region, is composed of thirteen bones, for the most part very thin and delicate or thick and porous, intimately connected together, and remarkably vascular. Its numerous muscles are chiefly concerned with the organs of mastication, taste, and sight. Its arte-. ries are derived from the external carotid; its veins empty into the jugular; and its nerves proceed directly from the brain. The soft structures of the face are endowed with great sensibility, and their supply of blood is naturally very great; circumstances which, as will presently be seen, exercise an im- ■portant influence upon the injuries and diseases of this region of the body. The principal affections to be considered under this division are the various kinds of wounds, especially the incised, contused, and gunshot. Of diseases, properly so called, very little need be said, as they will be fully discussed under other heads. Incised wounds of the face present nothing peculiar, except that they are frequently attended with copious hemorrhage, especially when they penetrate to a considerable depth or involve the bones, which, as„ already stated, are remarkably vascular. In their treatment, the usual rules of practice are to be observed, but additional care is requisite in approximating and maintain- ing their edges, otherwise, when the cure is completed, the patient's counte- nance will be apt to be marked with disfiguring scars. The best retentive means are small, delicate pins, or the finest cambric needles, introduced in the same manner as in the operation for hare-lip, the threads being so arranged as to obviate the necessity of adhesive strips, which, under no circumstances, must alone be trusted to, as they are extremely liable to be displaced by the action of the muscles of the face. -For years past, I have been in the habit of employing very slender gold pins in wounds of this region, and there is no mode of dressing which, according to my experience, is so likely to prevent the formation of a disagreeable cicatrice. With a sharp point and a head of sealing-wax, they are easily introduced, and may be retained for almost any length of time without the risk of provoking irritation. The wire suture also answers a good purpose as a retentive contrivance, but is, on the whole, ill adapted to incised wounds in this situation, where the avoidance of scars is a matter of such great importance to the welfare of the patient. When incised wounds of the face are complicated with extensive separation of the soft parts, or of the soft parts and of the bones, it may be necessary, in addition to sutures, to use a compress, confined by adhesive strips or a suitable bandage, the object being to afford gentle and equable support to the flaps. Contused and lacerated wounds of the face are sufficiently frequent, and are liable to be followed by very unpleasant effects, both temporary and perma- nent. Among the former are blood-stains, ecchymoses, extensive tumefaction, severe pain, and erysipelas; among the latter, disfiguring scars and paralysis of some of the muscles from injury to their nerves. _ A curious wound of the face, partly contused and partly incised, is occa- sionally inflicted by a blunt weapon operating upon the sharp border of the 270 INJURIES AND DISEASES OF THE FACE. superior maxillary and malar bones. The parts present very much the ap- pearance as if they had been divided by the sharp edge of a knife, at the same time that they are more or less bruised, and perhaps even discolored. A similar effect is occasionally produced by the edges of the teeth driven forcibly, by a blunt body, against the lips and cheeks. In the treatment of these lesions, the most important indication, after the removal of foreign, matter, is the gentle approximation of the parts with the pin or wire suture, followed by cold water-dressing, aided, if there be much contusion, by the addition of a little alcohol. The edges of the wound must be placed in the most accurate apposition, and the greatest care taken to keep down inflammatory excitement. Contusions, properly so called, of the face are always attended with more or less bleeding into the connecting cellular tissue, elevating and discoloring the skin, the hues varying from slight purple to deep scarlet, which, during the progress of the case, in consequence of the clfanges effected in the extra- vasated fluid, gradually diminishes in intensity, becoming at first brownish, then greenish, and finally yellowish. The most common sites of these effu- sions are the eyelids and cheeks, on account of the great abundance and laxity there of the areolar substance readily admitting of infiltration. One of the best examples of such an accident is the "black eye" of the pugilist, caused' by the rupture of the vessels of the lids and the extravasation of their con- tents into the connecting structures. Considerable swellings of this kind are occasionally met with in the lips and chin, and even upon the nose, especially its upper part. In fractures of the base of the skull, large quantities of blood are often poured out into the cellular tissue of the orbit, surrounding and compressing the globe of the eye. The most suitable remedies for the relief of these accidents are cold water and sorbefacient lotions. If there be much pain and swelling, the best appli- cation, at least for the first few days, will be a pretty strong solution of acetate of lead, Goulard's extract, or hydrochlorate of ammonia, with a small quan- tity of laudanum. For the milder forms of these accidents, the tincture of arnica, more or less diluted, is often prescribed, and, in general, its beneficial effects are very striking, the paiu, swelling, and ecchymosis rapidly disappear- ing under its influence. Mild spirituous lotions, camphor water and lauda- num, or a mixture of vinegar and water, may also be employed with advan- tage. When the extravasated blood refuses to yield to these and other measures, as occasionally happens when the parts are very much bruised, or when the fluid exists in large quantity or is devitalized, the best plan is to let it out by means of a small puncture, otherwise it may cause suppura- tion and other unpleasant effects. Gunshot injuries of the face are most liable to happen when men are fired at behind entrenchments. During the war in the Crimea, altogether, 533 cases of these lesions came under treatment among the English soldiers, or 7.4 per cent, of the entire wounded. Of this number 382 were cases of sim- ple flesh contusions and solutions of continuity, 272 being slight, and 108 severe. In 107 cases the wounds penetrated or perforated the osseous struc- tures, and in 44 they were complicated with injury of the eyes ; in 42 of one, and in 2 of both. Of the entire number 14 only died, or 2.6 per cent, of those treated. Of 40 cases which occurred among the officers, including 15 of more or less severity, not one proved fatal. The mortality in wounds of the face would thus appear to be remarkably slight, a circumstance which is the more surprising when it is recollected that these injuries are often attended with severe laceration of the soft parts and extensive fracture and comminution of the bones. The immunity, however, is readily accounted for by the fact that the face contains no vital organ, by the large quantity of .blood sent to this region, and by the free anastomosis of WOUNDS OF THE FACE. 271 its vessels. From these causes the fleshy and osseous structures readily unite in cases, generally, even of an apparently desperate character. For the same reason mortification and necrosis here, as a result of contusion and fracture, are extremely rare. Wounds of the face from shell, grape, and cannon shot are, other things being equal, more dangerous than those inflicted by the Minie or common rifle ball. The risk from hemorrhage, erysipelas, and pyemia, is much in- creased, and the deformity is often frightful and irremediable, the lesion, per- haps, involving the lips, nose, cheeks, jaws, tongue, and one or both eyes. In the treatment of gunshot wounds of this region, the rule is to save all and sacrifice nothing, as it is impossible, in any case, to determine beforehand whether the parts, even if desperately injured, will not readily heal when properly dealt with. Perfectly loose or detached pieces of bone should, of course, be removed, and any rough or sharp angles that may exist should be pared away with the pliers, so as to place them in a better condition for ultimate, if not speedy, reunion. The edges of the soft structures may some- times also be advantageously trimmed or smoothed off, although care should be taken not to remove any more than is absolutely necessary to insure their more accurate apposition. Maintenance is effected by the wire suture, aided by adhesive strips; the roller may usually be dispensed with. If the injury is very extensive, tepid water-dressing, with the addition of a little alcohol or tincture of arnica, will answer better than cold, at least for the first few days; but in general the latter will be preferable. One of the great sources of annoyance and danger in gunshot injuries of the face is hemorrhage, which is often exceedingly profuse and difficult to arrest, in consequence of the great depth of the vessels, or .the manner in which the blood wells up at the bottom of the wound. The only way to put an effectual stop to it is to secure every bleeding artery, however minute. If the trunk of the internal maxillary be divided," each extremity must be included in a separate ligature, precisely as in hemorrhage of the main artery of a limb. When the blood oozes out at numerous points, the flow may usually be easily arrested with the tampon, or the tampon and styptics, of which Monsel's salt and ice are among the very best. In desperate cases, it has been proposed to tie the common carotid artery, but such an expedient can seldom, if ever, be successful, owing to the free anastomosis existing be- tween the branches of the two opposite vessels. Secondary hemorrhage is of frequent occurrence in these lesions, com- mencing sometimes within a short period after the accident, and, although it may cease spontaneously, it is occasionally controlled with much difficulty. When the injury of the fleshy structures is accompanied with extensive fracture of the bones, the fragments should be carefully moulded into shape, and retained by light dressings. Everything like severe pressure must be avoided, as the parts will be particularly intolerant of such interference. When a large portion of the lower jaw is shot away, the tongue, having lost its muscular connections, is apt to fall back upon the glottis, threatening suffocation. To counteract this tendency, all that is generally required is to place the head in the prone position. If, notwithstanding this precaution, alarming symptoms arise, the point of the tongue should be transfixed with a thread or silver wire, so th$t the organ may at any moment be drawn forward by the patient or his attendants. In the management of wounds about the face, mouth, and throat, special care must be taken not to permit the offensive mucous and salivary secretions to pass into the stomach. The neglect of this precaution is liable to be followed by a low typhoid state of the system, very similar to what occurs in pyemia, or blood-poisoning. These effects are very common in bad cases of 272 INJURIES AND DISEASES OF THE FACE. gunshot wounds of this region, and I have repeatedly had occasion to notice them after operations upon the jaws, mouth, and even the nose. Another bad effect of these wounds is paralysis, partial or complete, of the face, in consequence of injury done to the branches of the facial nerve. Loss of sensation will be experienced if there be severe contusion or division of the branches of the fifth pair. The horrible and disfiguring gaps of the face consequent upon these lesions occasionally admit of closure by an autoplastic operation, the flaps being borrowed from the neighboring surface, or partly from this and partly from the arm. Tumors.—Various kinds of morbid growths, benign as well as malignant, are liable to appear in the face, commencing either in the skin, in the cellular substance, or in the osseous tissues; but as they do not differ, in any essential particular, from similar diseases in other regions, they do not require any special notice. The sebaceous tumor, of which a sufficiently elaborate account is given in the chapter on the diseases of the skin, is quite common in this region. It is easily distinguished by its tardy development, its mobility and freedom from pain, and by its soft, elastic consistence. Its shape is generally somewhat ovoidal, and its volume ranges from that of a pea up to that of. an almond. The skin over it is usually perfectly healthy. The fibrous tumor is occasionally, but very rarely, seen in this region, mostly directly over the antrum of Highmore; slow of growth, firm in its consistence, capable of attaining a large bulk, and liable to recur after extirpation. The fatty tumor of the face is met with chiefly in the upper eyelids, in con- nection with which it will hereafter be described. Upon the cheeks and lips I have never seen an instance of it. The cystic tumor is sometimes met with in the face, generally, if not inva- riably, as a congenital vice. In a case of this kind which fell under my observation in 1860, the size of the tumor was enormous. It involved the greater part of the left side of the face and neck, extending, on the one hand, from above the ear to the clavicle, and, on the other, from the angle of the mouth and nose to the posterior border of the sterno-cleido-mastoid muscle. The disfigurement was very great. A most extensive and tedious dissection was necessary; but, notwithstanding this, the child, who was only six weeks old, bore the operation well, and made a very rapid and complete recovery. Cystic formations in this region are generally multiple, the number of cells being sometimes very, great; they are generally closely grouped together, have thin transparent walls with serous contents, and vary in size from that of a millet-seed up to that of a large marble. In cases of long standing their walls and contents are liable to undergo various transformations, thus materi- ally changing their original character. The only remedy is excision. Aneurism by anastomosis, generally in the form of a congenital vice, not unfrequently occurs in the face, and requires the same kind of management as in other parts of the body. The great rule, when an attempt is made to remove such a growth by excision, is to carry the knife through the sound tissues, and not through its substance. A purely venous tumor, also generally of a congenital nature, is liable to appear on the face, and is easily and safely dealt with by excision, the opera- tion, if proper care be taken, being almost bloodless, even when the growth is of inordinate bulk. The annexed sketch, fig. 128, represents a large growth of this kind, which I removed from the left side of the face and lip of a young lady twenty-four years of age, with the loss of hardly three ounces of blood, although the operation necessarily involved the division of the coronary artery. The tumor had commenced early in life, aud had greatly disfigured an otherwise INJURIES AND DISEASES OF THE FACE. 273 very pretty face. During the excision, it literally shrunk away to nothing. Fig. 129 shows the result of the operation. Fig. 128. Fig. 129. Venous tumor of the lip and cheek. In the parotid region it is not uncommon to find enlargements of the lymphatic ganglions and various malignant affections, seated either in these bodies or in the substance of the parotid gland. To these particular atten- tion will be directed under their appropriate heads. Warts often grow upon the face, and, besides their unseemly appearance, are frequently a source of irritation and annoyance, not to say anything of their liability, in some cases, to take on malignancy. As long as they are FiS- 13°- stationary, and not productive of in- convenience, they may be let alone, otherwise they should be promptly removed. The only malignant disease of the face requiring passing notice here is the corroding lupus, or epithelioma, of which the annexed sketch, fig. 130, from Mr. Druitt, affords an admirable illustration. Generally taking its rise, in the form of a little fissure, superfi- cial ulcer, or warty excrescence of the skin, it gradually extends in depth and circumference until at length it involves, in many cases, the entire face—integument, muscle, cartilage, and bone—leading thus to the most frightful suffering and deformity. The period at which death occurs varies, on an average, from eighteen months to four or five years. Now and then, although very rarely, the disease, after having committed extraordinary ravages, gradually stops, the parts cicatrize, and the morbid action never recurs. The treatment of cor- VOL. 11—18 Corroding lupus, or epithelioma of the face. 274 INJURIES AND DISEASES OF THE FACE. roding lupus has been sufficiently discussed in the chapter on cutaneous affections. Broad and unsightly cicatrices of the face, especially those consequent upon burns and scalds, often admit of removal by a very simple operation, the vicious parts being included in two incisions, the edges of which are afterwards carefully approximated by suture. When the loss of substance is very great, it must be supplied with integument borrowed from the neigh- borhood. Finally, in surgical operations upon this region, especially such as are necessary for the removal of various kinds of morbid growths, the incisions should be planned with reference to the least deformity. This is generally best done by carrying the knife in the direction of the folds of the skin, when any exist, or where they will be likely to occur as the patient grows older. The most unseemly and disfiguring cicatrices are, as a rule, those which fol- low perpendicular or very oblique iucisions. DISEASES AND INJURIES OF THE EYE. 275 CHAPTER V. DISEASES AND INJURIES OF THE EYE. Writers upon ophthalmic medicine and surgery have almost an incredible catalogue of diseases and injuries of the eye, from the little louse that nestles at the root of the lashes to carcinoma, terminating in destruction of all the component tissues of the organ. Not content with describing what is pecu- liar to these structures, they give the most minute and tedious account of every lesion that can possibly occur in any other region of the body, thus needlessly confusing, perplexing, and botheriug the pupil, if not disgusting him with the study of a class of affections which, if properly discussed, could not fail to be of the deepest interest to him. Such a course is, to say the least, highly objectionable, if not -positively unscientific, and well calculated to retard the progress of ophthalmic investigations. The barbarous nomen- clature introduced by our German brethren, and which savors too much of charlatanry to be retained in our literature, has tended, perhaps, more than anything else, to inspire professional men with a dislike, if not positive aver- sion, to the study of the maladies of the eye, and has, doubtless, been one of the principal reasons why this class of affections is so often, both in this country and in Europe, in the hands of empirics. It is deeply to be regret- ted that writers on the diseases of the eye cannot content themselves with a proper simplicity and with what legitimately belongs to this department of medicine and surgery. There is no more necessity for the ponderous tomes of some of the French, German, and English ophthalmologists than there was for the overgrown medical folios of our ancestors. All that is truly useful in this department of pathology and practice might be comprised in a com- paratively small compass, and should be completely divested of the jargon of the pedant. Stripped of their meretricious character, works on the eye would be read with the deepest interest, and the consequence would be that its dis- eases would be understood a hundred-fold better than they now are, or can be so long as this course is continued. Why should we designate an adhesion of the iris to the lens as synechia, a protrusion of the iris across the cornea as myocephalon, a cohesion of the lids as ankyloblepharon, and an operation for closing a lachrymal fistule as dacryocystosyringokatakleisis 1 Really, this is quackery in its worst guise. MODE OF EXAMINING THE EYE. Ophthalmoscope—The most important discovery of the present century, as an auxiliary to the study of the diseases of the eye, is that of the ophthal- moscope, a contrivance by whose aid the dark background of this organ may be lighted up, and its delicate tissues clearly inspected. Of the many in- struments of the kind now in use, that devised by Dr. Anagnostakis, of Athens, is perhaps the most simple and valuable, combining, as it does, great facility of application with portability and cheapness. At all events, it is, with some unimportant modifications, the one now most generally employed. It essentially consists of a lens and of a concave, circular mirror, about two 276 DISEASES AND INJURIES OF THE EYE. inches in diameter, perforated in the centre by a small hole, to the back of which is fitted a plate of blackened copper, the whole being inclosed in a brass ring and mounted upon a short handle. During the examination, which must always be made in a dark room, the mirror is held in one hand, and the lens close before the eye in the other. Unless this precaution be adopted, it will be impossible, in the great majo- rity of cases, although the bottom of the organ may be highly illuminated, to obtain a distinct view of any of its individual parts. The lens may be bi- convex or bi-concave, with a focus of from one and a half to two inches, the former affording an inverted, and the latter an erect image. The inspection with the bi-convex instrument is generally to be preferred, as it is more easy, less trying to the eyes of the surgeon and the patient, and more satisfactory in regard to the range of the retina. In either case, the pupil must pre- viously be dilated with atropia, in the proportion of one-twentieth of a grain to the ounce of water, a small quantity of which is applied several times to the eye a few hours before. The observer and patient should sit facing each other, as in fig. 131, close by the side of a table on which stands a bright lamp, or, what is better, an Fig. 131. Mode of conducting an ophthalmoscopic examination. argand burner, as nearly as possible to the patient's side, only a little behind him, and on the same level with his eyes. The speculum, held in the right hand, is so placed that the light of the lamp is reflected by its polished sur- face upon the organ to be examined. The observer then applies his eye close to the hole, and approaches or recedes from the patient's face, keeping the flame all the while steadily upon the eye, until he sees the pupil appear of a bright-red color. The double convex lens, held between the thumb and in- dex finger of the left hand, is then placed close to the organ, when, by slowly moving the mirror back and forth, he can soon find the proper focal distance, and readily see a distinct bloodvessel, as well as other objects, at the bottom of the eye. This distance should be as firmly maintained as possible, and the vessel followed to its entrance into the optic papilla. This is done either by moving the mirror slowly from side to side, or, what is better, by displacing the lens slightly in the same way, keeping in mind that the objects at the MODE OF EXAMINING THE EYE. 277 Fig. 132. ■ Jlnl HiHBgpP Healthy appearances of the eye. Fig. 133. bottom of the eye move in the opposite direction from the lens. The optic papilla should be the first object sought and inspected; afterwards the ob- server may examine the adjacent parts of the retina and choroid as far for- wards even as the ora serrata. The papilla, fig. 132, is seen as a brilliant, well-defined, yellowish-white spot, usually circular in form, and contrasting strong- ly with the neighboring parts of the re- tina, which appear of a light pinkish-red color. Either in the middle of this spot, or a little to one side, are seen the central artery and vein of the retina, each having two branches, one ascending and the other descending, while several smaller ones extend outwardly. By looking steadily at these vessels while slight pressure is made with the finger on the ball, they may be seen to move distinctly and synchronously with the pulse at the wrist. The optic papilla is variously changed by disease. Among the milder affections, the most frequent is hyperemia, or congestion, the result of disease, or of excessive and long-continued fatigue of the eye, so common in sempstresses, engravers, watch-makers, proof-readers, and compositors. It is characterized by a dilated and injected condition of the vessels of the retina, which is sometimes so great as almost to conceal the papilla, as in fig. 133. Perhaps the most important alteration which the optic papilla experiences is an umbilical depression, with perceptible pulsations of the vessels sometimes seen in glaucoma. The phenomenon, how- ever, which is probably due to intra- ocular pressure, is usually not detected in this affection until a late period. It is occasionally conjoined with textural changes in the adjacent portion of the retina, and when this is the case the pa- pilla is liable to lose its distinctive ap- pearance, becoming insensibly lost in the surrounding parts. In inflamma- tion of the retina, both this membrane and the optic papilla are preternatu- rally vascular, and not unfrequently the seat of plastic deposits, superficial as well as interstitial, ecchymoses, and other alterations, exhibited in figs. 134 and 135. Sometimes the retina is partially detached from the choroid by dropsical accumulations, presenting themselves in the form of bluish-white, undulating bags, projecting forwards into the vitreous humor. Inflammation of the choroid, with exudation and subsequent thinning of that membrane, and absorption of its pigment, as in the disease called pos- terior sclerotico-choroiditis, is characterized by the appearance of brilliant white, irregular spots, produced by the strong reflection from the sclerotica. A number of cases have recently been described in which the cellular cysti- cerce, a peculiar form of entozoon, was found in the retina, between this mem- brane and the choroid, and in the vitreous humor. Hyperemia of the papilla. 278 DISEASES AND INJURIES OF THE EYE. The most common pathological changes in the vitreous humor are liquefac- tion of its substance with diffused turbidness, and brownish shreds, or cor- Fig. 134. Fig. 135. Inflammatory deposits on the retina. Extravasations of blood on the retina. puscles, of various shapes and sizes, floating in it, mounting up into the pupil when the eye is moved, and subsiding to the bottom of the organ when it is held still. These are either masses of lymph that have been detached from the retina, choroid, or ciliary body, the remains of blood that has been poured out into the eye, or, perhaps, portions of the disorganized hyaloid membrane. These changes of the vitreous body are nearly always attended with serious diseases of the retina, but it is often impossible to distinguish this membrane through the opaque substance. Such floating bodies are very readily detected by the ophthalmoscope without the use of the lens. The speculum is a useful means also for determining the degree of satura- tion of the crystalline lens in cataract and the different varieties of that dis- ease. Incipient and slight opacities of that organ, which had entirely eluded the most careful examination with the unassisted eye, have sometimes been easily detected with this instrument. They appear as a brownish, grayish, or drab-colored veil, or as streaks across the red background of the eye. No lens is necessary in examining the crystalline body ; and a weak light is pre- ferable to a strong illumination. Its opacities are more readily detected by looking obliquely into the pupil, when they usually appear of a grayish color. These are but a few of the pathological changes in the back part of the eye, which have already been brought to light by the ophthalmoscope. They are, however, sufficient to establish its indispensable importance in the dis- crimination of those numerous diseases which were formerly all grouped together under the general name of amaurosis. It need hardly be added that it requires much patience and practice with the instrument to give one that tact in the use of it so necessary to precision of diagnosis. Ocular Inspection.—In examining this organ with the unassisted eye, with a view of ascertaining its condition, the patient should sit upon a chair, in a good light, unless there is severe inflammation, in which event he must sit with his back towards it. The upper lid may be gently elevated by means of the index finger, the point of which is placed against its free border, or with an instrument specially constructed for the purpose, as one of those here represented in figs. 136, 137, and 138. The lower lid is easily depressed with the finger applied to the margin of the orbit, and drawing down the skin ; a procedure which, at the same time, freely exposes its inner surface. Eversion of the upper lid is effected by means of a probe, director, or pencil, MODE OF EXAMINING THE EYE. 279 placed horizontally along the upper margin of the tarsal cartilage, and gently pressed against the surface, while the surgeon, standing behind or in front Fig. 136. Fig. 138. Different forms of elevators. of the patient, raises the free margin of the lid by the cilia, with the thumb and forefinger. The observer must be careful not to mistake for disease the discoloration of the sclerotic coat from the long-continued use of nitrate of silver. The appearance thus produced is of a dusky, darkish character, depriving the eye of its natural expression. When the object is to examine the interior of the eye, for the purpose of ascertaining the condition of the crystalline lens, vitreous humor, retina, or choroid, the pupil should be previously dilated with a solution of atropia, in the proportion of about half a grain to half an ounce of water. Of this, a few drops may be applied to the ball every thirty minutes, until the object is attained; or, instead of this, a cloth, wet with a strong solution, may be kept upon the eyelids and eyebrow for several hours. The extract of belladonna, formerly so much employed for dilating the pupil, is now seldom used. It is worthy of note that the topical use of atropia occasionally, though very seldom, causes unpleasant nervous symptoms, as muscular tremors, numbness, and even delirium, as from an overdose exhibited internally. These effects, which I have seen in several instances, are generally readily relieved by an ordinary dose of morphia. The application of the extract of belladonna for dilating the pupil is also sometimes followed by bad symptoms, Fig. 139. Bandage for the eyes after operations. especially in children and very nervous persons. I have heard of two infants, laboring under congenital cataract, who were destroyed by wearing a bella- donna plaster upon the forehead and temple. 280 DISEASES AND INJURIES OF THE EYE. In all cases of inflammation of the eye, and after all important operations upon this organ, the light should be carefully excluded from the patient's apartment, as the smallest quantity, falling upon the retina, generally proves hurtful. Sometimes the light requires to be merely moderated, and when this is the case, the object may be attained by the use of a green shade of a semilunar shape, made of a piece of thin pasteboard, covered with silk, and secured to the head by means of tapes tied at the occiput. After operations on the eye, especially those for cataract and artificial pupil, the organ must always be completely screened from the light, either by a thin handkerchief, or a particular bandage, constructed after the fashion represented in fig. 139, and fastened by several turns of a roller. Sometimes we are obliged to close the lids carefully with adhesive strips, or strips of isinglass plaster, especially after wounds of the cornea. FOREIGN BODIES IN THE EYE. Foreign bodies are liable to pass into the eye, and to bury themselves in its structures, where they at once become a source of suffering and inflamma- tion. They are of various kinds, as scales of iron, bits of glass, particles of stone and coal, shot, splinters of wood, and percussion caps. Although every part of the organ may be thus injured, the cornea, from its exposed situation, is most frequently affected, the extraneous substance being either firmly im- bedded in its lamellas, lodged immediately beneath its epithelial investment, or forced into the anterior chamber, one end, perhaps, presenting externally. Great care is often necessary to detect its presence, especially when it is very minute, when it is composed of metal, or wrhen it lies immediately in front of the pupil, the black background of which has a tendency to obscure it, so as to prevent it from being easily seen. The best way to examine the part is to stand behind the patient, as he sits upon a chair fronting the window, and then, the lids being raised, make him move the eye about in different direc- tions, thus enabling the light to fall upon every point of its surface. In this manner no object, however minute, can possibly escape detection. The removal of foreign bodies from the cornea requires more skill and tact* than surgeons generally imagine. I have repeatedly had patients sent to me from a great distance, because the physicians in their neighborhood were unable to afford them the necessary relief, and that, too, when the case was of the most simple nature. When the eye is much inflamed, when the sub- stance is buried at a considerable depth, or when the patient is a child, or a very nervous, irritable or excitable person, it will be well to exhibit ether before we proceed to the extraction, otherwise we shall be sure to experience serious annoyance. The upper lid being properly elevated, and the glohe securely steadied by the finger, or, in the event of anassthesia being employed, by a suitable hook, very much as in the operation for strabismus, a delicate cataract needle, or the point of a lancet, is insinuated around the foreign body, which is thus lifted out of its bed without any digging, a process which cannot be too carefully avoided, on account of its liability to be followed by severe inflammation and extensive opacity. A scale of iron that has been retained in the cornea for a few days is liable to become oxidized ; hence, it may break under the instrument, and require to be extracted piecemeal. When the foreign body is firmly imbedded in the layers of the cornea, the best plan will be to make an incision over it, to its full length, with a cata- ract knife, and then to dislodge it with a small needle. Should it have per- forated the cornea in such a manner as to render it impossible to lay hold of it with the forceps, the puncture should be enlarged until this may be safely done, care being taken, if there be danger of the substance slipping back into FOREIGN BODIES IN THE EYE. 281 the anterior chamber, to make counter-pressure during the extraction by a delicate needle passed behind the cornea. It is, of course, needless to caution the surgeon about officious interference in these cases, especially rude and extensive probing, which might prove worse than the retention of the extra- neous substance. Among the more unfortunate accidents of this kind met with in this country are lacerated wounds of the eye, made by percussion caps, which often pass through the iris into the vitreous humor, causing violent and destructive in- flammation, followed by almost insupportable pain, lasting as long as the foreign body remains in the organ. I have seen more than a dozen such cases, in every one of which the sight was completely annihilated, and the pain of the most violent character. If probing of the eye is ever justifiable, it is under such circumstances ; and I am not certain whether we should not extract the foreign substance at all hazard. By putting the patient under the influence of anassthesia, the operation may be conducted with comparative safety, and with great probability of success. I have seen several bad cases of injury of the eye inflicted by small shot; and in military practice it is not uncommon for the organ to be wounded by bullets, pieces of iron, and splinters of wood. Destructive inflammation always follows the lodgment of such bodies, and the rule, therefore, is to get rid of them as speedily as possible. The question may here be asked, what should be the treatment when a foreign substance, lodged in the interior of the eye, cannot be extracted ? Should the humors be evacuated, or the organ itself be extirpated, as some have recommended, or should the case be managed upon general principles ? Manifestly the latter, unless there be great local and general suffering, or the integrity of the sound eye be seriously threatened by sympathetic action, in which event no time should be lost in effecting collapse, the extraneous substance almost invariably escaping along with the contents of the organ. As to the excision of the eye, I can hardly conceive of any case, however severe, warranting so ruthless a procedure, as the object can always be accomplished equally well by the other operation, which has the additional /advantage, in many instances, of affording a good stump for an artificial substitute. Dissection has shown that foreign bodies in the eye, as shot, pieces of iron, and percussion caps, may become encysted; but such an event is rare, and does not, besides, protect the organ against attacks of inflammation. As long, in fact, as the extraneous substance remains, it is liable at any time, whether free or adherent, to provoke suffering and disease. Gun-powder is often imbedded in the coats of the eye, and I have seen cases where it penetrated the cornea and became fixed in the lens and iris. The worst accidents of this kind occur in mining and rock-blasting. Exces- sive pain and discomfort attend, increased by the solution of the nitre in the tears, and followed by high inflammation. The treatment consists in picking out the grains of powder, without delay, lest the edges of the wound should close over them, and so oppose their removal. Terrible injuries are liable to be inflicted upon this organ by hot fluids, as water, steam, pitch, sulphur, lead, solutions of soda and soap, and also by hot iron, hammered upon the anvil, the sparks flying off and forcibly striking the eye. The effects vary according to the temperature of the sub- stance and the duration and violence of the contact. In the milder forms there may merely be some discoloration, or discoloration and slight vesica- tion, with more or less pain ; in the more severe, on the contrary, the part touched is either killed outright, or the tissues are so much injured as to slough from the consequences of the resulting inflammation. The indication, in these cases, is to remove any foreign matter that may be present, and then 282 DISEASES AND INJURIES OF THE EYE. to employ antiphlogistic measures, early and efficiently, in the hope of saving structure and function. Molten lead is apt to collect in the folds of the con- junctiva, and should therefore be sought for with great care, otherwise it may escape detection. Pitch, if firmly adherent to the eye, may be detached with olive oil; iron is best picked out with the point of the lancet. Various chemical irritants, as the alkalies and acids, are capable of pro- ducing severe injury by their contact with the eye, causing violent pain, opacity of the cornea, and excessive inflammation, often terminating in sloughing and total blindness. The treatment of such accidents is sufficiently obvious. The first indication is to wash away with the hand or syringe as much as possible of the extraneous matter by the free use of cold or tepid water, and the second to neutralize what remains by the application of some alkaline or acid lotion, according to the nature of the substance with which the mischief was inflicted. If the eye has been touched by an acid, the most efficient remedy will be a weak solution of bicarbonate of potassa; an alkali, on the contrary, is most effectually neutralized by an acid, as a wash of vinegar and water, aided, if necessary, by the vapor of hydrochloric acid. The eye, in either event, should be bathed for a long time after the extraneous sub- stance has been dislodged, and be afterwards well anointed with olive oil, a full anodyne being given to allay pain, and leeches used to moderate inflam- mation. Nitrate of silver, too freely put upon the eye, whether accidentally or designedly, is readily neutralized by a weak solution of common salt, followed by the application of the raw white of an egg. Quicklime, or oxide of calcium, speedily destroys the structures of the eye, by inflicting a double injury by its chemical action and by the evolution of heat under the influence of the tears and mucus. The foreign matter being picked away, the organ should be promptly syringed with a weak solution of vinegar and water, and then thoroughly coated with oil. It was formerly imagined that sugared water, freely used as a wash, would rapidly neutralize the lime under such circumstances, by forming a removable soluble com- pound, but more recent observation has proved this notion to be erroneous. DISPLACEMENT OF THE BALL OF THE EYE. Displacement of the globe of the eye, technically called exophthalmos, may be produced by various causes, of which the most common are different morbid growths in and around the orbit. A mass of fat or an exostosis, by filling up the bottom of this cavity, may thrust the eye forwards, out of its natural position, and even force it out upon the cheek, completely beyond the lids. Similar effects are sometimes caused by polyps of the nose, and by fibrous tumors of the maxillary sinus. When the displacement is very great, so that the optic nerve is put much upon the stretch, as well as compressed, dimness of sight, if not total blindness, is apt to ensue. When the dislocation is the result of an accumulation of fat in the orbit, it may affect both organs simultaneously, as in the following case, which fell under my observation in 1848:— Powtan, a black boy, twelve years old, tall and slender, has had a remark- able protrusion of both eyes ever since he was two years old. At present, the balls hang, as it were, from their orbits, projecting nearly half an inch beyond the level of the nose, which, however, is rather flat. They preserve their natural direction, but cannot be moved about, and they do not appear to be at all enlarged or hypertrophied. The sight is unimpaired. The upper lids are remarkably full towards the eyebrows, and are one inch and a half in the vertical direction, by two inches and a quarter in the transverse. Not- withstanding this inordinate development, they are insufficient to cover the DISEASES OF THE CONJUNCTIVA. 283 ball of the eye completely. The lower lid is about the natural size. The right cornea, at its inferior part, has an opaque spot upon it, and the pupil has the appearance of having been injured, being vertically elongated. The orbits do not seem to contain any hard substance or tumor, as the finger may be pushed into them some distance between the brow and upper part of the ball. The boy has occasionally had neuralgic pains in the eyes, with lachry- mation, but in other respects he has been free from suffering. His general health is good. The protrusion has been stationary for some time past. By a singular coincidence, this boy died, while under my care, of gastritis, thus affording me an opportunity of seeing his eyes by dissection. Upon removing the eyes, or, rather, the contents of the orbits, I found the cause of the protrusion to be an accumulation of fat behind each ball, and within the muscles; it was of a yellowish color, and rather more firm than common. The ball rested upon it as in a cup. The optic nerves were normal, but apparently somewhat longer than usual. The straight muscles of the right eye were larger than those of the left. The lachrymal glands were forced considerably forward, but were of the natural size, color, and structure. The inner wall of the orbit, especially the left, was more prominent than common, but had no agency in producing the protrusion. Both eyes were perfectly sound. A partial displacement of the eye is sometimes caused, at least apparently, by an elongated and relaxed state of the straight muscles. This affection, which always imparts a disagreeable expression to the features, is most common in weak, hysterical females, and demands a tonic, invigorating course of treatment. The eye is occasionally dislocated from its socket by external violence. I have never met with such a case in the human subject, but some years ago I saw one in a little poodle, which, in a fight with a large mastiff, only half an hour previously, had the misfortune to suffer from this accident. The eye hung completely out upon the cheek merely by the optic nerve, without any injury to the ball, but with great stretching of the different muscles, two of which were torn nearly entirely across. The displacement had evidently been produced by the canine tooth of the mastiff. Without any difficulty I re- placed the eye into its socket, and had the satisfaction to find my patient make a rapid recovery, without the slightest apparent impairment of vision. Although I had expected, in this instance, merely to visit the lady, and not her poodle, I never shall forget the interest which the case afforded me, and with what pleasure I watched its progress. DISEASES OF THE CONJUNCTIVA. ^ Inflammation—The conjunctiva is the seat of various forms of inflamma- tion, known by the generic term ophthalmia, assigned to them long ago by writers on the eye and still generally recognized by authors. There is no class of diseases whose nomenclature has been more uselessly encumbered with unmeaning epithets than this. There is an array here of names well calculated to alarm any one, even the most courageous ; the conjunctivitises are, in fact, almost endless. Thus, we have the simple, the catarrhal, the idiopathic and traumatic, the pustular, aphthous, purulent, gonorrhoea!, granular, strumous, exanthematous, and ever so many besides. If writers can discover any reason for such divisions and subdivisions, it is more than 1 can, and I shall, therefore, not adopt them. 1. Simple Inflammation.—The most simple form of conjunctivitis, as well as the most common and most easily managed, is that which results from the suppression of the cutaneous perspiration, exposure of the eye to intense "gut, the lodgment of a foreign body, disorder of the digestive apparatus, or, 284 DISEASES AND INJURIES OF THE EYE. in short, from any slight, common, and transient cause, whether operating directly upon the eye itself, or indirectly through the general system. The symptoms denotive of the morbid action are abnormal redness of the con- junctiva, pain, lachrymation, and intolerance of light, with a slight discharge of mucus, barely sufficient, perhaps, to glue the lids gently together in the morning or after a few hours' sleep. The vessels, as seen in fig. 140, are small, tortuous, and few in number. There \ is no tumefaction of the lids, no involvement of the cornea, iris, or sclerotica, and no purulent secretion. In a word, the inflammation is of the most simple nature, and, unless neglected or badly managed, generally disappears in from two to three days at farthest, the eye rapidly regain- ing its natural characters and functions. An inflammation like this, however, may, in consequence of mismanagement or a continuance of the operation of the exciting cause, become a much more serious affair, and, in the end, be simple conjunctivitis. productive of extensive structural mischief. The discoloration will then be more diffused, the con- junctiva exhibiting a uniform scarlet or bloodshot appearance ; and there will be excessive lachrymation, great increase of pain, severe intolerance of light, a muco-purulent discharge, more or less profuse and glutinous, and involve- ment of some of the other structures of the eye. The redness of conjunctivitis is peculiar, not only in the milder and more common forms of the disease, but in every other. It is of a scarlet hue, and may occur either in circumscribed spots, or, as is more generally the case, he diffused over the whole anterior surface of the ball, except the cornea, accord- ing to the extent of the inflammation ; very generally it affects also the inner surface of the lids, and it may even be greater there than elsewhere. It is seated exclusively in the conjunctiva and ocular fascia, or in the conjunctiva and the subjacent cellular tissue, and is usually most conspicuous where the membrane is reflected from the lids over the sclerotica. The arrangement of the vessels is also peculiar. They are spread out arborescently, and are per- fectly movable, tortuous, and remarkably distinct, hundreds being visible in every direction, where in the natural state there is hardly one. As the dis- ease augments in intensity, the vessels are, as it were, lost, the inflamed sur- face exhibiting a uniform scarlet appearance. There is a great difference between the redness of conjunctivitis and the discoloration of sclerotitis, and, as the subject is one of much practical im- portance, it cannot receive too much attention. In the former, the color of the inflamed surface is scarlet, especially if the disease has made considerable progress; in the latter, on the contrary, it is pink or lilac, the reddish hue contrasting beautifully with the naturally bluish tint of the fibrous structure; in the one it is superficial and movable, in the other deep and fixed. In con- junctivitis, the vessels are large and raraiform, anastomosing with each other in every conceivable direction; in sclerotitis, they are very small, and dis- posed longitudinally, running from behind forwards in parallel lines towards the cornea, where they form a distinct zone, often extending completely around the eye. In violent conjunctivitis, all trace of vessels is lost; in sclerotitis, on the contrary, they always remain distinct, however severe the attack. A little attention to this subject will soon familiarize the young sur- geon with these characteristics, and enable him without difficulty to form a correct diagnosis between the two affections requiring such opposite modes of treatment. DISEASES OF THE CONJUNCTIVA. 285 The pain in conjunctivitis is seldom severe, except in the more violent forms, when it is often exquisite. In general, there is merely a sense of un- easiness, or a feeling as if there were a particle of foreign substance in the eye; an occurrence due to the distended state of the vessels. The uneasi- ness, pain, or aching, is steady, but liable to vesperal exacerbations and re- missions, and confined mainly to the site of the disease. In sclerotitis, it is severe, deep-seated, paroxysmal, and circumorbital, generally affecting the temple, cheek, and forehead. The lachrymation is often considerable, even in the milder forms of con- junctivitis; the tears are hot and scalding, and often gush out in a full stream the moment the lids are separated. The flow may continue profusely for au indefinite period, but, in general, it lasts only a few days, when it sensibly diminishes, and soon after entirely disappears, especially if there be much muco-purulent secretion, a plentiful discharge of tears and matter seldom co- existing for any length of time. The intolerance of light varies; sometimes it is quite insignificant, at other times excessive. In general, however, it is an important symptom, for there is hardly a case of ophthalmia where there is not more or less of it. In the strumous variety it is characteristic, and is often so excessive as to induce the sufferer to bury his face in the bedclothes, or, if he is a child, in his nurse's lap. Much difference also obtains in regard to the discharge of mucus, pus, or muco-purulent matter. In the more simple cases, there is usually only a slight increase of the natural secretion ; but if the disease is at all severe the discharge will be abundant, thick, glutinous, and of a decidedly muco-puru- lent nature. Indeed, there are certain varieties of ophthalmia which derive their distinctive features from the character of the secretion thrown off by the inflamed surface; as, for example, in purulent and gonorrhceal conjunctivitis. The Meibomian glands, participating in the inflammation, also furnish an abundant secretion, of a peculiarly viscid nature, which, mingling with that derived from the mucous membrane, causes the agglutination of the edges of the lids, so common and so annoying in the more severe forms of conjuncti- vitis. In sclerotitis and corneitis, the discharge of mucus is generally trifling, while a formation of pus is a comparatively rare occurrence. Tumefaction of the conjunctiva is present only in some cases, and is dependent, not upon any marked distension of the membrane itself, but upon the infiltration of the sub- jacent cellular tissue, commonly known at the present day as the ocu- lar fascia, a structure which, I be- lieve, I was the first to describe, in ISo!), and which plays so important a part in all the more violent forms of conjunctivitis. Possessed of great laxity, this texture admits of extraordinary distensiou with serum, or sero-plastic matter, giv- ing rise to the state called chemosis, fig- 141, and which is so frequent a source of sloughing of the cornea. When the tumefaction exists in its Fig. 141. Chemosis, or swelling of the conjunctiva. 286 DISEASES AND INJURIES OF THE EYE. worst degree, it forms a kind of rim around the cornea, often several lines in depth, causing the front of the ball to have a cup-shaped appearance. Much swelling is also frequently present at the inner canthus, and at the point of reflection of the conjunctiva from the lids over the sclerotica. It is worthy of note that this symptom is entirely absent in sclerotitis and corneitis, as well as the more deep-seated inflammations of the eye. Swelling of the lids is rarely present in simple conjunctivitis, or even in many of the more severe cases; in purulent and gonorrhceal ophthalmia, on the contrary, it forms a conspicuous and troublesome symptom, greatly increasing the local suffering, as well as materially interfering with the examination and medication of the eye. In this respect, again, conjunctivitis differs remark- ably and characteristically from sclerotitis and corneitis, in which the lids are either not swollen at all, or only very slightly. 2. Granular Inflammation___The lids are occasionally the seat of a villous condition of the conjunctiva, liable to degenerate into little bodies, which, from their resemblance to the structures observed upon a healing ulcer, are denominated granula- tions, and which are well seen in fig. 142. These bodies, which are nothing but enlarged villi, found in such abundance upon nearly all raucous surfaces, are never present in ordinary conjunctivitis, while they are exceedingly common in certain varieties of that disease, especially such as are attended with purulent discharge, often forming in an almost incredibly short time. They are always most abundant upon the upper lid, where they are frequently extremely large and numerous, giving the mucous surface a rough, mammillated appearance, not unlike that of a strawberry; they are of a deep red color, and usually occur in groups, which are often separated by well-marked fissures. Similar bodies are generally met with on the lachrymal caruncle, though seldom in large numbers. On the lower licl they are always comparatively small, and more straggling than on the upper. In the Southwest, where these granulations are extremely common, I have often seen them form in immense numbers, and of quite a large size, in less than forty-eight hours after the commencement of the inflammation which precedes and accompanies them. In some regions of that country, especially in the Wabash Valley of Indiana, and some parts of Illinois, Kentucky, and Mississippi, the disease is occasionally epidemic. Boatmen on the Ohio, Mississippi, and other rivers are remarkably prone to its attacks. During my residence at Louisville, I treated large numbers of cases of this kind, and other cities, as St. Louis, Memphis, New Orleans, and Chicago, have always had a full share of them. I have found the malady much more common in men than in women, and in young and middle aged subjects, than in children and old persons, and I have often thought that it was, at times, of a mias- matic origin, though I have no proof that this is really the fact. It is, never- theless, true that it is much more frequent in those regions of the Southwest where neuralgia and intermittent fever are most prevalent. Persons who sleep out in the open air, or who travel much at night, are particularly liable to its attacks. The disease is always attended with a profuse discharge of thick, viscid, yellowish pus, and with the other phenomena of the more violent forms of conjunctivitis. From the friction which the granulations constantly exert upon the ball, the cornea soon becomes involved in interstitial deposits, being often rendered thereby completely unfit for the purposes of vision. This Granular lid. DISEASES OF THE CONJUNCTIVA. 287 peculiar state of the lids can be ascertained only by a careful examination of their inner surface, and I would, therefore, advise that they always be thoroughly everted whenever there is the slightest purulent discharge, leading to a suspicion of their existence. I have seen an immense number of cases where total blindness was produced by this disease, without the attending physician having ever inspected the condition of the lids, or known what the nature of the affection really was. Such neglect cannot be too strongly reprobated. 3. Purulent Inflammation.—The purulent ophthalmia of authors derives its characteristic features from the nature of the attendant discharge, which is generally excessively profuse, thick, viscid, and irritating; setting in within a few hours after the attack, and continuing steadily until the disease disap- pears. The affection, from being very common in Egypt, has received the name of Egyptian ophthalmia, althongh it occurs in all parts of the world, particularly in the warmer latitudes, where it is often epidemic. Sporadic cases are constantly met with everywhere. It is most common among the humbler classes, and seems to be caused by atmospheric vicissitudes. The matter which is so profusely secreted is contagious, being capable of com- municating the disease by actual contact or inoculation. The inflammation is of the most vehement character, being accompanied with the most atrocious pain, swelling, discharge, and intoler- ance of light; the lids, as seen in fig. Fig. 143. spreads under circumstances of the atmosphere favorable to its propagation. Of the blacks, 160 in number, among whom it first broke out fifteen days after their departure from the coast of Africa, thirty-nine of those who survived were totally blind, twelve lost each an eye, and fourteen had corneal opacity. Of the crew, consisting of twenty-five persons, only one escaped, and he was attacked soon after he landed at Guadaloupe. It is asserted that 30,000 cases of this disease occurred in the Prussian army, from 1813 to 1821; and the Belgian army, it would seem, has suffered still more extensively. Purulent ophthalmia occasionally occurs in the infant within a few days after birth, in consequence, as has frequently been supposed, of inoculation with gonorrhceal or leucorrhceal matter derived from the mother at the time of birth. That such a thing is possible is unquestionable, for multiplied observation has fully established the fact; but that it is generally, or even frequently the cause of the disease, is certainly not true. Of all the cases that I have seen, and the number has been quite considerable, I have never been able to trace a solitary one to the effects of inoculation of any kind, notwithstanding the most minute and circumstantial inquiry into their history. 288 DISEASES AND INJURIES OF THE EYE. The mothers in all the cases were beyond the reach of suspicion, as it re- spected their chastity, and, as far as could be ascertained, perfectly truthful. My conviction is that the disease, as it usually appears, is of atmospheric origin, depending upon the same causes as the purulent ophthalmia of adults, and that it is, therefore, wholly free from specific poison, although, perhaps, capable of being communicated by inoculation. However this may be, it is characterized by an abundant discharge of a thick, yellowish pus, great red- ness of the conjunctiva, and so much swelling of the lids as to render it ex- tremely difficult, if not impossible, to separate them, so as to get anything like a fair view of the cornea, which is often early involved in the disease. These appearances are well seen in fig. 144. The most healthy children, as Fig. 144. Purulent ophthalmia in newly-born infants. well as the most puny, are subject to this disease, the former, according to my experience, suffering more frequently than the latter; it generally runs a rapid course, and, unless, properly managed, often eventuates in total blindness, especially when, as usually happens, both eyes are affected. 4. Gonorrhceal Ophthalmia.—This disease is produced by the contact of gonorrhceal matter. It is a most virulent form of inflammation, spreading with great rapidity from the conjunc- Fig. 145. State of the lids in gonorrhceal ophthalmia. tiva to the other structures of the eye, which is usually completely destroyed in a few days. Its principal pheno- mena are excessive discoloration, and swelling of the conjunctiva and of the lids, profuse muco-purulent discharge, of a yellowish and very viscid cha- racter, great pain, lachrymation, and intolerance of light, and early opacity of the cornea, which soon dies and sloughs, thus permitting the escape of the humors with the consequent col- lapse of the eye, as in fig. 145. Posi- tive inoculation is necessary to the production of this disease; I have never seen an instance where it showed itself as a secondary affection, and I strongly question the possibility of such an occurrence, notwithstanding the many apparent proofs that have DISEASES OF THE CONJUNCTIVA. 289 been adduced in its support. The disease usually begins in one eye, but in most cases the other becomes also involved from the accidental contact of the matter. There is something very curious about this disease, which has not yet been satisfactorily elucidated. If gonorrhceal ophthalmia is really an entity, why is it that it does not occur more frequently, for there are thousands of per- sons, ignorant and filthy, who, while laboring under specific urethritis, con- stantly carry their fingers, besmeared with matter, to the eye, often rubbing and scratching it, and yet do not contract the disease ? May we infer from this that it is difficult of propagation, or that it can only be produced in this way in some individuals and not in others ? Authors constantly adduce cases in which this variety of ophthalmia is said to have been induced by the con- tact of the patient's urine, employed for bathing the eye, under the popular belief that it is a good and speedy cure for the disease. Now, is this possi- ble ? Does not this admixture of the two fluids effectually destroy the specific poison of gonorrhoea ? Could the matter of smallpox, chancre, and other diseases withstand the neutralizing influence of so acrid and readily- decomposed a fluid as the urine ? These questions afford food for reflection, and should, if possible, be settled before we receive as true all that has been written upon the subject. This is the more necessary, because it is well known that the ordinary, non-specific form of purulent ophthalmia often destroys the eye completely in less than three days after its outbreak. Meantime, the only evidence that the disease is of a gonorrheal nature is derived from its history; that is, we cannot be certain that the affection of the eye is specific, unless we know that the patient is laboring under specific urethritis. Such a diagnosis is, to say the least, not very philosophical, for it may well be asked whether it is not possible for a non-specific but destructive inflamma- tion of the eye to take place during the progress of an ordinary gonorrhoea, and yet be entirely independent of it ? As for myself, I can readily conceive of such an occurrence, although, granting all that might be said respecting it, it would be very natural to view the two affections in the light of cause and effect. As to strumous ophthalmia, the consideration of such a disease would evi- dently be misplaced among the conjunctivitises; it is an affection of the whole eye and of the constitution at large, and must, therefore, be brought in under another head. Treatment.—In the treatment of conjunctivitis, even of the more severe varieties, the practitioner must constantly divest his mind of the idea of specifics; he must recollect that the affected structure is mucous in its cha- racter, and that the disease, except in its milder grades and forms, will speedily extend to the adjoining parts, involving them in mischief, if not in irreparable ruin. His attention must be particularly upon the alert when the inflammation is attended with muco-purulent discharge, great swelling of the lids, chemosis, and atrocious pains; for, under such circumstances, there is great danger of serious involvement of the other tunics of the eye, particu- larly of the cornea, the slightest opacity of which always awakens the most painful apprehensions on the part of the experienced surgeon for the safety of the affected organ. Any such appearance should put us upon our guard respecting the prognosis of the case, while it should induce us to redouble our efforts to arrest the morbid action. An examination of the eye should not be made oftener than is absolutely necessary to observe its condition, but such information should not be neglected on any account, although it may be obliged to be obtained at the expense of considerable suffering. The milder forms of conjunctivitis generally yield to very simple treatment. Confinement in a dark room for a short time, light diet, an active purge, and vol. ii.—19 290 DISEASES AND INJURIES OF THE EYE. tepid, cool, or cold bathing of the eye, with, perhaps, a Dover's powder at bedtime, constitute the most appropriate remedies. When the inflammation is more violent, or disposed to be somewhat obstinate, the list may be in- creased by the addition of the antimonial and saline mixture, with greater restriction of the diet, and the abstraction of blood from the neighborhood of the affected tissues by leeching or cupping. Depletion by the lancet can be required only when the patient is plethoric and the inflammation intense. Under such circumstances the surgeon never hesitates to take blood freely, drawing it from a large orifice in a bold and rapid stream, just as we do in any other inflammation threatening loss of structure and function. Judging from the remarks of some recent ophthalmic writers respecting general bleed- ing in diseases of the eye, one would suppose that they considered this organ as forming a sort of system by itself, not governed by the ordinary laws of the economy. I am certainly not inclined to carry the operation so far as some practitioners, who, according to their own reports, have occasionally reduced their patients to the very verge of the grave by it, draining them to almost complete anemia, or until the countenance was of a deadly, waxen, pallid appearance, and the poor sufferer could hardly raise his head off his pillow. Such a course is quite as censurable as the opposite. One good, thorough bleeding, at the commencement of the disease, while the patient is in the semi-erect posture, will often cut short an attack, which, without such a measure, might eventuate in the destruction of the eye, or, at all events, in great suffering and more or less impairment of sight. The same rules that are applicable to bleeding in other diseases are applicable to this. The robust countryman will bear the loss of blood much better than the man who lives in a crowded city, who is the inmate of an ill-ventilated hospital, or who has spent half his time in intemperance and dissipation. The extremes of life, the state of the system, and the nature of the attack, must all be taken into the account. When general bleeding is contra-indicated, blood may nearly always be taken, with great advantage, by leeching and cupping, prac- tised early and efficiently, but not indiscriminately and causelessly. Among the more important remedies in the different forms of conjunctivitis cathartics hold a prominent rank ; unless there is some positive contra-indi- cation, they should partake somewhat of the drastic character, so that they may produce both a derivative and purgative effect. They should be given early and late in the disease, with proper regard, of course, to the strength of the patient and the state of the intestinal mucous membrane. Among the more appropriate articles are senna and Epsom salts, jalap and cream of tartar, and the compound calomel pill. When decided evidence of gastric disorder exists, the use of the purgative may be preceded by the exhibition of an emetic. Vomiting, however, is only admissible so long as there is no tendency to disorganization of the eye; for when this is present, the concus- sion which it would cause could hardly fail to prove injurious. Nauseants must be used more or less freely in all stages of the inflammation ; either in the form of the antimonial and saline mixture, or in that of a solution of tartar-emetic and morphia; the dose and the frequency of its repetition being regulated by the exigencies of each particular case. Mercury is now rarely given in any form of conjunctivitis, whatever may be its degree or character, experience having shown that it is destitute of controlling power. It is only when there is much disorder of the secretions that it should be thought of in connection with the disease. Anodynes must be given freely, whenever there is much local suffering, or inability to sleep, at every stage of the malady, and in all classes of subjects, unless there are strong and decided contra- indications ; for, besides answering these important purposes, they usually prove of immense benefit in affording quietude to the affected organ, an object of such great consequence in the treatment of inflammation generally. Ele- DISEASES OF THE CONJUNCTIVA. 291 vation of the head and exclusion of the light will, of course, receive due attention. Locally, none but the mildest remedies should be employed. - It is a great mistake, yet one which is constantly committed even by men otherwise ex- perienced, to use strong applications to the eye in every form and stage.of the inflammation. Nothing can be more erroneous and unscientific, and, consequently, more prejudicial to the parts, than such a procedure. How often have I seen the simplest conjunctivitis, which in a few days might have disappeared spontaneously, converted into a most violent, obstinate, and pro- tracted disease by the untimely use of a collyrium ! If a collyrium be admis- sible at all, it is only, as a general rule, after the morbid action has been, in some degree, subjugated by other means, when it has assumed a subacute character, or when it is about to become chronic ; in ordinary cases, I gene- rally dispense with such applications altogether. When the symptoms are very urgent and threatening, I sometimes depart from this rule, but even then usually not without regret. In the purulent and gonorrhceal varieties of the affection, most ophthalmic surgeons urge the employment of strong collyria, even at an early stage of the attack, on the ground, as it is alleged, of their beneficial effects in controlling inflammation. I have used them myself in such cases, but seldom without doubt and misgiving, if not the positive con- viction of their injurious effects. I feel as if I could hardly inveigh too forcibly against this practice, knowing, from sad experience, what an immense amount of mischief it has done and is still doing. The most valuable articles of this class of remedies are the different pre- parations of lead and zinc, wine of opium, and the nitrate of silver, the latter of which is at once the most potent and the most abused. The lead or zinc may each be used in the form of solution, in the proportion of one, two, or three grains of the salt to the ounce of distilled water, a few drops being poured upon the inflamed surface once or twice in the twenty-four hours. If the application smart beyond a few minutes, it must be weakened, or em- * ployed less frequently. The best preparation of opium is Sydenham's lauda- num—the wine of opium of the shops—diluted with three or four parts of water, or dropped upon the eye in a pure state. The strength of the nitrate of silver should vary from the eighth of a grain to two grains for the more ordinary cases, while in the more violent it may range from five to sixty. When the solution is very strong, it should be applied by means of a camel- hair pencil, the inflamed surface having been previously dried with a soft linen rag. When the lids also suffer, the best plan is to touch them and not the ball, their return to their natural position serving to diffuse the caustic over the whole of the diseased structure. Whatever collyrium be used, its effects must be carefully watched, and whenever they are found to flag, ano- ther must take its place. The solid nitrate of silver ought never to be used about the eye. In the more severe cases of conjunctivitis, the patient will derive great comfort from poppy fomentations, cloths wrung out of warm water and opium, and the application of medicated steam, directed upon the eye by means of an inverted funnel. Sometimes a light poultice is very soothing, especially when the surface is wet with laudanum, or laudanum and acetate of lead. In purulent, gonorrhceal, and other forms of ophthalmia, attended with unusual swelling and a rapid extension of the morbid action, the most appro- priate measures are, free incision of the outer surface of the lids, extensive scarification of the chemosed conjunctiva, and the injection of the eye, every half hour, with a solution of opium and bichloride of mercury, in the proportion of two grains of the former and one-eighth of a grain of the latter to the ounce of tepid water. If the discharge of pus is very profuse, the inner surface 01 the lower lid may be pencilled over twice a day with a strong solution of 292 DISEASES AND INJURIES OF THE EYE. nitrate of silver, as above directed. The bichloride of mercury is a remedy of great potency in all cases attended with copious puriform deposit. When the lids are enormously swollen I have found great benefit from the applica- tion to them of a large blister, the surface being well protected with gauze, to prevent the fly from falling into the eye. The use of the syringe I regard as of paramount importance in these cases, as it is the only means by which we can obtain clearance of the irritating matter, and effectually medicate the inflamed surface. If these measures, aided by the constitutional remedies previously referred to, cannot save the cornea and the deep structures of the eye, I confess myself unable to point out any other likely to bis of service. In the purulent ophthalmia of infancy, I have usually effected excellent, and even rapid, cures, by the injection every few hours of tepid water, or milk and water, followed immediately after by a solution of bichloride of mercury, from the eighth to the twelfth of a grain to the ounce of water, and the con- stant application of a light elm poultice, medicated with acetate of lead, and frequently renewed. Internally, we may give, every eight hours, a minute quantity of Dover's powder, with the twelfth of a grain of calomel, or the same quantity of calomel and ipecacuanha, to act upon the skin, to allay pain, and to quiet the diseased structures. The bichloride of mercury is, of all the local remedies that I have ever tried in this affection, the most effica- cious in its action, making generally a most rapid and decided impression upon the discharge. Yery weak solutions of lead, zinc, and alum are also advantageous, but altogether inferior to the bichloride. One of the great points in the treatment of this and other forms of purulent ophthalmia, is to get rid of the acrid secretions, which, if allowed to remain, always act as local irritants. As to leeches and counter-irritation, I never employ them in this disease as it occurs in infancy. If the child is feeble, a minute quantity of quinine is given three or four times a day, and in all cases proper care is taken that it obtain a sufficiency of good nourishment from the mother. As the disease improves, exercise in the open air is enjoined. It is often very difficult to obtain a satisfactory view of the condition of the eye in this affection, owing, as before stated, to the excessive tumefaction of the lids. The proper way to accomplish this object is to place the child's head between the knees, and then to draw the lids gently apart with the index fingers, no attempt being made at eversion, which, under such circumstances, is quite impossible. The eye should always be well syringed a moment before the examination, to prevent the matter from obscuring the ball. In regard to granular conjunctivitis, the practice of ophthalmic surgeons has hitherto been eminently uncertain, if not empirical. Without detailing what others have said upon the subject, I shall content myself with giving an outline of the treatment which I have myself usually found most efficacious, premising that I have seen many hundred cases of the disease, in all its gra- dations, from the mildest to the severest, from the most transient to the most protracted and rebellious. The first thing that should claim our attention is the state of the general health, which.is often seriously deranged, in consequence of the joint agency of disease, confinement, and ill-treatment. Purgatives are generally indicated, and often afford immense relief; the diet must be carefully regulated; exercise must be interdicted; and, if there be much pain, interfering with sleep, a full anodyne must be administered at night, either by itself or along with a dia- phoretic, or a drachm of the wine of colchicum, the latter being particularly serviceable when the pain is of a rheumatic character, or diffused over the side of the head. If the patient is plethoric, the antimonial and saline mix- ture must be given three or four times a day, along with a small quantity of morphia in each dose. When the cutaneous surface is at fault, Dover's DISEASES OF THE CONJUNCTIVA. 293 powder is an excellent remedy, given every night towards bedtime in doses of fifteen or twenty grains, and, under similar-circumstances, a tepid salt bath is sometimes useful. The bowels must be moved by medicine regularly every fourth day, for I consider systematic and thorough purgation as of paramouut importance; and the diet must be light and farinaceous,.without being too nutritious. The only form of counter-irritation which I have of late years employed is the seton, introduced into the corresponding arm, or into both limbs, if the disease involve both eyes. Dr. C. S. Fenner, of Memphis, has used, with great advantage, in this complaint, a strong decoction of phytolacca, given in wineglassful doses every two or three hours until it causes pretty active purgation, when it is adminis- tered in smaller quantity or at longer intervals. It is considered particularly valuable in the rheumatic form of the malady, attended with severe pain in and around the eye. If the granulations are very large and exuberant, I shave them off with a sharp scalpel close down*to the conjunctiva, without including this membrane in the operation; and, having encouraged the flow of blood as long as possi- ble with a sponge and tepid water, I immediately cauterize the raw surface with a stick of sulphate of copper, expressly prepared for the purpose. The part, being again exposed to a stream of water, to get rid of the redundant salt, is permitted to resume its natural position; the patient being directed to bathe* the eye frequently for the next two days, and to anoint the edges of the lids at night with a little thick cream or fresh lard. If, on the other hand, the granulations are comparatively insignificant, I dispense with the use of the knife, and resort at once to the application of the copper. This should be repeated every third or fourth day, care being taken always to dry the surface previously with a soft rag, and to wash off the redundant salt. The copper is never applied directly to the ball or lower lid, as that on the upper lid soon diffuses itself over the whole of the inflamed surface. In the intervals of the.cauterization, the eye is bathed, more or less frequently, with cool, tepid, or cold water, simple, mucilaginous, or slightly astringent, as may be most agreeable to the part and system, or favorable to the reduction of the morbid action. Instead of the copper, I sometimes use a strong solution of nitrate of silver, twenty, thirty, or even sixty grains to the ounce of water, applied very care- fully by means of a camel-hair pencil to the inner surface of the upper lid, also previously everted and dried. The two remedies may occasionally be advantageously alternated. Pencilling the granular surface with Goulard's extract is now and then followed by speedy amendment; but, on the whole, it is inferior to the copper and nitrate of silver. The great objection to this article, and also to the ordinary solutions of lead, is their liability to incrust the cornea, and thus produce mechanical obstruction. When the reproductive tendency of the granulations is very great, I have found marked benefit from frequent scarification of the lid, and the occasional application of two or three leeches to the neighborhood of the outer canthus. I know that the former of these remedies has met with much opposition, but I can attest its beneficial effects from ample experience. When the general health is enfeebled, a tonic course of treatment will be required, and this will be the case with a majority of the patients whom we are obliged to attend in our larger cities, and in the wards of the more crowded hospitals. Under such circumstances signal benefit will accrue from the use of quinine and iron, iron and extract of bark, cod-liver oil, and similar arti- cles, with a nutritious diet, exercise in the open air, and attention to the skin. Whatever means be adopted, steady perseverance, both on the part of the patient and his surgeon, will be indispensable to a final and permanent cure. 294 DISEASES AND INJURIES OF THE EYE. All indiscretions must be avoided, for there is no disease more liable to relapse than granular conjunctivitis. The corneal opacity, which is so common an attendant upon this disease, unless very great, usually disappears as the lids regain their normal condition. Should it be slow in going away, the cure may be expedited by the daily application to the edge of the lower lid of a little very dilute ointment of the oxide of zinc, nitrate of silver, or red oxide of mercury. The same means will also be useful in effecting the removal of the granulations. Finally, in concluding my remarks upon the treatment of conjunctival ophthalmia, I feel it my duty to impress upon the mind of the practitioner the indispensable necessity, in every case attended with muco-purulent dis- charge, of isolation of the patient as far as the use of his bed, towel, and basin is concerned ; for, although it would be absurd to say that every discharge of "the kind is contagious, yet we cannot observe too much circumspection in regard to those whose duty compels them to be constantly in contact with the subjects of these maladies. If we must err, it is certainly best to err upon the side of safety. Pterygium.—Pterygium is a membranous growth of the conjunctiva, or, more properly speaking, a hypertrophous state of the conjunctiva, generally remarkably vascular, several shades darker than the surrounding surface, and of a triangular shape, the apex corresponding to the cornea, and the base to the outer canthus, as shown in fig. 146. It is commonly situated dpon the nasal aspect of the eye, but it may occur upon the temporal side, or even in the perpendicular diameter of the organ. Only one such growth is ordinarily met with ; in some cases two are observed, as in fig. 147, and instances have Fig. 146. Fig. 147. Pterygium. Double pterygium. been recorded where there were as many as three, and even four, although such a phenomenon is extremely rare. Sometimes, also, the pterygium, instead of being horizontal or perpendicular, is more or less oblique, and deviates remarkably from the triangular form. % The starting point of a pterygium is generally a short distance from the cornea, presenting itself in the form of a little elevation, of a vascular and somewhat yellowish appearance, which, gradually assuming a membranous form, extends, on the one hand, outwards towards the canthus of the eye, and, on the other, inwards towards the cornea, upon which it always encroaches to a greater or less extent, rarely, however, in any case, passing beyond the ' middle line. When it is developed upon the nasal side of the eye, it gene- rally, in its progress, involves the semilunar valve, and hence it has sometimes been supposed, though erroneously, to originate in that structure. The causes which give rise to pterygium are generally such as produce chronic DISEASES OF THE CONJUNCTIVA. 295 inflammation, but in many of the cases which have fallen under my observation it came on spontaneously, without any antecedent or accompanying disease of this kind. Pterygiums vary much in their structure; some are quite thin, as if they consisted merely of an additional la^er of conjunctiva; others, on the con- trary, are very thick, and of a tough, fibrous consistence. Numerous vessels, generally arranged in a straggling manner, and occasionally little granules of fat, usually exist in them ; but in cases of long-standing they are often very white, and non-vascular. That they consist mainly in a hypertrophous condition of the conjunctiva, is shown by the fact that the morbid growth is inseparably incorporated with that membrane, that it always lies loosely upon the sclerotica, and that it follows the conjunctiva in its reflection over the cornea, where its attachment is always extremely close and firm. The principal inconvenience of a pterygium is of a mechanical character, interfering somewhat with the movements of the eye. It is seldom productive of pain, but the subjects of it are more prone to inflammation than common persons. Vision is not materially impaired, except when the membrane en- croaches considerably upon the cornea. The affection is much more common in elderly subjects than in-young, and in men than in women. Nothing is to be expected from local applications in pterygium, even in its earlier stages; I would, therefore, strongly advise against any measures of this kind, nor would I recommend interference so long as the eye is compara- tively comfortable, and vision is not materially impaired; the disease is attended with no danger to the eye, and unless the patient is very particular about his appearance, he may as well put up with his inconvenience, for it really seldom amounts to anything more. Should an operation be demanded, it is easily executed by seizing the pterygium at its middle with a pair of forceps, and, drawing it away from the globe, shaving it off with a narrow scalpel. Special care is taken to dissect away its corneal attachments, which, as already stated, are always very firm. Some surgeons prefer making the excision with the scissors, but I am satis- fied that the operation can be performed much more effectually, though per- haps not so rapidly, with the knife. As soon as the morbid growth has been removed, a piece of sulphate of copper should be gently applied to the wound, especially to its corneal portion, in order to prevent a recurrence of the disease, to which there is generally, especially in elderly subjects, a re- markable proclivity. The application is afterwards repeated every fourth or fifth day, until it is found that all repullulating tendency has ceased. A few leeches, applied near the canthus of the eye, will sometimes greatly accelerate the cure. Xeromd.—The word xeroma is employed to denote a remarkable dryness of the conjunctiva, chronic in its character, and associated with more or less thickening and induration of the membrane, which looks more like skin than mucous tissue. The best idea that I can give of -the diseased structure is, that it resembles the eyelid of the land frog, and similar reptiles. The morbid change is usually universal, affecting the entire conjunctiva, although it is commonly most distinctly marked in the ocular portion. In two of the three cases that have fallen under my observation, it was also very conspicuous in the epithelial lining of the cornea, which was singularly dry, slightly opaque, and studded with little grayish points, not larger than a clover seed. Of the origin and nature of xeroma we have no definite information. It has gene- rally been ascribed to the effects of inflammation, but if this disease is capable of producing it, why does it not more frequently follow in its wake ? Xeroma is extremely rare, while eonjunctivitis is one of the most common of maladies. Again, it has been supposed to be caused by deficient lachrymal secretion; but such a state has been assumed rather than established by direct observa- 206 DISEASES AND INJURIES OF THE EYE. tion, and in a number of the reported cases of the disease it has been most satisfactorily demonstrated that the functions of the lachrymal gland were not materially, if at all, impaired. Nor can the affection be justly ascribed to a want of the proper secretion of the conjunctiva, seeing that the suppression of this secretion is a consequence, and not a cause of the morbid change. Xeroma is usually confined to one eye, the sight of which is necessarily more or less impaired, if not wholly destroyed. The three cases, which I have had occasion to observe, all occurred in old subjects; they had been in progress for many years, were attended with nearly total blindness, and came on without any assignable cause. A stiff, dry feeling of the eye, with some impediment of motion, was the chief inconvenience under which the patients labored. Xeroma is an incurable affection. Temporary improvement sometimes follows the use of mildly stimulating unguents; but beyond this, nothing is to be hoped for from local applications. In cases of recent standing, it might be justifiable to try the effects of excision of the diseased membrane, removing it in large sections at three or four sittings, at intervals of so many weeks. Such a procedure might, unless the regenerative tendency is very great, be perfectly successful. Encanthis.—The lachrymal caruncle and the fold of the conjunctiva, called the semilunar valve, are liable to hypertrophy, known under the name of encanthis, represented in fig. 148. The enlarge- F,£- 148- ment, which occasionally attains a considerable bulk, extends along the inner margin of the lids, impedes the movements of the eye, and keeps up more or less irritatiou, with discharge. The tumor is often connected with obstruction of the lachry- mal passages, and generally has an angry, reddish appearance. The proper remedies are leeching, scarification, and the application of nitrate of sil- ver, with attention to the general health, which is frequently involved in the causation of the disease. A malignant tumor, of a mixed scirrhous and encephaloid character, some- times springs from these structures; it is of a livid or purple hue, rough, knotty, or tuberculated on the surface, hard to the touch, aud rapid in its growth, often attaining a considerable bulk in a few months. Its tendency is to progress, ulcerate, fungate, and finally to destroy life. Early and tho- rough excision affords the only chance of relief, which, however, is always very remote and unsatisfactory. Diseases of the Submucous Cellular Tissue.—The only affections of the sub- conjunctival cellular tissue requiring notice, are, hemorrhagic effusions, oedema, fatty deposits, and the little parasite, called the cellular cysticerce. Blood may be effused into the sub-conjunctival cellular tissue by accident, as a blow, or spontaneously, without any apparent cause, mental or physical. Of the latter variety I have seen a number of instances, chiefly in young persons, who were otherwise in the most perfect health. The occurrence is unattended with pain, and the extravasated blood is either limited to one or two small points, or extensively diffused over the anterior part of the eyeball. The resulting redness is altogether different from that of inflammation, and cannot be mistaken by any one at all familiar with ophthalmic affections. Very little is necessary in the way of treatment; indeed, the fluid usually rapidly disappears of its own accord. When the patient is very solicitous about himself, the discussion may be promoted by the use of astringent lotions, or a poultice composed of equal parts of the scraped root of the black bryony and the crumbs of bread, renewed from four to six times in the twenty- four hours. DISEASES AND INJURIES OF THE CORNEA. 297 (Edema of the areolar tissue beneath the conjunctiva is of two kinds, the passive and active. The first is the result of a slow effusion of serum, in con- sequence usually of a retarded state of the venous circulation, of which the exciting cause is compression by some tumor, abscess, or other obstruction; the conjunctiva is elevated in the form of a small bladder, of a white, almost shining appearance, soft and inelastic, and perfectly free from pain. The active variety, usually known under the name of chemosis, is a much more serious disease; it has already been described in connection with purulent ophthalmia, with which it so often co-exists, and of which it forms one of the" most dangerous complications, from its tendency to induce gangrene of the cornea. It is always produced under the influence of inflammation, and is frequently of a sero-fibrinous character, instead of being purely serous a,s in the passive form. When it exists in its highest grade, the swelling forms a ring around the cornea, often a few lines deep, by which this membrane is sometimes nearly buried. The proper remedy, as before remarked, is free scarification, to afford vent to the effused fluids, followed by the application of a weak solution of nitrate of silver. Nothing short of this will be likely to save the cornea. A little fatty tumor occasionally forms beneath the conjunctiva, from the size of a currant to that of a pea, irregujarly rounded, movable, and of a pale yellowish color. It generally receives a few straggling vessels, grows slowly, and is surrounded by a thin layer of condensed cellular tissue. The proper remedy is excision. A species of hydatid, the cellular cysticerce, has been met with in this situa- tion ; the containing vesicle is about the size of a pea, and looks like a little bladder filled with water. Under the microscope, the parasite is seen to have its mouth encircled by distinct hooklets. It is sometimes developed at a very early age. The only remedy is extirpation. DISEASES AND INJURIES OF THE CORNEA. The most common affections of the cornea are inflammation, abscess, gan- grene, ulceration, opacity, change of form, technically termed staphyloma, and fatty degeneration. Foreign bodies are also liable to enter it. 1. Wounds.—Wounds of the cornea may be the result of accident or de- sign, and are either incised, punctured, lacerated, or gunshot, according to the kind of weapon with which they are inflicted. Incised wounds are gene- rally caused by penknives and similar instruments; punctured wounds, by needles, pins, thorns, and splinters of wood ; lacerated wounds, by percussion- caps, pieces of glass, particles of iron, and fragments of stone; and gunshot wounds by small shot discharged in hunting birds. Sometimes the cornea is ruptured by a severe blow or fall upon the eye. However induced, the injury is always attended with an escape of at least the aqueous humor, if not also of the lens and the vitreous humor, thus greatly complicating the case, and often permanently injuring vision. Another accident, also frequently of a very serious nature, is prolapse of the iris, varying in extent, according to the size of the wound, from the smallest pin-head to nearly the whole mem- brane. Finally, another source ofcomplication is the penetration of the vul- nerating body into the interior of the eye, and its retention in the humors or tunics of the organ. Unless the lesion is considerable, there is seldom much hemorrhage; nor is the pain generally so great as we might suppose from the delicate structure of the cornea. W ouuds of the cornea, even when of considerable size, may easily be over- ooked, especially when there is no separation of their edges, because of the lability of the membrane to preserve its normal appearance. In general, however, there is no difficulty in arriving at a knowledge of the nature of the 298 DISEASES AND INJURIES OF THE EYE. case by standing behind the patient and looking at the cornea, as the eye, turned towards the light, is moved about in different directions, the lids being at the time held carefully out of the way. In addition to this, the iris often presents a peculiarly collapsed appearance, contrasting strikingly with that which it exhibits in the normal state. Little superficial abrasions, resembling the merest possible scratches of the skin, are now and then found upon the cornea, as the result of external vio- Jence; they involve simply the epithelial covering of the membrane, and are distinguished by the exquisite pain which attends them, which is often much greater than when the wound is deep and extensive. The first indication, in wounds of the cornea, is to clear away foreign mat- ter,.and to replace the.prolapsed iris or other internal structures ; the second, to control the movements of the organ, and to moderate the resulting inflam- mation. If the vulneratingbody is imbedded in the substance of the cornea, it should be carefully withdrawn with the forceps; if it has passed beyond, into the interior of the eye, and is accessible, it may, perhaps, be extracted in a similar manner; at any rate, an attempt should be made to seize and dislodge it, lest, if permitted to remain, it may not only produce destructive inflammation, but become a source of the most horrible suffering, for which it may be neces- sary, at a subsequent period, to evacuate the humors of the organ. Replacement of the iris is best effected with a delicate probe, the patient, especially if a child, being under the influence of chloroform. Unless this be the case, it will often be extremely difficult to succeed in our efforts. The surgeon, availing himself of the#temporary calm, restores the prolapsed mem- brane, and carefully adjusts the edges of the wound, which generally unites by the first intention, leaving little, if any, defect in vision. If the lens be- comes opaque, in consequence of involvement in the lesion, the case is after- wards treated as one of ordinary cataract. The second indication is fulfilled by strapping the lids of both eyes, keep- ing the patient in a dark room, and employing the antiphlogistic regimen. A full anodyne is administered immediately after the accident. The patient must be closely w-atched, and if he be plethoric, we should not hesitate to re- move blood by the lancet and by leeches. Care must be taken, however, not to carry the depletion too far, otherwise we may seriously interfere with the reparative process. 2. Inflammation.—Corneitis, delineated in fig. 149, is characterized by a hazy state of the affected surface, and a zone-like appearance of the vessels at the periphery of the cornea, which is often quite Fig. 149. vascular for the distance of nearly a line be- yond this point. The vessels are greatly engorged, yet so extremely delicate as to render it difficult to distinguish them.well without the aid of a magnifying glass. The conjunctiva, iris, and sclerotica usually par- ticipate in the morbid action, and hence the case is apt to exhibit the characters common to inflammation of all these structures. The opacity of the cornea begins at an early period of the disease,#and sometimes extends over the whole surface of the membrane, Corneitis although, in general, it is more distinctly marked at some points than at others. Its immediate cause, of course, is an interstitial deposit of plasma. The pain of corneitis is severe, and is seldom limited to the inflamed mem- brane, but extends to the other structures of the eye, the orbit, temple, cheek, DISEASES AND INJURIES OF THE CORNEA. 299 and forehead. Hemicrania is often a marked symptom. The eye is exceed- ingly intolerant of light, and there is abundant lachrymation, although but little secretion of#mucus, or deposit of muco-purulent matter. . When the inflammation is unusually violent, there may be constitutional involvement, as indicated by fever and other disorders ; but in most cases, there is an absence of general derangement. The characteristic phenomena are the opacity of the membrane, and the zonular arrangement of the vessels at its circumfer- ence. In iritis, the vascular zone does not extend* quite so far forward ; hence there is always a narrow ring of comparatively healthy sclerotica be- tween it and the cornea. The causes of corneitis are various, and often difficult of recognition ; in most of the cases, however; that fall under the observation of the American practitioner, the disease is induced by external injury, or by a scrofulous taint of the system. The eruptive fevers, as measles, scarlatina, and smallpox, are frequently followed by a bad form of corneitis. In rheumatic and syphilitic sclerotitis, the cornea is very apt to participate in the morbid action. Corneitis may terminate in resojution, the haziness and vascularity of the affected tissues gradually disappearing ; or it may pass into the chronic state; or, finally, it may lead to suppuration, ulceration, or gangrene. In the treatment of corneitis, care must be taken not to carry our antiphlo- gistic measures too far, as we should be likely to do, if we were to adopt, without reserve, the injunctions of some ophthalmic writers. Unless the action is extremely violent, we shall rarely have occasion for the use of the lancet, or even the application of leeches, the disease generally yielding, in due time, to gentle, but steady, purgation, abstinence, the antimonial and saline mixture, and the exclusion of light. The eye is kept in a state of quietude by anodynes, given either in small and repeated doses, or, what I prefer, in one full dose, once or twice in the twenty-four hours. When the disease is of a strumous nature, the best remedy, according to my experience, is quinine, along with a minute quantity of antimony and opium, steadily persevered in for many weeks. Where there is an anemic condition of the system, the quinine and other articles here .mentioned may be advantageously combined with some preparation of iron, as the iodide, sulphate, or precipitated carbonate. Should the inflammation be plainly of a rheumatic origin, colchicum will be indicated, used in the manner detailed under the head of sclerotitis. The syphilitic form of the disease is to be treated with mercury and opium, either alone, or in combination with iodide of potassium. Inflammation of the cornea dependent upon measles, scarlet fever, and smallpox, must be treated with mild means, as poppy fomentations, tonics, especially quinine, anodynes, and a supporting diet. Active treatment is out of the question. When corneitis, however induced, becomes chronic and rebellious, benefit will accrue from change of air, tepid bathing with salt water, tonics, and gentle, but steady, counter-irritation. 3. Abscess.—Abscess of the cornea is an occasional consequence of acute inflammation, especially of the traumatic and variolous forms; it is also met with, but much less frequently, in the strumous variety of the disease. The matter may be situated immediately beneath the epithelial covering of the cornea, but more commonly it is found in its substance, nearly equidistant from its two surfaces, not in a distinct, circumscribed cavity, as the term abscess would imply, but as an infiltration among the softened and disorga- nized fibres of the membrane. The matter, which is of a yellowish hue, is not true pus, but a mixture of pus and lymph, and hence it is always remarkably tough and viscid. The suppurative process is generally limited to a particu- 300 DISEASES AND INJURIES OF THE EYE. lar portion of the cornea, usually the central or inferior, but we now and then meet with cases where it is spread over its whole surface. The formation of matter is denoted by a yellowish appearance of the cornea, and by a marked aggravation of all the local symptoms. As the fluid accu- mulates, the cornea becomes more prominent, and finally yields at the most diseased part, followed by an imperfect escape of its contents. It is not always, however, or perhaps even generally, that the abscess points externally; on the contrary, it freqaently bursts its posterior wall, and discharges itself into the aqueous humor. Suppuration of the cornea, unless extremely slight, is one of those unto- ward circumstances, the effects of which are never entirely recovered from; indeed, when the quantity of matter is considerable, the resulting opacity generally eventuates in total blindness. Hence, the practitioner should spare no pains to prevent its occurrence. The moment he finds that it is likely to take place, he should redouble his efforts to bring about resolution; he must be cautious, however, that he does not carry his antiphlogistic measures too far, otherwise he will be sure to accelerate the crisis instead of successfully counteracting it. If the patient be plethoric, additional depletion may be called for and well borne ; but the reverse may be the case; he may be pale and exhausted from suffering and previous treatment, and then stimulants and tonics, with nutritious food and drink, may be proper. Much judgment will, therefore, be required to enable us to steer a correct course ; one calculated to save structure and function. In regard to mercury, so frequently recom- mended in this affection, I believe that it will generally be found to be pre- judicial, and it would probably be well if its use were dispensed with altogether. Locally, none but.the blandest remedies should be employed. Puncture of the abscess may be had recourse to in the event of the matter being concen- trated, to afford an opportunity for gradual drainage; but under opposite circumstances it will be well to let it alone, trusting to the operations of nature. When the abscess bursts both externally and internally, there will be a gradual collapse of the anterior chamber; the iris will fall forwards against the cornea, and vision will be irretrievably destroyed. 4. Gangrene—Gangrene of the cornea is a frequent occurrence. It is most common in persons of a delicate, feeble constitution, after the operations for cataract, and the more severe forms of ophthalmia, especially those conse- quent upon smallpox and the contact of specific matter. It is often produced by escharotic substances. Chemosis, a disease previously described, is very liable to produce gangrene of this structure, unless the greatest care is taken in its treatment to prevent the strangulation of the vessels of the cornea. "When this event is about to take place, there is a great and rapid increase of opacity, and the membrane soon assumes a sodden, macerated, and corru- gated appearance. The local symptoms suddenly increase, but as the gan- grene spreads the pain usually very sensibly diminishes in intensity. A de- posit of pus often precedes the occurrence of gangrene. When gangrene is threatened, all depletory measures must, as a general rule, be at once dismissed, and the patient put upon tonics and stimulants, with a good nutritious diet, aided, if he be at all enfeebled, by milk punch and other suitable means. The cornea is touched every six or eight hours with a weak solution of nitrate of silver, consisting of about two grains to the ounce of water, and the system is kept under the full influence of opiates, both to insure quietude to the eye and to promote sleep. If mercury have been previously used, it is immediately discontinued, as it cannot fail, if per- sisted in, to do serious harm, by still further depressing the part and system. 5. Ulceration.—Ulceration of the cornea, exhibited in fig. 150, is a very common event of inflammation, both of the traumatic and specific kind. We DISEASES AND INJURIES OF THE CORNEA. 301 frequently see it as a consequence of the lodgment Fig. 150. of a foreign body, and also as a sequel of strumous, variolous, morbillous, and other forms of ophthal- mia. The peculiarity of its structure, indeed, ren- ders this membrane quite prone to this species of morbid action; it bears a very close resemblance to articular cartilage, and the slightest causes are sometimes found to lead to its erosion. Disease of the fifth pair of nerves is a source of ulceration of Ulceration of the cornea. the cornea. It is probable that the protracted use of unwholesome food, especially of articles deficient in azotized matter, may induce the affection by producing an impoverished state of the blood ; a con- , dition of the system ill calculated to resist the effects of inflammation. Once set up, it is often difficult to arrest its progress, and to prevent the formation of disfiguring and injurious cicatrices. The disease may occur at any period of life, and under almost every possible variety of circumstance as to consti- tution and health, but is most common in young subjects of a feeble, delicate organization. Ulcers of the cornea present themselves in every possible form and size, so much so as to render it very difficult to furnish an accurate description of them. The most common variety, perhaps, is the dimple-shaped erosion, in which the part has an excavated appearance, as if a solid portion of the cornea, comprising several of its layers, had been scooped out. In another series of cases the ulcer looks like a superficial abrasion, involving merely the epithelial investment of the cornea. In the third place, the ulcer may be almost perfectly circular, and not larger, perhaps, than the diameter of a pin; this form of erosion is by no means infrequent, and is the more interesting because of its proneness to lead to perforation. Whatever form a corneal ulcer may assume, its edges are generally somewhat everted, and more or less irregular, if not ragged, as may easily be seen by a careful inspection with the aid of a glass. It is seldom that we find them inverted or undermined ; cases occur in which they are very steep and abrupt, as if a piece had been cut out of the cornea with a punch. In general they have a slight hazy appearance, especially when cicatrization is about to begin, or has already made some progress. The bottom of the ulcer is either natural, or it is of a pale ash hue, and more or less irregular. In regard to size, ulcers of the cornea vary from that of a clover seed to that of a split pea. Ulcers of the cornea are generally attended with considerable pain, lachry- mation, and intolerance of light, along with more or less vascularity of the diseased structures. If their progress be not early checked, they may extend in depth until they cause perforation of the membrane, followed by an escape of the aqueous humor and prolapse of the iris. Another bad effect to which they are apt to lead is incurable opacity, a natural result of the reparative process, especially when the erosion is of any depth or extent. Unless great care be exercised, an ulcer, even of considerable size, may exist upon the cornea, and yet entirely escape detection. To conduct the examination in a proper manner, the surgeon should stand behind the patient, who sits with his face fronting the window. The eye being now depressed, while the lids are held out of the way, the light will fall in a full stream upon the cornea, and thus disclose any breach that*may exist upon its surface. The treatment of ulceration of the cornea requires more judgment than practitioners are usually aware of; perhaps I ought to say than they usually possess. Under an idea that the disease is generally one of over-action, the plan commonly pursued is to deplete the patient, if not by the lancet, at least by leeching and purgation, to a point beyond what is proper for the restora- tive process. The consequence too often is that the disease is aggravated 302 DISEASES AND INJURIES OF THE EYE. instead of being relieved. Experience has shown me that, in nearly every instance, the affected part will be immensely benefited by an invigorating plan of treatment, consisting in the liberal use of quinine, or quinine and iron, along with a nutritious diet, and a full anodyne at least once in the twenty-four hours, especially if there be much pain. When the system is plethoric, and when there is an unusual degree of vascularity of the cornea and other structures, a few leeches occasionally to the neighborhood of the outer canthus, and the steady, but moderate, use of the antimonial and saline mixture, with a grain or a grain and a half of quinine to every dose, will go far in putting a speedy stop to the disease. As it respects direct applications, the fewer we make, as a general rule, the better. Under the means just pointed out, the reparative process usually proceeds very kindly, and, unless the breach is uncommonly large, little or no opacity may be expected. It is only, or, at least, principally, when there is a disposition in the ulcer to extend, as when it has a foul, unhealthy aspect, that local remedies are at all called for, and then great care should be taken that they are as mild and soothing as possible. Of these, the most eligible is a solution of nitrate of silver, in the proportion of from two to ten grains to the ounce of water, applied directly to the sore by means of a very small camel-hair pencil once a day, or every other day, according to the exigencies of each particular case. A very dilute ointment of the oxide of zinc, or oxide of mercury, also answers a good purpose, but is, on the whole, inferior to the caustic. When the ulcer is of an unhealthy, phagedenic, or sloughing character, its surface may be touched with a stronger solution of nitrate of silver, or this article may be applied very gently in substance, shaped to a very minute point. 6. Opacity.—Opacity of the cornea exists in various forms and degrees, from the smallest visible speck to a patch large enough to cover its entire surface. A hazy appearance of the membrane is present in almost all cases of corneitis, however slight. .The more marked and concentrated forms of opacity are generally the result of the cicatrization of deep ulcers and badly healed wounds. When the opacity is slight, it is usually designated by the term nebula, literally'signifying a cloudy condition of the part; the hard, white, milky, concentrated spot, on the contrary, is known by the name of albugo, represented in fig. 151. As meaning the same thing, the word leucoma is •sometimes employed. The distinc- tion between nebula and albugo has a real prac- tical significance ; the former often disappearing spontaneously, or under very simple measures, whereas the latter seldom wholly subsides, what- ever treatment may be adopted for the purpose. Nebula, as it usually presents itself, is situated either in the epithelial investment of the cornea, or immediately beneath it, in the superficial layer of this membrane, and often occupies a large extent of surface; in some cases it is seated more deeply, and instances occur, although they are rare, in which it is seated between the membrane of Demours and the posterior lamella of the cornea. Albugo, which fre- quently embraces the entire thickness of the cornea, is generally very hard and dense, white, milky, or chalk-like in its appearance, and of a circular, linear, or angular shape, its surface being sometimes smooth, at other times rough. It is essentially an analogous tissue, but so imperfect a copy of the original that it can hardly be safrj to bear any resemblance to it. Finally, cases occur in which this substance is partially transformed into fatty matter, fibro-cartilage, cartilage, and even bone. Fig. 151. Opacity of the cornea; an exam- ple of albugo. DISEASES AND INJURIES OF THE CORNEA. 303 The slighter forms of corneal opacity often disappear with the inflammation which has produced them, or within a short time after, under the influence simply* of the absorbents, now no longer kept in abeyance by the secernents. Should the case prove tedious, or not proceed satisfactorily, measures must be taken to promote the removal of the effused matter, among which the best are alterant tonics, as quinine and iodide of iron, with a very minute quantity of tartar emetic, as the one-twentieth of a grain, three times a day ; iodide of potassium ; or a very mild course of mercury, carried to the extent of the slightest possible ptyalism. The cure will be expedited by the use of some mild local stimulant, as a few drops, twice a day, of a very weak solution of acetate of zinc, nitrate of silver, or acetate of lead, or a very weak ointment of oxide of mercury, nitrate of silver, or oxide of zinc. I have derived great benefit, under such circumstances, from a little thin molasses poured upon the opaque cornea once a day, and also from washing the eye night, and morning with tepid water, rendered gently stimulating with a little common vinegar or salt. Indeed, almost any substancfe, provided it does not act as an irritant, will prove useful in most cases of nebula. For albugo in its various forms, surgery holds out no prospect of relief; it is an organized tissue, part and parcel of the cornea, and no remedies, either local or general, can remove it. The idea of curing an albugo by paring it away is simply ridiculous, and implies a very imperfect knowledge of the nature of the disease. The operation of excision, and of uniting the wound by suture, proposed by Dieffenbach, is still more preposterous; and the recent suggestion of Dr. Nussbaum, to cut out the^opaque spot, and make the patient wear a small piece of glass, shaped like a shirt-stud, caps the climax of absurdity. When the opacity does not affect the entire centre of the cornea useful vision may occasionally be procured by constant dilata- tion of the pupil with atropia. 7. Staphyloma.—Alterations of form of the cornea are technically known under the name of staphyloma ; they are an occasional effect of inflammation and external injury, and occur in every intermediate degree, from the slightest aberration of the normal shape to the most hideous deformity. Two prin- cipal varieties of the disease are usually recognized by authors, the spherical, seen in fig. 152, and conical, shown in fig. 153, but as they do not differ from Fig. 152. Fig. 153. Spherical staphyloma. Conical staphyloma. each other in their character or mode of development, the distinction might as well be abolished, as it is only calculated to lead to erroneous notions of pathology and practice. The immediate cause of staphyloma is a weakened and attenuated condi- tion of the cornea, especially of its central portion, in consequence of which jt is incapably of resisting the pressure of the aqueous fluid as it accumu- lates, now in increasing quantity, in the anterior chamber. More or less °Pacity a.nd a certain degree of abnormal vascularity attend the development o the disease, the progress of which is always tardy, several years usually 304 DISEASES AND INJURIES OF THE EYE. passing by before it attains much bulk. The tumor is commonly of a coni- cal form ; and, as it proceeds, it gradually projects beyond the lids, separating them from each other, and descending towards the cheeks, its length varying from a few lines to several inches. That portion which lies beyond the level of thejids is usually very hard, more opaque than the rest, and constantly inflamed, from the fact that it is incessantly exposed to the light, and the contact of all sorts of irritants. When the disease is fully developed, the anterior chamber is annihilated, the iris being lacerated, and closely adherent to the posterior surface of the cornea. Vision is always greatly impaired, and often completely destroyed. The staphyloma, after having attained a certain height, remains either stationary, or ulceration sets in, followed by perforation of the membrane, and the escape of the aqueous humor. There is a form of this affection which appears to consist in a hypertrophous condition of the cornea, its development being altogether independent of inflammatory action. The affection involves both eyes, though rarely in an equal degree, and is most common in young subjects, from the age of eighteen to thirty. The tumor is smaller than in the inflammatory variety, and also retains a greater amount of transparency, the opacity being generally limited to the part projecting beyond the lids. The iris preserves its normal posi- tion, the pupil moves with its accustomed freedom, and the anterior chamber, instead of being obliterated, as in the ordinary form of the disease, is only enlarged and changed in shape. Vision is more or less impaired, and the cornea is remarkable for its glistening, sparkling appearance. The cause of the lesion is not understood. In the incipient stage of staphyloma a gently antiphlogistic course will sometimes be of service, if not in permanently arresting the disease, at all events in staying for a time its progress, and in preventing it from attaining so great a development as it otherwise would. The best remedies will be mild astringents, particularly the different preparations of nitrate of silver, ointment of the oxide of mercury, and solutions of zinc and lead, with fre- quent puncture of the cornea to take off the pressure of the aqueous humor. In general, however, these means will fail, and the surgeon will, therefore, be compelled to resort to other measures, especially if the tumor has attained so much bulk as to be constantly irritated by the contact of extraneous mat- ter. The most appropriate remedy in this case is excision of the cone, or of all that portion which projects beyond the edges of the lids. For this purpose, the lids being held carefully out of the way, the apex of the tumor is transfixed with a tenaculum, and the knife—a sharp, narrow bistoury—is rapidly carried from above downwards, cutting off the requisite amount at a single sweep. Care is taken not to remove too much, otherwise the eye may either collapse from the evacuation of its humors, or, at all events, shrink so much as to interfere with the wearing of an artificial one. For the non-inflammatory species of conical cornea there is no cure. The probability is, as before stated, that it is merely a form of hyper-nutrition, and if this opinion be correct, it is not surprising that it should be entirely beyond the control of remedies. 8. Fatty Degeneration.—Fatty degeneration of the cornea is rather of pa- thological than of surgical interest, and may, therefore, be dismissed in a few words. This affection, formerly known under the name of the senile arch, has been shown, withiu the last few years, to consist essentially in a transfor- mation of the horny tissue of the eye into a substance resembling fat; it is of a dim pearl color, loaded with oily matter, and considerably softer than the adjacent healthy structure, in which it is insensibly lost. The altered part presents itself in the form of a ring, at the periphery of the cornea, near its junction with the sclerotica. The fatty transformation is not peculiar to the old, as the term senile would suggest, although they are undoubtedly DISEASES AND INJURIES OF THE SCLEROTICA. 305 most subject to it. It has occasionally been witnessed in children, and I have myself seen two cases of it before the age of twenty. It is often asso- ciated with fatty degeneration of the heart, arteries, liver, and other organs. DISEASES AND INJURIES OF THE SCLEROTICA. The sclerotica is liable to wounds, staphyloma and inflammation. 1. Wounds.—Wrounds of the sclerotica may be of various kinds, as incised, punctured, and lacerated. They are, in general, easily recognized by their gaping appearance, caused by the retraction of their edges, which is always proportionately great. If the sclerotica alone has been divided, the bottom of the wound will be formed by the surface of the choroid, and will, conse- quently, present a black appearance. If this membrane be also divided, there will probably be a sac-like protrusion of the retina; and should the lesion embrace all the tonics, there will necessarily be an escape of more or less of the vitreous humor. Incised wounds of the sclerotica readily unite by adhesive inflammation, the plasma which fills the gap becoming speedily organized and transformed into an analogous tissue. To promote this occurrence, both eyes should be subjected to the most perfect repose, for at least a week, by confining the lids with strips of isinglass plaster, as after the operation for cataract and arti- ficial pupil. The patient remains in a dark room, purges himself well, and lives upon light food. Laceration of this membrane may be caused by a blow of the fist, by the forcible contact of a sjick, or by a fall upon the globe. What is remarkable is, that the rupture usually occurs at a point opposite to that to which the violence has been applied, by a sort of contre-coup, or excessive distension of the fibres of the tunic. Hence, its most common site is either the upper or inner part of the sclerotica, where injury is seldom or never inflicted, the nose and superciliary ridge serving to shield it. The rupture may be limited to the sclerotica, or it may involve the other tunics; in which case it is liable to be attended with escape of the vitreous humor, and of the crystalline lens into the sub-conjunctival cellular tissue. The treatment is the same as in an ordinary incised wound. If the lens be dislocated, it should immediately be removed by a small incision, otherwise it may, by its pressure, interfere with the repair of the breach in the sclerotica. 2. Staphyloma.—Staphyloma of the sclerotica signifies a tumor formed by the protrusion of this membrane beyond its natural level. The exciting cause^ is usually an abnornal accumulation of aqueous humor in the posterior cham-' ber of the eye, in consequence of the occlusion of the pupil, or of the attach- ment of the iris to the surface of the cornea. The pressure thus occasioned produces atrophy, and, finally, excessive attenuation of the sclerotica, followed by a separation of its fibres and the protrusion of the other membranes of the eye. The fact is, the mode of formation is identical with that of the pouches which sometimes occur in the intestines and the urinary bladder, and which are so minutely described in most works on pathological anatomy. The affection is always accompanied by a discolored and disorganized condition of the inner structures of the eye. The size of the tumor varies from that of a currant to that of a hazelnut; it may be rounded or ovoidal in its shape, and has usually a bluish, purplish, or blackish appearance, from the presence of the coloring matter of the choroid. When the membrane is diseased at several points, there may be a corresponding number of protrusions, occurring either singly or in clusters. The annexed sketch, fig. 154, conveys an excel- lent idea of the situation, size, and shape of these tumors. the prognosis of this affection is of the worst character; its very existence auords irrefragable evidence of incurable disease of the other structures of the vol. ii._20 306 DISEASES AND INJURIES OF THE EYE. Staphyloma of the sclerotic coat, seen in profile. Fig. 154. eye ; and hence it would be folly to subject the patient to treatment, except in so far as it may be designed to relieve deformity. With this object, the removal of the tumor may be attempted by snipping off the most pro- minent portion, trusting to shrinking for the disappear- ance of the remainder. 3. Sclerotitis.—Inflammation of the sclerotica seldom exists as a pure, uncomplicated affection; most com- monly it arises during the progress of other ophthalmic diseases, especially corneitis and iritis. As an inde- pendent lesion, it may be induced by various causes, of which the principal are exposure to cold, a rheumatic or gouty state of the constitution, the action of the syphilitic poison, and the effects of mercurialization. It is most common in middle aged and elderly subjects, and winter and spring are its favorite periods of attack. The symptoms of this disease are in general well marked. The pain is severe, throbbing, deep-seated, and liable to vesperal exacerbations; it usu- ally extends to the forehead, temples, and upper part of the cheeks, and is aggravated by recumbency, and by the slightest motion of the eye, which feels full and tight, as if it were compressed by the hand. When the pain is less, severe, the organ is sore and tender, or the seat of a distressing aching sensation. During the night, the suffering is often so excessive as to deprive the patient entirely of sleep, compelling him to sit up in bed, or walk the floor. In many cases there is hemicrania, or a dull, b,eavy, aching pain in the side of the head, with great tenderness on pressure. In some cases, again, the pain is of a neuralgic character, recurring in regular paroxysms once or twice in the twenty-four hours. The eye is intole- rant of light, the smallest quantity generally prov- ing a source of extreme suffering; and there is' always an abundant secretion of tears, though usually very little discharge of mucus, or of mucus and pus. Hence the edges of the lids do either not adhere at all, or only in a comparatively slight degree. If the eye be carefully inspected, it will be found that the discoloration is deep-seated, and of a faint bluish pink, or lilac appearance, the vessels upon which it depends being exceedingly delicate, and disposed in parallel lines, converging towards the cornea, as in fig. 155, immediately Fig. 156. Sclerotitis extending to the internal tunics. behind which they are very numerous and conspicuous, forming a well- marked zone around its periphery. The disease, in its earlier stages, is in great degree, if not exclusively, limited to the sclerotica; in a short time, however, it involves the other structures, especially the conjunctiva, cornea, and iris, as is seen in fig. 156. When this is the case, the ball of the eye often exhibits a bloodshot appear- ance ; there is more or less haziness of the cornea, with an enlargement of its vessels; the pupil is sluggish, or entirely immovable, and the surface of the iris is altered in its color. The lids are rarely, under any circum- DISEASES AND INJURIES OF THE SCLEROTICA. 307 stances, materially involved in the morbid action. Much diversity obtains in regard to the state of the constitution ; in many cases there is an entire absence of fever, while in others it may be present from the beginning, and constitute one of the most prominent symptoms. The diagnosis of sclerotitis is sufficiently easy, particularly in the earlier stages.of the disease. The history of the case, the character and intensity of the pain, the excessive lachrymation and intolerance of ligjft, and the peculiar nature of the vascularity of the affected membrane, cannot fail to enable the-practitioner to distinguish it from other ophthalmic affections. In conjunctivitis, the discoloration is superficial, and of a scarlet hue; in sclerotitis, it is deep-seated, and of a pale pink, bluish, or lilac tint; in the « former, the vessels are very large and arranged arborescently ; in the latter, extremely small, almost hair-like, and disposed in straight, parallel lines, .extending from behind forwards towards the cornea. Finally, in conjuncti- vitis, the vessels are movable; in sclerotitis, on the contrary, they are fixed. In the treatment of this malady, the practitioner must be influenced by the nature of the exciting cause, and the actual condition of the system. The milder, non-specific forms of the disease will generally readily yield to active purgatives, light diet, and diaphoretics, particularly Dover's powder, or anti- mony and morphia, with cupping or leeching of the temple. If the patient be plethoric, and the inflammation very severe, blood should be taken freely from the arm, and the system be kept constantly under the influence of the saline and antimonial mixture, with calomel and an anodyne at night, to act upon the secretions, and to promote sleep. In rheumatic sclerotitis, the best remedies are colchicum and morphia, given in full doses early in the evening, and in small doses several times during the day. My usual practice is to administer a drachm of the wine of colchi- cum, towards bedtime, along with a grain of morphia, using a hot and slightly stimulating foot-bath immediately after, so as to get the patient, if possible, into a copious sweat. The next morning, about ten o'clock, half the quantity of these articles is given, or the dose may be still smaller, according to the tolerance of the system. Syphilitic sclerotitis must be treated with calomel and opium, or some other form of mercury, carried to gentle ptyalism ; or, what will usually be found to answer better, the iodide of potassium, in doses of from ten to twenty grains three times a day, combined with an anodyne, especially towards bed- time. A similar plan will be called for when the disease has arisou from the inordinate use of mercury; in this case, indeed, gentle ptyalism is generally an indispensable element in the treatment. Anodyne liniments, embrocations, and unguents, applied freely to the fore- head, cheek, and temple, are often of great benefit in sclerotitis, however in- duced; the use of medicated steam, directed upon these parts, will also be found very agreeable and soothing. In most cases, it will be necessary to take blood from the neighborhood of the inflamed organ by cups or leeches. As to counter-irritation, in all its forms, I am generally averse, to it, for the reason that I have usually seen it do harm instead of good. This is espe- cially true when it is applied to the temple, behind the ears, or even to the nape of the neck. It is less objectionable when applied to the arm, but even then it often fails to be of any materfal use in removing the morbid action. When sclerotitis becomes chronic, a mild course of alterants and tonics will be necessary, aided by a properly regulated diet, tepid bathing, and change of air. 308 DISEASES AND INJURIES OF THE EYE. DISEASES AND INJURIES OF THE IRIS. The iris is liable to various accidents and diseases, of which the most com- mon and important are, wounds, inflammation, prolapse, and morbid adhe- sions. I am not aware that it is ever the seat of any of the heterologous formations. The inflammation which assails it may be of the common kind, although thjs is exceedingly rare, or it may be caused by a rheumatic, syphi- litic, or strumous state of the system. Finally, the iris is often the seat of interesting and delicate operation's, rendered necessary on account either of its own diseases or of diseases of the cornea obstructing vision. 1. Congenital Vices.—The iris is subject to congenital malformations, of which the most common are absence of the membrane and irregularity of the pupil. The former of these defects, which has" been termed irideremia, is necessarily attended with very imperfect vision, the eye, in ordinary light, ■ being constantly dazzled by objects, and disposed to roll about. In the only instance that I have ever seen of it, the child was nearly blind, and the inte- rior of the globe, instead of being of a reddish tint, as usually represented by authors, was remarkably black. In some of these cases, the iris is not completely absent, but exists in a rudimentary state, forming a narrow ring at the periphery of the cornea. In a case of malformation which I saw not long ago, the pupil had the appearance of being double. It occurred in a man, aged twenty-eight, whose sight was perfect, although both eyes were in Fig. 157. precisely the same condition. The pupil, which readily obeyed the light, was situated nearer the inner than the outer side of the globe, and occupied the inferior portion of the iris, extend- ing down to the margin of the cornea. The more common variety is represented in the an- nexed sketch, fig. 157. The defect is called coloboma of the iris. The fissure is of a trian- gular shape, the apex extending downwards towards the, ciliary margin of the iris. In rare Congenital fissure. cases, the pupil, although well formed, has been found to be situated out of its usual place. 2. Wounds.—Wounds of the iris are inflicted either designedly, as in the attempt to form an artificial pupil, or accidentally, as in the operation for cataract, and under other circumstances. The chief interest' which such lesions possess is that they are seldom productive of serious inflammation, although the plastic matter that is poured out is very apt to cause morbid adhesions, interfering more or less with vision. Sometimes the iris is torn off from its ciliary attachments by a blow or fall, leading thus to the formation of a species of artificial pupil; the opening, even if comparatively small, never closes; while, if it be at all large, it will seriously encroach upon the natural one, diminishing its size, changing its form, and crippling its action. What- ever the character of the injury may be, the treatment must be strictly anti- phlogistic, it being of the greatest importance that the resulting inflammation should be subdued as promptly as possible. If there be any plastic deposit, mercury, carried to slight ptyalism, will" be required. 3. Inflammation.—Iritis is a much more frequent affection than is gene- rally supposed. From what I have seen of the diseases of the eye, in private and hospital practice, I am persuaded that it is very often entirely overlooked, the malady under which the patient labors being mistaken for inflammation of the conjunctiva and sclerotica. That this should be so is not surprising when we reflect upon the fact that iritis altogether escaped the attention of practitioners until the commencement of the present century. Now, how- DISEASES AND INJURIES OF THE IRIS. 309 ever, that its characters are so well understood, there is really no excuse for errors of diagnosis. With a little attention on the "part of the medical attendant, it is as easily recognized as a boil upon the nose, a stye on the eyelid, or a wart on the finger. Iritis may proceed from a considerable variety of causes, of which the most important are, external injury, exposure.to intense light, suppression of the cutaneous perspiration, a strumous, gouty, or rheumatic state of the consti- tution, and the operation of the syphilitic virus. It often begins as a primary affection; but in many cases it is altogether of secondary origin, being the result of an extension of disease from the surrounding tissues. Finally, it may be acute or chronic, and occur in both sexes, in every class of individuals, and at all periods of life, even in very young children. When it attacks the latter as an independent affection, the probability is that it is owing to a syphilitic taint of the system, although this is by no means necessarily the case. The disease frequently begins in a very insidious manner, and hence great and irreparable mischief is sometimes done before the practitioner is made aware of the nature of the case. Such an occurrence is the more likely to happen because there is often an entire absence of the more ordinary pheno- mena of ophthalmia, especially discoloration of the superficial tunics, and also everything like severe local suffering, calculated.to aroijse attention. In general,, however, p^in is an early and prominent symptom, or, if it is not, it is sure soon to become so; lachrymation and intolerance of light are also well marked. Unless the inflammation involves the conjunctiva, the disease may go on through its different stages, and even ultimately destroy the sight com- pletely, and yet not occasion any considerable redness. In general, the dis- coloration is limited, at least in great degree, to the sclerotica, at the anterior extremity of which there is always a distinct zone, as in fig. 158, formed by the Fig. 158. Fig. 159. Acute iritis. vessels of the fibrous coat as they dip down into the eye, to anastomose with those of the iris and choroid. This zone, which is never absent, is at first of a faint rose color, but afterwards, when the inflammation is fully es- tablished, of a deep red, cinnamon, or brick hue. At the beginning of the disease, there is a narrow ring of white between it and the cornea, but, as the morbid action advances, this is gradually lost by an extension of the vascularity. The vessels which produce the zone have a fine hair-like ap- pearance, with a radiated arrangement, and are seated beneath the conjunc- tiva, in the substance of the sclerotica, in which they are immovably fixed, as seen in fig. 159. When the disease has made considerable progress, the peculiarity of this vascularity is lost, by reason of the excessive discoloration of the conjunctiva; and it should not be forgotten, as was previously inti- mated, that, in complicated cases or in secondary forms of iritis, it may be completely masked, even at the beginning of the attack. Iritis; showing the characteristic vas- cularity of the globe, the iris being clogged with lymph, and the pupil con- tracted and irregular. 310 DISEASES AND INJURIES OF THE EYE. The pain of iritis varies,; in general it is very severe and distressing, but I have seen cases, even of a very bad character, as it respected the state of the sight, where it was absolutely absent from first to last. Such cases are, of course, exceptional. Usually the pain is deep-seated, beginning appa- rently in the orbit, and rapidly involving the globe; becoming more and more severe and constant as the disease progresses; subject to violent noc- turnal exacerbations; and generally, especially in the more confirmed stages of iritis, extending to the surrounding parts, particularly the temple, eye- brow, and cheek. Sometimes there is the most violent jiemicrania. The iris itself experiences most important alterations. Even at an early stage of t^e disease it is already quite sluggish, while somewhat later it is entirely insensible to every kind of stimulant, however strong or long con- tinued. Its anterior surface loses its smooth, shining, fibrous appearance, and becomes rough, puckered, and dull; the pupil diminishes in size, and is ultimately almost obliterated, being, perhaps, hardly as large as a pin-hole; at the same time it is observed to be deformed, and adherent to the capsule of the lens. In addition to these characteristics, there is an extroardinary change in the color of the iris, contrasting strikingly with that of the healthy membrane, and evidently dependent upon the injected condition of the proper tissues of the part, vvith a slight effusion of blood, or blood and lymph. The morbid hue, usually somewhat reddish, or of a dusky bjick, is most conspi- cuous when the iris is bluish; less so, when it is brownish or hazel. Finally, the iris is often preternaturally.convex, especially towards its circumference; the pupillary margin is greatly thickened; the aqueous humor is augmented in quantity, and rendered more or less turbid; aud masses of lymph are fre- quently observed in the anterior chamber, either loose, or adherent to the diseased membrane. When the malady is fully developed, the sight is either much impaired, or completely destroyed ; for not only is the pupil greatly contracted, so as to interfere materially with the transmission of light, but there is often opacity of the cornea, cataract of the lens and its capsule, and a disorganized state of the retina and choroid, as is evinced by .the frequent attacks of corrusca- tions and other symptoms of deep-seated disease. Fever, often of a' high grade, attends the earlier stages of iritis. The diagnosis between ordinary iritis and iritis dependent upon rheumatism and syphilis, is often extremely obscure, and,"therefore, difficult of determina- tion. This, however, is the less to be regretted because the treatment is essentially the same, whatever may be the exciting cause. The distinction between the rheumatic and syphilitic forms will be best understood by the subjoined tabular arrangement:— Rheumatic Iritis. 1. Usually co-exists with rheumatism or gout. 2. Mo^t common in elderly subjects. 3. Often only one eye suffers. 4. The zone aroun<| the cornea is of a dull, rusty red, with a white ring in front. 5. There is little or no lymph in the anterior, chamber and upon the anterior surface of the iris. 6. The aqueousjhumor is usually clear, or'nearly so. 7. The pain is nearly constant, though liable to exacerbations, especially at night. Syphilitic Iritis. 1. With papular eruptions, sore throat, and other evidences of syphilis. 2. May occur at any age, even in in- fancy. 3. Generally both eyes are affected; first one, and soon after the other. 4. Is of a cinnamon or brownish hue, and soon extends quite up to the cornea. 5. The plastic deposits are always promi- nent, often presenting themselves in the form of little, fleecy, vascular, reddish- looking tubercles, attached to the surface of the. iris. 6. Generally turbid, often highly so, and very albuminous. 7. Very bad at night, but almost, if not entirely, absent during the day. DISEASES AND INJURIES OF THE IRIS. * 311 •The prognosis of iritis may be gathered from what precedes. Whenever the disease is of long standing, or severe in degree, little hope need be enter- tained of ultimate recovery. The patient, it is true, may be able to discern light, and perhaps grope his way, but, as it respects useful vision, he will not be likely to get any ; for it may confidently be asserted that there is no form of inflammation, which, if allowed to progress, is more certain to damage the deep structures of the eye, than iritis, especially the rheumatic, and syphi- litic varieties. The treatment of iritis is conducted upon the same principles which govern the practitioner in the management of ophthalmic diseases generally. Blood is taken freely from* the arm, if the patient is plethoric, and, under almost any circumstances, by cupping and leeching from the temples. The bowels are thoroughly evacuated by efficient purgatives, as calomel and jalap, or senna. and salts, the action of the heart is controlled by the antimonial and saline mixture, and pain is allayed by the liberal use of anodynes. In the rheumatic form of the disease, colchicum proves a valuable adjuvant. But the great remedy in iritis, in all Cases, excepting, perhaps, the most simple, is mercury, carried to the extent of rapid ptyalism. For this purpose the medicine should be given in full doses, its effects, however, being carefully watched, lest profuse salivation should arise. The best article is calomel, in doses of from two to three grains every four or six hours, properly guarded with opium, and continued until th%gums become tender, when it must be either withheld or administered in smaller quantities. When the calomel is tardy in its action, it may be assisted by mercurial inunctions ; for, as already hinted, the object is to make as speedy an impression as possible upon the disease, in the hope of preventing its direful effects upon the pupil and lens, the integrity of which is so important to the preservation of the sight, and which is always so much endangered by neglect and ill management. It is true that ptyalism is not at all essential to the success of the treatment, for it has been shown that the inflammation often vanishes where, although Jhe article is freely employed, no such effect follow* its administration ; but the occurrence is always anxiously looked for because it serves to assure us that the medicine is doing its duty. It is not necessary here to inquire into the mode of operation of mercury in iritis. The disease derives its chief importance, as far as the danger is concerned, from the fact that it is attended with an effusion of plastic matter, not only into the proper substance of the membrane, but upon its surfaces and also into the chambers of the eye, embarrassing the movements of the iris, plugging up the pupil, and causing adhesions between the affected struc- ture and the capsule of the lens. Now, the object in administering mercury is to prevent the deposition of this substance, and to promote the absorption of that which has already taken place, and that it is well calculated to do this, experience has abundantly established, although we cannot explain the precise mode of its operation. Mercury, then, is the great remedy in this disease, the remedy par excellence, and should be given early and freely, until it has effected the object for which it is exhibited. Its action is less apparent m the traumatic forms of iritis than in the rheumatic and syphilitic, in which it is absolutely indispensable. The effects of the remedies here mentioned may be aided by counter-irri- tation, by blisters, croton oil, or tartar-emetic ointment behind the ears or to the nape of the neck; but all direct applications should be dispensed with, except such as are of the most soothing character, as,the steam of hot water and opium, fomentations, and light, emollient, and medicated poultices. The circumorbital pains are often abated by anodyne embrocations, lotions, and unguents. Much stress has been laid by authors upon the propriety of keeping the pupil well dilated with atropia during the progress of this disease. While 312 • DISEASES AND INJURIES OF THE EYE. every one must perceive the force of the injunction, the misfortune is that atropia does not possess this property, nor is there, so far as is at present known, any article that does. The moment the iris is actively inflamed, that moment it ceases to be influenced by narcotic applications; the pupil con- tracts, and no stimulus, however powerful, can afterwards excite it. I have no experience with the use of turpentine in the treatment of this- disease; I have, however, given it in several instances, apparently quite favorable for the appropriate action of the remedy, and I have not been able to satisfy myself that it has been of any benefit. In the syphilitic variety of the complaint, iodide of potassium may advantageously be exhibited, to aid in completing the cure, after We* have made fair trial of mercury. In debili- tated persons, in chronic cases, and in the latter stages of the acute attack, tonics may be demanded. 4. Prolapse.—Prolapse of the iris may depend upon three circumstances, namely, wound, ulceration, and sloughing of the cornea, and may present itself in two varieties of form, the partial and the complete, of which the former is by far the more common. Indeed, complete protrusion of the membrane can only occur when there is most extensive injury of the anterior portion of the ball. Partial prolapse is usually caused by ulceration of the cornea, attended with perforation of all its lamellae. The opening thus made is immediately followed by an escape of the aqueous humor, with protrusion of the iris, by which the gap is effectually closed, and further mischief pre- vented. Plastic matter being effused, the prolapsed portion contracts ad- hesions to the edges of the ulcer, the site of which is afterwards indicated by a black spot with a slight peripheral opacity. From the manner in which the iris is dragged out of its normal position, the pupil, except in the milder varieties of the accident, undergoes important changes in its form, size, and situation, attended with corresponding alterations of sight. When the dis- placement is considerable, vision may be completely destroyed. The treatment of this affection must be regulated by circumstances, it being impossible to lay down any particular plan for the guidance of the surgeon. In complete prolapse, depending upon extensive destruction of the cornea, the case is, of course, hopeless ; if, on the other hand, it is caused by wound, the membrane should immediately be replaced by means of a probe, and the lids kept well closed with adhesive strips, until the parts have become thoroughly united. The success of the treatment will be greatly influenced by the care with which the operation of replacement is performed; if the patient be a child, quietude should always be insured by the administration of anaesthetics, as it will hardly be possible to execute the procedure in a satisfactory manner without this precaution. The • Fig. 160. after-treatment is, of course, conducted upon strictly antiphlogistic principles. When the prolapse is the effect of ulcerative per- foration of the cornea, our hands are equally tied, as in the complete form of the affection. To push back the iris, under such circumstances, w,ould only lead to worse results; instead of this, therefore, the part is allowed to keep its place, for it is nature's plug, and is absolutely necessary to close the artificial opening, however much it may impair vision. This Prolapse of the iris. variety of prolapse is well illustrated in fig. 160. The protruded part projects beyond the level of the cornea, looking soraew"hat like the head of a small fly; whence the term myocephalon, applied to it by professed oculists. When the iris protrudes through several apertures, it may give the surface of the cornea a black, tuberculated aspect, and may require retrenchment, in order to prevent in- jurious friction of the lids. ARTIFICIAL PUPIL. 313 In the treatment of recent prolapse, dependent upon wound of the«ornea, free use should be made of belladonna, or atropia, with a view of bringing the iris as speedily as possible under the full influence of the remedy. By dilating the pupil, the membrane is drawn away from the cornea, and is, therefore, less likely to be permanently intercepted by the edges of the wound. Synechia is the name gjven to an abnormal adhesion of the iris to the cor- nea and capsule of the lens, the term anterior being added to designate the former, and posterior to signify the latter. Anterior synechia is caused by wound, ulceration, or sloughing of the cornea; posterior, by iritis, and other diseases, attended with plastic deposits. The lesion, in whatever form it may" present itself, is always attended with impairment of vision, and occasionally with total blindness. Posterior synechia is often complicated with cataract. When the cornea and lens preserve their transparency, and the pupil is not completely obliterated, sight may sometimes be improved through the agency of belladonna, and, at other times, by operation, the nature of which must be regulated by the character of the concomitant lesion. 5. Obliteration of the Pupil.—Obliteration of the pupil may be caused by symptomatic disease of the eye, or of the general system ; by loss of power in the muscular fibres of the iris in consequence of interstitial deposits; or the presence of plastic matter, filling up its aperture, either as an amor- phous substance, or as an adventitious membrane, adherent to its edges. In the latter case, the affection constitutes what is termed a false cataract. The treatment must be regulated by the exigencies of the case ; by atten- tion to the general health, when that is obviously at fault; by the removal of ophthalmic trouble, as when the affection is symptomatic; by the use of atropia, and by operation. When the iris is not adherent, a very useful de- gree of vision may sometimes be obtained by permanent artificial dilatation by means of atropia. Operation is indicated when the obliteration is de- pendent upon the presence of organized lymph, and may be executed either with a delicate needle, introduced through the cornea, as in the anterior ope- ration for cataract, or with a cataract knife, as in the operation of extraction. » Finally,' when other means are unavailing, an artificial pupil may be formed, although the success of "this is not by any means .always, or, perhaps, even generally, certain. ARTIFICIAL PUPIL. The establishment of an artificial pupil, by which is meant a new opening for the transmission of light, may be rendered necessary by various causes, besides those mentioned in the foregoing paragraphs. Thus, although the natural pupil may be perfectly healthy, yet there may be such an amount of , corneal opacity as to cause complete blindness. This, indeed, is one of the most frequent reasons for this operation; for, as already stated, the other causes of blindness occasionally admit of relief by other means. The operation for artificial pupil demands extraordinary skill for its suc- cessful execution, and should, therefore, never be attempted by any one who does not possess the requisite, accomplishments. Besides, it should not be undertaken unless there is at least a fair prospect of success. Some preli- minary treatment is usually necessary, just as in the operation for cataract; and we should be fully satisfied that the internal structures of the eye have not been destroyed by pre-existing disease, otherwise, even if we succeed, vision will not be at all improved. As a general rule, it is proper not to in- terfere if the patient has no longer any perception of light; or if there is marked evidence of former iritis, of a dissolved condition of the vitreous humor, or of serious organic lesion of the retina, or of the retina and choroid. Finally, no operation should be performed until the eye has completely re- covered from the effects of the morbid action creating a necessity for it. 314 DISEASES AND INJURIES OF THE EYE. Various plans have been devised and practised for the establishment of an artificial pupil, but as far as it respects their utility, they may all be referred to three principal classes, namely, incision, detachment, and excision. When- ever it is practicable, the new aperture should occupy the site of the old, or, at all events, be as close to it as possible, because the nearer it is to the natu- ral axis of vision the more likely will it be to answer the object; under op- posite circumstances, it should be placed towards the inferior part of the iris. or towards the inferior and external part. Unless the condition of the eye renders it absolutely necessary, we should never make the opening above, as it will be constantly interfered with by the lid. Some surgeons prefer the nasal side of the iris, but this has certainly no appreciable advantages over the other situations just pointed out. In regard to the size and shape of the pupil, no definite rules can be given. An opening, such as the iris presents in ordinary vision, in a clear, but not too bright a light, will be quite large enough, and when this is the case, it does not matter particularly what shape it has, whether it is circular or angular, although the former will certainly be the more seemly. The instruments required for the Fig. 161. Fig. 162. Fig. 163. operation are delicate scissors, a cornea-knife, an iris-knife, and two hooks, one sharp and the other blunt. The scissors are curved on the edge, and are provided with exceedingly slender blades, one of which is probe-pointed and longer than the other, which is sharp, and, when the instrument is shut, com- pletely shielded by its fellow. The handles are long, and furnished each with a large ring so as to command a firm grasp. A.good idea of this instrument is conveyed by the an- ' nexed sketch, fig. 161. I have never had occasion to use tbe ca- nula-scissors, invented by Mr. Wilde, of Dublin, for making an artificial pupil, and, although it is a very ingenious instrument, it is difficult to perceive of what use it iris scissors. iris hooks. can be in such an operation, seeing how very difficult it is to expand and move its blades. The cornea may readily be divided with any delicate cataract knife. The hooks, figs. 162 and 163, which are usually employed in this operation, are extremely delicate, and shaped in such a manner as to enable the operator to retain a firm hold upon the iris. The sharp hook is usually objected, to, on the ground that it is liable to endanger the lens, but with a little care every- thing of this kind may effectually be avoided. Fig. 164. - • g Knife for artificial pupil. 1. The operation by incision is usually performed with a very delicate knife, or needle, with a double cutting edge, fig. 164, introduced through the 4& , ARTIFICIAL PUPIL. 315 sclerotica, at the usual place of entrance in the operation for cataract. The instrument having pierced the iris, at the point of election, is carried across the anterior chamber, so as to divide, either horizontally or verti- . .cally, and by a sort of sawing motion, the membrane in one-third of its extent, as represented in fig. 165. The knife must be extremely sharp, otherwise great difficulty will be experienced in making the aperture of the requisite dimensions. The success depends upon the amount of contraction of the muscular fibres of the iris; when this power is lost, as it often is after violent inflam- mation, the edges of the wound will not only not recede, but speedily reunite, and thus effectually frustrate the intention of the surgeon. The same process is, therefore, obliged to be repeated, perhaps a number of times, and even then the result may be very unsatisfactory. For this reason, as well as because the operation always necessarily endangers the integrity of the lens, it has become nearly obsolete, although it cannot be denied that it now and then succeeds most beautifully, as it has done several times in .my own hands. Another mode of performing this operation, one that is altogether prefer- able, because more certain in its execution and more satisfactory in its results, is to divide the cornea with a common cataract knife, to the extent of about three lines, and then cut through the iris with a smaller instrument. 2. The operation by detachment, exhibited in fig. 166, consists in tearing away a portion of the iris from its ciliary connections; it is adapted chiefly to cases of great central opacity, and is never performed as a matter of choice, but as one entirely of necessity. For reasons already mentioned, the artificial opening is never, if possible, placed at the upper margin of the iris. The operation is executed with a small cataract needle, curved rather abruptly at the point, which, being passed through the cornea, near its junction with the sclerotica, is pushed across the anterior chamber, and inserted into the periphery of the iris, which is then carefully separated from its attachments to the extent of at least two lines. Great care must be taken to make the aperture larger than in the central operation, for, as the pupil is not in the line of the natural axis of .vision, it will re- quire a much greater number of rays ■ of light to produce useful sight. • Or, instead of the above operation, a small opening is made into the cor- nea, and a portion of the detached iris is drawn out by means of a hook, seen in fig. 167, between its edges, where it is permanently retained. • 3. The most unexceptionable procedure, however, of all is excision; it is- indeed almost the only one that should be performed when we can have our choice, as it neither endangers the lens, nor is followed by closure of the artificial aperture. The cornea is divided as iu the preceding case, when, if the pupil be not effaced, a blunt hook is passed round its margin, which 'is then drawn down and snipped off with the scissors ; or, instead of this, the iris is brought down with a sharp hook, and a piece excised; or, finally, the membrane is seized as just stated, and a portion cut out with a pair of sharp- pointed scissors. Sometimes the iris protrudes as soon as the knife has left the oornea; when this is the case the procedure is greatly simplified, as the required flap may be removed without introducing any instruments into the anterior chamber. In performing this operation, a great deal of care is neces- sary, lest we wound the*lens, and thus provoke the formation of cataract. Occasionally the cornea and iris are simultaneously divided, especially when Operation by detachment. 316 DISEASES AND INJURIES OF TnE EYE. there is permanent occlusion of the pupil, as in fig. 168. The requisite por- tion of the iris is then removed with the hook and scissors. A knowledge of the operations now de- Fig. 168. scribed will enable the young surgeon to, "make such modifications as the various exigencies of the cases he may. meet with in practice may call for. To attempt to give even an outline of these modifications here would be as tiresome as it would be useless. The whole subject of artificial pupil has been treated by the specialists in the most weary and cumbersome man- Simuitaneous division of cornea and iris. ner, well calculated to digust any sensible man with a branch of operative surgery which, if properly simplified, might be made one of the most delightful, useful,' and fascinating that could possibly engage attention. The fundamental prin- ciples being thoroughly understood, the details of each particular case must necessarily be left to the judgment of the surgeon. The after-treatment is extremely simple, strongly resembling that of cata- ract. Both eyes are carefully closed by strips of isinglass plaster, and a grain of morphia is given the moment the patient is placed in bed, to insure the repose of the affected organ. The light is carefully excluded from the room, and the diet is strictly farinaceous for at least a week, when, especially if the person be old, or rather feeble, a little tender meat may be allowed, or, if preferred, a glass of porter. The dressings are taken off at the end of the third day to be renewed, and kept on, if necessary, for some time longer. Exposure to light must be very gradual, for the eye remains long weak and predisposed to inflammation. DISEASES OF THE CHAMBERS OF THE EYE. The only affections of the chambers of the eye requiring any special notice are dropsical accumulations, effusions of blood, and the development of hydatids. ' 1. A morbid accumulation of water, constituting what is called hydroph- thalmia, may exist simultaneously in both chambers or be confined to one, • more commonly the anterior. Dropsy of the anterior chamber is usually caused by inflammation of the membrane of Demours, a serous structure lining the cornea and the iris, both of which become more or less changed during the progress of the disease, the former being always abnormally pro- minent, and often somewhat nebulous, the latter dull and lustreless, with the pupil in a motionless and rather dilated condition. The ball is very hard in the earlier stages of the affection, but, as the dropsy advances, it generally becomes very soft, and fluctuates distinctly under pressure. The patient, experiencing a sense of distension, but no pain, is annoyed by deceptive vision, and gradually loses his sight, which is occasionally completely de- stroyed. The disease is sometimes congenital, or, at all events, arises soon after birth. In posterior hydrophthalmia, there is always, or nearly always, a dissolved state of the vitreous humor; the eye is very large, hard, painful, and moved with difficulty; the sight progressively diminishes; the iris is pushed for- wards into the anterior chamber; and the patient ultimately becomes com- pletely blind. Of the causes of this form of dropsy nothing is known. The prognosis in hydrophthalmia is extremely unfavorable, especially in the posterior variety. An attempt may be made at relief by frictions around the eye with mercurial ointment, and the use of minute doses of calomel, with CATARACT. 317 an occasional hydragogue cathartic, counter-irritation -behind the ears, and repeated evacuation of the fluid by means of a small puncture of the cornea. Rational, however, as this treatment apparently is, I have rarely derived any essential benefit from it. 2. In consequence of external violence, as a blow upon the ball, or surgical operations, or spontaneous rupture of some of its vessels, an effusion of blood occasionally takes place into the chambers of the eye. In the female, it has been observed to occur as an effect of amenorrhoea, and in both sexes as a symptom of a scorbutic state of the system, attended with hemorrhage in other parts of the body. The fluid usually disappears in a short time by absorp- tion ; when the quantity, however, is inordinate, it may prove a source of irritation by its pressure upon the iris and cornea, and should then be eva- cuated by a small puncture through the latter membrane. 3. A species of hydatid, the cellular cysticerce of naturalists, has been met with, in a few rare instances, in the anterior chamber, floating about in the aqueous humor. It has hitherto been observed exclusively in young subjects, mostly under Fig. 169. to excite inflammation in the inclosing struc- tures. On this account, it should be promptly removed by an incision through the cornea, the patient being under the influence of anaesthesia. DISEASES AND INJURIES OF THE CRYSTALLINE LENS AND ITS CAPSULE. CATARACT. Cataract may be defined to be an opacity of the crystalline lens, or of its capsule, or of both. In the first case it is called lenticular cataract, in the second, capsular, and in the last, capsulo-lenticular. These distinctions are of great practical moment, as'they exert an important influence -upon the operations which are required for their cure. There is another variety of the disease described by writers as cataract of the liquor of Morgagni, a fluid which is interposed between the lens and its capsule, and which occasionally assumes a milky appearance. Of the existence of this affection} as a distinct lesion, I entertain great doubt. Cataract may be single or double; simple or complicated; traumatic or idiopathic; recent or old ; mature or imma- ture. The import of these terms is so evident as not to require explanation. Of these different forms of cataract, the capsulo-lenticular is the most com- •mon; but of its relative frequency we have no knowledge. My own convic- tion is that both the others are very rare, from the fact that one of these structures cannot be diseased for any length of time, or to any considerable extent, without the other participating in the morbid action. I presume, indeed, that, whenever the capsule is at all seriously affected, the lens must also speedily suffer, although the converse of this statement may not be true; cases occasionally occurring where the lens incompletely opaque, and yet the capsule retains its transparency. 318 DISEASES AND INJURIES OF THE EYE. Cataract is a very common disease, and is liable to occur at all periods of life, from the moment of birth to the most profound decrepitude. Indeed, there is reason to believe, that it occasionally exists as an intra-uterine disease. Although it may show itself-at any age, yet experience has proved that the greatest number of cases are met with after the fiftieth year, or between .that period and. the sixty-fifth. Many cases also occur between the fortieth and fiftieth year. Young persons are comparatively exempt from it. The number of cases among children is considerable ; most of those that I have witnessed were either congenital, or arose-within the first few months after birth. The disease sometimes occurs in every member of the same family, as in a case mentioned to me by the late Professor Drake, where as many as six children suffered in this way. Twelve years ago, a man hrought to me three of his children, two sons and a daughter, on account of double cataract. Of his other six children, three were affected with strabismus. In another family, concerning which I was consulted more recently, four children out of six were the subjects of this disease, two having been affected with it from birth. Ur. Thomas J. Kennedy, of Tennessee, communicated to me, in 1842, the particu- lars of a family consisting of six children, of whom three had congenital cataract. Of these, two were idiotic, besides which one of them labored under hare-lip and cleft palate. Occasionally, again, the affection would seem to be hereditary, cases occurring in parents and their offspring for seve- ral successive generations. Males are more frequently affected with cataract than females; but in what ratio has not been determined. The probability is that the number of cases would be nearly, if not quite, alike in both sexes, if both were equally ex- posed to the exciting causes of the disease; for it can hardly be supposed that the difference depends upon any other circumstance, certainly not, so far at least as we can perceive, upon any difference in the organization of the eye. Causes.—Of the causes of cataract very little is known with any degree of certainty. My own belief has long been that the disease is generally developed under the influence of inflammation, leading to a deposition of fibrin or of fibrin and serum, into the substance of the lens and its capsule. It is in this way only that we can account for the opacity which takes place in these structures, and upon which the disease in question essentially depends. When cataract forms very rapidly, it is probable that these parts are struck with a species of senile gangrene, in consequence of obstruction of the central artery of the retina, thus cutting off the supply of blood, and producing a change of nutri- tion. What lends support to this view is the fact that opacity of the lens occasionally exists, without any disease apparently of its capsule, whereas, disease of the capsule, especially of its posterior segment, is always promptly followed by a change of color of the inclosed structure. Now, it is well known that the capsule of the lens receives the ramifications of the central artery of the retina; and, although we are not able to trace any of ita branches into the lens itself, yet it is reasonable to suppose that some of them pass into its substance. If we assume this to be the case, as I think we may, it is only necessary to imagine that these vessels are in a state of disease, and we will have an easy explanation of the formation of cataract When once the vascular connection of the lens and its capsule is destroyed, opacity is, inevitable. Of this occurrence we frequently see examples in injuries of the eye, attended with lesion or displacement of the lens, which are invariably followed by cataract, and that generally in a few hours. In old people, in whom cataract is so very common, the disease is probably the result of a species of atrophy, dependent upon a gradual diminution of the supply of blood, and ultimately complete arrest of the circulation. However we may explain the manner of its formation, cataract generally CATARACT. 319 comes on without any assignable cause, the subjects of it being often in the most perfect health at the time of its appearance, as well as during its subse- quent progress. Sometimes, but this is rare, it is traceable to the effects of external violence, as a blow upon the eye, or injury upon the head. Wounds of the lens and its capsule, whether incised, punctured, or lacerated, are, as was before stated, always followed by cataract. Violent ophthalmia, espe- cially when it involves the deeper structures of the eye, frequently leads.to this "disease, along with some of its worst complications. There are certain circumstances which are generally regarded, though, perhaps, not with sufficient reason, as so many predisposing -causes of cata- ract. ' Thus, it is said that cooks, blacksmiths, foundrymen, and persons of other kindred pursuits, are particularly prone to the disease. It is also supposed that sempstresses, watchmakers, and other artists, whose eyes are constantly upon the stretch in viewing minute objects, are unusually liable to suffer from cataract. Without wishing to assert that these statements are wholly untrue, I have no hesitation in declaring that I have seen nothing in my own practice to countenance them. Most of the cases of cataract that have fallen under my observation have occurred among farmers, mechanics, physicians, lawyers, and divines, who never injured themselves in this way, nor, so far as I. could ascertain, in any gther. Besides, the disease often occurs in infants and young children, at an age when such exposure is impos- sible. I have never had a case of cataract in a watchmaker, in a foundry- man, or even in a literary man who sat up late at night by the flame of his lamp or gas-burner. I believe, therefore, that many of what are considered as predisposing causes of cataract, exert no such influence, or only in a very remote degree. Of the effect of temperament upon the production of this disease we are totally ignorant; all that has been written respecting it is purely conjectural. Attention was called in 1859 by Mr. France, of London, to diabetes as a cause of cataract; and he has lately collected, from various sources, upwards of twenty cases illustrative of the truth of the position then assumed. In all of ^hese cases both eyes suffered simultaneously, and the affected lens, besides being soft, was always remarkably increased in its antero-posterior diameter, thereby sensibly encroaching upon the anterior chamber of the eye and even'upon the iris. Diabetes does not,-it wTould seem, cause cataract until it has reached its more advanced stages. Cataract generally forms in a very slow and gradual manner, several months usually elapsing from the time it becomes first apparent until it exhibits the characteristics of maturity. Occasionally, however, it is developed with great rapidity, altogether out of the ordinary course, as in a few hours, a night, or a day. A case in which a cataract seemed to have been formed in less than twenty-four hours was shown to me in 1855; by Dr. John Bartlett, in the surgical ward of the Louisville Hospital, in an old man, a gardener by occupation. .He first noticed that his sight was at fault in the morning, while at work in his grounds; it grew gradually more and more dim, and before night it was totally lost. An examination of the eye disclosed the existence of a well-developed cataract. The man was perfectly well at the time. He had lost the sight Of the other eye by inflammation some years before. The disease may begin simultaneously in both eyes, or one organ may suffer for a time, and then "the other may become affected in the same man- ner. There are cases, however, and they are by no means uucommon, in which the cataract is limited to one eye, the other escaping altogether, even it the patient survive the occurrence a long time. It is generally supposed that, when one eye is cataractous, the other will, sooner or later, become 320 DISEASES AND INJURIES OF THE EYE. cataractous also, in consequence of their sympathetic connection ; such an explanation, however, is obviously altogether insufficient, and we shall pro- bably be much nearer the truth if we ascribe the secondary affection to the same causes as the primary one. The starting point of the opacity is usu- ally the centre of the lens, from which it.gradually extends towards its peri- phery until the whole body is changed in its appearance. Morbid Anatomy.—Cataract varies much in its color, form, and consistence; so much, indeed, is this the case, that hardly any two instances of the disease are precisely alike. The most common color of cataract is whitish, with various intermediate shades of grayish, yellowish, greenish, or brownish. The whitish appear- ance may be dull and lustreless, or of a shining, glistening, or pearly cha- racter, like the interior of certain shells, or the surface of a silver coin. A yellowish, cineritious, amber, or pale buff tint is sometimes observed, although it is infrequent. A greenish, olive, or bluish-gray hue is also rare, and is generally indicative of a complicated state of disease. A brownish cataract is very uncommon ; and, as to the black variety of the affection, so much insisted upon by Beer and other German authors, I have never seen an ex- ample, although I would not go so far as altogether to deny its existence. That it is extremely rare is evideut from the fact that it is so seldom met with in practice. The color of cataract is rarely uniform throughout the entire extent of the diseased structure ; on the contrary, it is generally a shade or two darker at the centre than at the circumference. Cases occur in which the lens has a radiated, spoke-like, or stellar disposition,'caused simply by the lines which produce this appearance being of a darker color than the intervals between them. The capsular cataract is often a few shades lighter than the lenticular, and is also generally of a more uniform color. It has sometimes a speckled, dotted, or punctiform appearance. In its consistence, cataract varies from the fluidity of milk to the solidity of cheese, fibro-cartilage, cartilage, and even bone. The softer forms of the disease are most common in children and young subjects ; the harder, in old age and decrepitude. The fluid cataract is a rare occurrence; I have never seen more than three cases of it, and in those the lens was so soft-that its contents escaped and diffused themselves through the aqueous humor the moment the needle penetrated the capsule. In general, the consistence of the lens is equal to that of jelly, curds, a thick solution of isinglass, or the white of a soft-boiled egg. The hard cataract exhibits numerous varieties. Thus, it may be of the solidity of hard cheese, cartilage, bone, chalk, or earthy matter, very dry, inelastic, and incompressible. Capsular cataract is generally more or less tough, especially when old, and indisposed to yield under the pressure of the needle. The Morgagnian cataract is always fluid, or composed of a substance resembling whey, milk, or thin curds, both in color and consistence. It is worthy of note that an opaque lens is usually a few shades darker 1n the eye than it is after it has been extracted. The size of the lens, in a state of opacity, may be natural, augmented, or diminished. An increase of volume is most common in young subjects; elderly persons, on the contrary, have more* frequently atrophy of the lens. In congenital cataract, or cataract coming on soon after birth, the lens is often completely destroyed, or so much wasted that it may be said to exist only in a rudimentary state. The capsule, in such a case, either retains its normal volume and shape, or it is shrivelled into a small, hard, and irregular mass, hardly as large as a currant. A form of cataract, to which the term lamellar has been applied, has recently excited a good deal of attention. It was first noticed by Jaeger, CATARACT. 321 and was afterwards well described by Graefe. A short but graphic paper on the subject, setting forth the peculiar nature of the disease, was published by my friend Dr. E. Williams, of Cincinnati, in the North American Medico- Chirurgical Review, for September, 1857. It is most common in children under seven years of age, and essentially consists in a circumscribed opacity of a thin lamella of the lens; the periphery and central nucleus of which generally retain their natural transparency. Its progress is usually very slow, and it frequently happens that it remains completely stationary for years, if not during the rest of life. Cataract may exist as an independent affection, or it may be associated with other lesions. In the idiopathic form of the disease the different struc- tures are generally healthy; but when it has been caused by inflammation or external injury, it is often associated with disease of the cornea, iris, choroid, and retina, which thus seriously complicates the capsulo-lenticular malady, and exerts an unfavorable influence upon the prognosis. The general health may be perfectly natural, or variously altered; and this circumstance, again, may materially affect the issue of our curative measures. Symptoms.—Cataract usually begins as an opaque speck immediately be- hind the pupil, in the centre of the crystalline lens, from which it gradually extends, until the whole of this body is of a whitish, milky, grayish, or drab color, as seen in fig. 170. Sometimes the affected part, instead of being distinctly opaque, has merely a nebulous appearance, as Fig. 170. if it were suspended in the interior of the lens ; at other times the opacity shows itself simultaneously at every point, though not with equal distinctness. The pupil is generally natural, and readily dilates and contracts under the influence of the light, its free margin forming a dark circle immediately in front of the Cataract. cataract. The iris is unchanged in its shape, unless the diseased lens is unusually large, when it may be pushed a little forwards, and thereby rendered slightly convex. The cornea and aqueous humor retain their normal characters. During the formation of cataract, the patient is conscious of impairment of vision, usually very slight at first, but gradually augmenting in proportion to the increase of the opacity of the lens and its capsule. He sees objects indistinctly, and, as it were, through a veil, haze, or mist; his sight is better in cloudy weather than in clear, and in twilight than in the bright sun, be- cause the pupil, being then more dilated, admits a greater amount of light. In general, too, he can discern objects more distinctly by looking at them laterally than when they are placed directly in front of him. This is owing to the fact, already adverted to, that the opacity of the lens is generally greater at the centre than at the periphery, thus still permitting a certain quantity of light to come in contact with the retina. It is for the same rea- son that the sight is always temporarily improved by dilating the pupil with atropia. The formation of cataract is unattended with pain, intolerance of light, lachrymation, or disorder of the general health; and hence, but for the gradual loss of sight, the patient would not be aware at all of the existence of the disease. Diagnosis.—The only affections with which cataract is liable to be con- founded, are amaurosis and glaucoma. From these, however, it may, in general, be readily distinguished by the following circumstances, placed, for the sake of greater clearness and more easy reference, in tabular form :— VOL. ii._21 322 DISEASES AND INJURIES OF THE EYE. Cataract. 1. Impairment of vision is gradual, se- veral months generally elapsing before it is completely lost. 2. The opacity begins at the centre of the lens, from which it gradually spreads towards the periphery; it is superficial, well defined, and of a grayish, whitish, yellowish or pearl color. It is seen equally well, whether we view the eye sideways or directly from before backwards. 3. The pupil is natural, with a dark circle, and readily dilates and contracts under the influence of the light. It ex- pands readily and freely under the appli- cation of atropia. 4. Vision is best in cloudy weather, in twilight, in shady places, and when the back is turned towards the light. It is also increased under the influence of atropia. 3. The pupil is widely dilated, insensi- ble to light, and without any marginal circle. It dilates slowly and imperfectly, if at all, under the influence of medicine. 4. The patient sees objects most dis- tinctly in a bright light, and in a particu- lar direction, owing to the fact that the retina often remains sound, for some time, at one or more spots. No improvement of vision follows artificial dilatation of the pupil. 5. In amaurosis and glaucoma, there ia often, if not generally, hemicrania, with neuralgia in or about the eye, sick head- ache, and other marked evidence of gas- tric and general derangement. 6. In amaurosis and glaucoma, objects of the most grotesque appearance are con- stantly floating before the eye, and the patient is annoyed with scintillations or flashes of light. 7. Completely lost in the confirmed stage of the disease; prior to this, it is often alternately better and worse, in consonance with the condition of the general health. 8. The countenance has a singularly vacant appearance, and the eye looks as if ■ it were dead. 9. In amaurosis and glaucoma, the ball is often very soft, so that it may almost be indented with the point of the finger. Much stress has been laid by some writers upon the value of the catoptric test, as a means of diagnosis in cataract. It consists in holding a lighted taper before the eye, the pupil being previously dilated, and the examination being conducted in a dark room. If the cornea and lens are in a sound condition, three images will be perceived, two being erect, and the middle, or inter- mediate one, inverted. Of these images, the anterior is produced by the cornea, and is the most distinct; the posterior depends on the anterior sur- face of the lens, and is comparatively faint; the central is caused by the con- cave surface of the posterior wall of the capsule, and is the smallest of all. If the taper be moved, the two erect figures follow the light, but the inverted passes in the opposite direction. Now, in cataract, the middle one will be found, even at an early stage of the disease, to be very obscure, if not alto- gether absent, and the deep, erect one, very indistinct. In pure amaurosis, the three images of the candle are quite distinct. In glaucoma, on the con- trary, especially in its more confirmed stages, the inverted one is obliterated. It is remarkable that any surgeon, however ignorant, should ever mistake opacity of the cornea for cataract; such an occurrence would hardly seem credible if I had not repeatedly witnessed it in my practice. I have, again 5. Cataract forms without pain, head- ache, intolerance of light, or constitutional disorder. 6. In cataract, there is merely a mist or haziness before the eye, with a distorted appearance of objects. 7. The sight is seldom entirely destroy- ed, however protracted the disease. 8. The expression of the countenance is comparatively natural and cheerful; the only perceptible change in the eye is the pupillary opacity. 9. The eyeball retains its natural con- sistence. Amaurosis and Glaucoma. 1. Vision fails rapidly, and is often lost in a few days or weeks ; sometimes, in- deed, in a few hours. 2. It begins simultaneously at different points, is deep-seated, diffused, indistinct, and of a bluish, greenish, or azure hue. It is seen most satisfactorily when we look directly into the eye, not laterally. CATARACT. 323 and again, had patients sent to me from a great distance by men who ought to have known better, on account of supposed cataract, which, upon inspec- tion, proved to be nothing but a white speck upon the cornea, the result of former inflammation. Such mistakes are always highly disreputable, since any one of the slightest knowledge or experience cannot fail, with proper care, to arrive at a correct diagnosis, and that, too, without the aid of the catoptric test, and of the ophthalmoscope, which are at present such hobbies with professed oculists as means of exploration. The diagnosis of cataract will be greatly facilitated by the application of atropia, which, by dilating the pupil, enables us to observe the condition of the lens, and to determine the site of the opacity, as well as its nature and extent. Useful information in regard to the consistence of the cataract may generally be obtained by a consideration of the age of the patient, the dura- tion of the disease, and the color and size of the opaque body. The cataract of infancy is frequently capsular, or, if any portion of lens remains, it is quite small; in children and young subjects, the lens is generally soft; in elderly persons, on the other hand, it is nearly always hard. A very white or pearl- colored cataract is ordinarily soft; so, also, a cataract of unusually large volume. The very hard cataract is commonly small, and of a yellowish, drab, or amber hue. A recent cataract is generally soft; an old cataract, hard. To these rules, however, there are, as might be expected, numerous exceptions, which should have due weight in our attempts at the establish- ment of a correct diagnosis. The most important symptoms of lamellar cataract are nearsightedness and a peculiar expression of the features, such as so commonly attends par- tial blindness. The diagnosis, however, can seldom be satisfactorily deter- mined without the aid of the ophthalmoscope. What is called a false cataract is nothing but a layer of plastic matter, in a state of organization, which either completely fills the pupil, or which is stretched across the orifice, from one point of its margin to another. The opacity is immediately within the pupil, which is, at the same time, generally considerably contracted, and perfectly immovable, even, perhaps, under the influence of atropia. Vision is more or less impaired, and sometimes com- pletely destroyed, the pupil being so completely shut up as not to admit a ray of light. Treatment.—When cataract has once commenced to form, no remedies, or mode of treatment, can arrest its progress ; on the contrary, it will be sure to advance until the opacity is complete, and vision is almost entirely lost. Should one eye alone be originally affected, the other is extremely liable to become affected also ; whether by sympathy, or in consequence of the same causes which occasioned the disease in the first instance, experience has not determined. The result of operation, which alone can prove of any benefit in curing the disease, will be influenced by a great variety of circumstances, among which the most important are the state of the patient's health, the presence or absence of complications, and the amount of inflammation conse- quent upon the interference. Infancy and old age are no bar to surgical interference or its success; I have operated repeatedly, with the most happy effect, within the first six weeks after birth, and upon subjects after the seven- tieth year. In three cases I have succeeded in restoring excellent vision at eighty, eighty-two, and eighty-three. In my own practice I never pay any attention to season, as is the case with some foreign surgeons. I prefer, however, to operate in the spring and autumn, although I never put off a case merely on account of cold or hot weather. A spontaneous cure of cataract is possible, but certainly extremely uncom- mon. One such case was reported in the Maryland and Virginia Medical Journal for February, 1861, by Dr. Peachy, of Richmond, the patient being 324 DISEASES AND INJURIES OF THE EYE. a man, fifty-four years of age. The lens, apparently hard, and of an amber color, escaped into the anterior chamber of the eye, below the axis of vision, where it underwent complete absorption, followed by perfect restoration of the sight. The disease had existed for many years. It is customary with all surgeons to subject their cataract patients to a certain amount of treatment before they have recourse to operative inter- ference. Such a course cannot be too highly commended. It is particularly necessary in middle-aged and elderly subjects; not so much so in children and young adults, while in infants at the breast it may, in general, be alto- gether dispensed with. The extent of this preliminary preparation of the system must depend upon circumstances. If the patient is otherwise per- fectly healthy, it need not be carried beyond the observance of rest and light diet for a week or ten days, and the administration of one or two very mild purgatives ; under opposite circumstances, however, a longer ordeal may be called for. This is particularly true when there is a rheumatic or gouty state of the system, a disposition to neuralgia, or a tendency to inflammation of the eye. When this is the case, it is hardly possible to be too careful respect- ing the preliminary treatment. For the want of proper attention to this point I have seen more than one eye lost. In general, it is advisable not to operate until we are certain that the secretions are in the most healthy condition, and that all tendency, if any existed, to inflammation of the eyes has disappeared. If the individual is inordinately plethoric he may be bled once at the arm, and take an active cathartic every other night for a week before the opera- tion. AVhen a gouty or rheumatic predisposition exists, a preliminary course of colchicum may be necessary ; and in such cases I have sometimes been in doubt whether interference should not always be postponed until warm weather has set in, as there will then be less likelihood of an attack of the disease. It is a good rule not to operate so long as one eye only is affected; for the reason that, if violent inflammation should arise, it may extend to the sound organ, and thus jeopard the safety of both. Besides, even if there were no risk of this kind, which, I think, has been much exaggerated, but the result be ever so favorable, still, the eyes, not being in the same focal condition, could not enjoy a similar amount of vision, and therefore the patient might, at least for some time, be worse off than before, although he had gotten rid of the opacity of the lens, and the consequent disfigurement of the part. Such operations are operations of expediency, and their per- formance is always of questionable propriety. In case, however, cataract exists in both eyes, although only in an incipient degree in one, the rule ia to operate upon the bad eye now, and at some future period, when the sight shall have more declined, upon the other. What should be our rule of con- duct when both organs are affected in an equal degree, or when the person is nearly or totally blind ? This question has been answered differently by different writers. For my own part, I never hesitate to attack both eyes at the same sitting, believing that there is no more risk than when we operate only upon one organ, while the procedure has the great advantage of obvia- ting protracted confinement, and preventing mental anxiety. I do not think that I have ever had cause, in a solitary instance, to regret this step. The operations which have been devised for the cure of cataract are quite numerous, but they may all be referred to three principal methods, namely, displacement, division, and extraction. As these methods are not equally adapted to all cases, much judgment is often required in regard to their par- ticular application. Thus, it may be stated, as a general rule, that extrac- tion can be practised only when the cataract is hard, and division when it is soft. A hard cataract may also be depressed, but not a fluid one. Age likewise influences the choice of the operation. In infants and children we never extract, but limit ourselves to couching and laceration. CATARACT. 325 1. Division of the Lens.—Divisiou of the cataract, or the operation by solution, consists, as the name implies, in cutting the opaque leus and its cap- sule into numerous pieces, and pushing them forwards into the anterior chamber, in order to subject them more effectually to the influence of the aqueous humor. The pupil is thoroughly dilated by atropia, and the lids are Fig. 171. Fig. 172. Operation of solution. disposed in the manner exhibited in fig. 171, the patient sitting upon a chair with the head well supported by an assistant. The needle which I generally employ is one of remarkable delicacy, perfectly straight, and sharp-pointed. Some surgeons prefer a curved in- strument, as that of Scarpa, represented in fig. 172; but I have not been able to satisfy myself that it possesses any advantage over, if indeed it is equal to, the straight. Whatever may be its shape and size, it should be intro- duced at least two lines and a half behind the cornea, a little below the horizontal diameter of the eye, in order to avoid the long ciliary artery ; the point should then be directed forwards in front of the lens and its capsule, which are now pierced and thoroughly comminuted, care being taken, before the instrument is withdrawn, to push as many fragments forwards as possible through the di- lated pupil into the anterior chamber. The object of the whole proceeding is to bring the opaque structures, after they have been properly divided, under the influ- ence of the aqueous humor, and the more effectually this is done the more rapidly will they be dissolved. It is still a mooted point whether the aqueous humor really possesses any solvent power or not, or whether the dis- appearance of the cataract is not entirely due to the ac- tion of the absorbent vessels of the membrane of De- mours. When we take into consideration the fact that pieces of cataract, both lenticular and capsular, which float about in the aqueous humor, often vanish in a very short time, without any but the most casual and tran- sient contact with the structure here adverted to, it seems difficult to deny to this fluid such a property, although we may not be able to discover Scarpa's needle. 1. Front view. 2. Side view. 326 DISEASES AND INJURIES OF THE EYE. where it resides, seeing that it is composed essentially of water and a little saline matter, which are destitute of such properties out of the body. Dr. Hays, of this city, who has much experience as an ophthalmic surgeon, has devised an ingenious instrument for cutting up hard cataracts, and expe- rience has shown him that the operation is generally followed by the most gratifying results. The instrument, which is here represented of the natural size, fig. 173, combines both the advantages of a knife and a needle; it is very acute at the point, and has a double cutting edge, a little over four lines in length on one side, but much less on the other. The whole arrangement bears a very close resemblance to that of an iris-knife. The instrument is introduced in the usual manner, and brought in contact with the anterior surface of the opaque lens, which, together with its capsule, is then freely lacerated and divided in front, in order that the remainder of the body may be fully exposed to the action of the aqueous humor, and so become softened Fig. 173. A Fig. 174. Keratonyxis. and ultimately absorbed. If this be slow in taking place, an- other operation is performed. If the cataract be comparatively soft, the whole of it may be completely divided at the first sit- ting. The pupil should be well dilated at the time of the ope- ration, and, also, for some days afterwards. There is another method of performing this operation, in which the needle is introduced at the lower part of the cornea, as in fig. 174, and made to act upon the capsule and lens through the anterior chamber. This is called the operation of kera- tonyxis, or, simply, the anterior operation. The pupil being widely dilated, the head and eyelids are secured as in the more ordinary procedure, when the cataract is freely divided with a very delicate needle, either straight or slightly curved, as many of its fragments as possible being brought forwards in front of the iris. The instrument must be inserted near the outer border of the cornea, so that the resulting inflammation, if severe, may not lead to any injurious opacity, interfering with the transmis- sion of light. I have performed this operation only a few times, and the result was such as to induce me to form rathex an un- favorable opinion of it, as I found it not only awkwara of exe- cution, but followed by too much excitement, at the same time that it does not possess, so far as I can perceive, any superiority over the posterior method. The operation by solution is admirably adapted to the cata- ract of infants and young children. The patient, being under the influence of anassthesia, should be supported upon the lap of an assistant, or, what is preferable, his head should be placed between the surgeon's knees, while the body and limbs are held by a second person. If the exhibition of chloroform be unde- sirable, the little child is wrapped up tightly in an apron, as in the operation for hare-lip. This precaution is indispensable to the success of the undertaking. In other respects, the proceeding is the same as when we operate upon the adult. Hays's knife- needle. CATARACT. 327 The question is often asked, At what period is it proper to operate in cases of congenital cataract ? To this I unhesitatingly reply, at any period, provided the ej"e and general system are in a sound condition. I have re- peatedly operated upon children under six months, and once upon an infant hardly four weeks old, and in almost every instance with the most gratifying results. Indeed, I have never, except in a solitary instance, and then I did not have charge of the after-treatment, seen anything like active inflamma- tion after the operation, however early performed. My experience is that children, in general, bear this kind of meddling much better than grown per- sons, their nervous system, although easily shocked, recovering much sooner from the effects of the operation than adults. The operation of drilling, devised by the late Mr. Tyrrell, of London, is a modification of keratonyxis, and may sometimes be usefully employed in false cataract, or in ordinary cataract attended with great contraction of the pupil, or contraction of the pupil and adhesion of its edges to the anterior surface of the lens. It is executed by carrying the common straight needle through the cornea, and thence on across the pupil, into the centre of the opaque lens, which is then perforated in such a manner as to admit the aqueous humor. The process is generally obliged to be repeated from four to eight times, before a sufficient tunnel is obtained for the transmission of light for useful vision. Such an operation is of questionable utility, and might, I should suppose, be advantageously replaced, in every case, by the posterior pro- cedure; for, besides the awkwardness attendant upon its performance, its frequent repetition is well calculated to lead to serious, if not destructive, inflammation. 2. Displacement of the Lens.—In the operation by displacement, more com- monly called the operation of couching or depression, the lens is removed from the axis of vision, and buried in the substance of the vitreous humor. The pupil being widely dilated, the patient's head properly steadied, and the lids held out of the way, a curved needle, very delicate, and somewhat spear- shaped, is pushed across the coats of the eye, at least two lines and a half behind the cornea, and carried carefully forwards until the point becomes visible in front of the cataract, as in fig. 175. The point being now applied Fig. 175. Fig. 176. Depression of cataract. against the lens, this is next pressed downwards and backwards into the vit- reous humor beyond the axis of vision, and out of reach of the retina and the ciliary processes, as shown in fig. 176. The needle, being disengaged, is re- tained for a few seconds in the eye, to ascertain whether or not the cataract is disposed to rise ; if it is, it is again depressed, and now with still greater care. I do not find it necessary, as some operators seem to do, to lacerate the anterior segment of the capsule as a preliminary step in this operation ; on the contrary, I prefer, whenever this is practicable, to dislodge both lens and capsule at the same time. Where this precaution is neglected, there is 328 DISEASES AND INJURIES OF THE EYE. danger that a portion of this membrane will remain, and afterwards act ob- structingly. Two circumstances are absolutely necessary to insure the successful execu- tion of this operation, namely, a certain degree of firmness on the part of the cataract, and a tolerably healthy condition of the vitreous humor. If the lens be soft, it will be impossible to depress it; and, on the other hand, if the vitreous humor be fluid, or partially dissolved, it will be impossible to prevent the lens from rising after it has been displaced. These facts are self-evident, and do not, therefore, require any special illustration. The result of the operation is liable to be marred by the occurrence of retinitis; and the possibility of such an occurrence is not merely in the first instance, within a few days or weeks, for example, after the operation, but secondary, that is, a long time after the patient has recovered from its primi- tive effects, and, perhaps, years after he has enjoyed excellent sight. The cause of this is the pressure which the depressed lens exerts upon the retina and the ciliary processes ; and hence, as already intimated, the surgeon can- not be too cautious in guarding against this contingency in performing the operation. This, however, unfortunately, will not always be a sufficient guarantee against this occurrence ; for it is well known that the weight and pressure of the lens, even when this body is originally most eligibly situated, may gradually bring about a dissolved condition of the vitreous humor, and thus enable it to come in direct contact with the delicate and important structures here referred to. Such contact, no matter when it may take place, will, in most cases, excite inflammation of the retina, followed by complete disorganization of its substance, and, consequently, total loss of sight. There is reason to believe that the lens, if not too hard, ultimately disappears after this operation, or, at all events, all but its central and more compact portion; but cases are met with, as dissection has demonstrated, in which nearly the whole of it remains, and it is these which are likely to become a source of difficulty, perhaps, long after the eye has recovered from the primitive effects of the operation. Professor Pancoast, with a view of obviating the objections against the operation of couching, as usually performed, has devised a modification of it, which he denominates horizontal displacement. The pupil being widely dilated, the needle, which is a delicate, angular, hooked one, is inserted just behind the commencement of the non-plicated portion of the ciliary body, either a little above or below the horizontal diameter of the eye; and the moment it has fairly entered the anterior portion of the vitreous humor, the handle is inclined backwards, in order that the convex part of the point may be carried safely forwards in front of the lens, without endangering the iris and ciliary processes. The capsule being now freely lacerated, the hook is fixed in the centre of the lens, which is then gently drawn backwards, along the track made by the needle, until it comes opposite the puncture, where it is allowed to remain, care being taken not to let it press with any force against the retina. The advantages of this operation, as claimed by Professor Pancoast, are, first, that it is not attended with any injury to the iris and ciliary processes, and, secondly, that, being suspended in the vitreous humor, the dislocated lens is not liable to press upon the retina, and so cause destructive inflam- mation of that membrane and of the choroid. He states that he has per- formed the operation in numerous cases, and always with the most gratifying results. For many years past, I have been in the habit of performing a mixed operation for cataract, consisting in a combination of division and couching. The procedure, as the name implies, is executed by breaking up the outer and more fluid portions of the opaque lens, and burying the remainder in the CATARACT. 329 substance of the vitreous humor. It is, consequently, not adapted either to the very soft or to the very hard cataract, but to a union of the two ; an occurrence sufficiently frequent to render the operation one of no little im- portance. Not having preserved a record of my cases, I am not able to state how often I have performed this operation, or with what results; I am, how- ever, positively certain that it has never been productive, in my hands, of violent, much less of destructive, inflammation, and that in nearly every in- stance the patient had good vision afterwards. The pupil is dilated, as in the ordinary procedure, and everything else is precisely similar. I do not deem it necessary to describe the operation of reclination, as it is termed, a modification of the ordinary process of displacement, inasmuch as, in my judgment, it should be banished from practice. I have never performed it myself, but the cases of it that have fallen under my notice have all speedily terminated in total blindness. 3. Extraction___The operation of extraction is a much nicer and much more delicate procedure than that of depression or laceration ; it requires great coolness and dexterity on the part of the surgeon, and the most thorough co-operation on the part of the patient, for its successful execution. It is said of Wenzel that he spoiled a whole hatful of eyes before he had learned the art of extracting. This statement, without being strictly true, affords an excellent illustration of the difficulties which attend this operation, and a reason why so few practitioners are found who are ready and willing to under- take it. Extraction is adapted only to certain forms and conditions of cataract. Thus, it is absolutely necessary that the cataract should be hard ; that there should be a very convex cornea, and a sound pupil; and lastly, that the eye should not be situated too deeply in its socket, or, what is the same thing, that there should not be too prominent an arch, interfering with the requisite manipulation in performing the operation. Where the reverse of these con- ditions obtains, extraction of the lens will either be wholly impracticable, or attended with so much risk as to render the attempt improper, if not unjusti- fiable. Infancy and childhood are also bars to the operation. When well executed, and all the pre-existing circumstances are propitious, it is the least objectionable operation of all; the whole of the opaque body is disposed of at a single sitting, the corneal wound generally heals by the first intention, and there is no danger either of immediate or secondary injury to the internal structures of the eye. On the other hand, if the greatest precaution be not exercised, there may be a sudden and unexpected escape of the different humors of the organ, followed by complete collapse, or the eye may be de- stroyed within the first few days by the resulting inflammation. The latter risk, however, is shared by this operation in common with that of depression and of laceration. In performing the operation, the patient may either sit upon a chair, with his head reclining against the breast of an assistant, and held perfectly quiet; or, which I always prefer, lie upon a lounge, sofa, or narrow bed, the head and shoulders being properly supported by pillows, so as to render the former almost horizontal. If the patient is very timid or nervous, I do not hesitate to place him under the influence of chloroform, satisfied that the risk of losing the eye by vomiting is an extremely remote and improbable one. The pupil is not dilated as in depression and laceration. The upper lid is raised by an assistant, with the precaution of not pressing upon the eye, while the globe is fixed by seizing hold of a fold of the conjunctiva a quarter of an inch below the cornea, with the instrument sketched in fig. 177, and which also depresses the lower lid. The eye is now drawn somewhat down, when the surgeon, armed with a Beer's knife, represented in fig. 178, to which 1 generally give the preference, inserts the point—supposing he is operating 330 DISEASES AND INJURIES OF THE EYE. upon the left organ—into the cornea within a third of a line from its junc- tion with the sclerotica, and a short distance below the horizontal equator. Fig. 177. Fig. 178. Conjunctiva forceps. Superior section of the cornea. carried carefully and slowly across towards the opposite side, in front of the iris, and brought out in such a manner as to divide fully one-half of the cornea, either at its upper, lower, or infero-external aspect, as may be most convenient; for, in point of utility, it really does not matter which, though the upper section is usually preferred. The extremity of the knife issues at the same distance precisely from the sclerotica as that at which it entered. These several procedures are represented in figs. 179, 180, and 181. Fig. 180. Fig. 181. Inferior section of the cornea. Exterior and inferior section of the cornea. The section of the cornea being completed, the eye is immediately libe- rated, and permitted to conceal itself behind its lids, in order to enjoy a moment's repose. The next step of the operation consists in gently separating the upper lid, with a view of ascertaining whether the lens has any disposition to advance A CATARACT. 331 across the pupil. If it have, its expulsion is promoted by slight pressure upon the ball of the eye with the handle of a knife or the end of the index finger. Should this fail, the surgeon then introduces a delicate hook, represented in the accompanying cut, fig. 182, and lacerates the central portion of the capsule; the lens, being thus liberated, now issues of its own accord, or, at all events, with the aid of a little friction upon the globe. Fig. 183 represents the lens as it is passing through the wound in the cornea. Fig. 183. Lens passing through incision of the cornea. The third and last stage of the operation consists in replacing the iris, should it be prolapsed, in re-adjusting the flaps of the cornea, and in confining the lids by means of several strips of isinglass plaster, with the twofold object of keeping them quiet and of preventing the introduction of the light. A light band- age, or, what is better, a very thin handkerchief, carfied around the head, completes the dressing. Several accidents are liable to happen during this operation, which the surgeon should take great care to avoid. 1st. The point of the knife may become entangled in the iris in making the section of the cornea; should this happen, the instrument must be disengaged, but not withdrawn, and the iris stimulated to contraction by gentle friction upon the cornea. This failing, the knife is laid aside, and the division completed with a probe-pointed bistoury, fig. 184, or a pair of scissors, fig. Fig. 184. Curved cornea knife. Fig. 182. 9 Curette with silver scoop. 185, one blade of which is blunt at the end. The flap, as already stated, should comprise fully one-half of the circumference of the cornea. 2d. There may be prolapse of the iris; this occurrence is by no means unusual, and is generally easily remedied, replacement being readily effected with a small probe. 3d. There may be an escape of the vitreous humor, followed by partial or complete collapse of the globe. This may be occasioned simply by the in- voluntary action of the muscles of the eye, and, therefore, be wholly beyond the control of the surgeon ; or it may be caused by too free a section of the 332 DISEASES AND INJURIES OF THE EYE. cornea, or by inadvertent pressure upon the globe. However induced, the eye should instantly be closed, and after having had a brief period of repose, the parts should be re-adjusted, as under ordinary circumstances. Fig. 185. Probe-pointed scissors. 4th. The capsule may remain, the lens alone escaping, and thus rendering the cure imperfect. The proper plan, in such a case, is either to extract the capsule on the spot, or to dispose of it with the needle, when the eye shall have recovered from the immediate effects of the operation. It sometimes happens, after the operation of extraction, that a portion of the capsule, hard, shrivelled, and incapable of absorption, remains in the eye, sadly interfering with vision, floating, perhaps, about behind the pupil. When this is the case, riddance is best effected by what is called linear extraction, performed by making a small opening into the inferior and outer portion of the cornea, not more than the sixth or eighth of an inch in extent. Through the aperture thus made the offending substance may easily be drawn with a delicate hook or pair of forceps. A similar procedure may be employed when portions of a hardjcataract, pushed forwards into the anterior chamber during the division of the lens, press injuriously against the cornea. The operation has the advantage of being very simple, and of not being followed by severe inflammation. After-treatment.—The after-treatment, in all these operations, is conducted upon the same rigid antiphlogistic principles. The light is carefully excluded from the apartment, the patient's head and shoulders are constantly main- tained in an elevated position, the diet is of the mildest character, and the bowels are acted upon, at least every other day, by a moderately brisk cathar- tic. If active inflammation arise, blood is taken freely from the arm, and by leeches or cups from the temples, blisters are applied to the inner surface of the arm, and the eyes are frequently fomented with warm chamomile tea containing a few drops of Goulard's extract and wine of opium. If there be much pain, especially if it is of a neuralgic nature, calomel and opium, calo- mel and Dover's powder, or, what will be found more efficacious than either, wine of colchicum and acetate of morphia, are freely used. As a general rule, the eye should not be inspected until the end of the third day, and then only in the most cautious manner possible; for the contact, even of the smallest quantity of light, often proves immensely injurious. The bandage may usually be dispensed with in a week or ten days, a green shade being used as a substitute. The eye must not be employed upon minute objects for several months, and the patient should consider himself for a long time as an invalid, avoiding all indiscretions, both bodily and mental. As the sight improves in strength, aud all tenderness consequent upon the operation has disappeared, but not until then, he may begin to wear cataract glasses, DISLOCATION OF THE CRYSTALLINE LENS. 333 of which he should furnish himself with two pairs; one for ordinary purposes, and the other for reading. Much of the success which has attended these operations in my hands may, I think, be ascribed to the care which I have always taken in preparing the patient's system, and to the practice which I have pursued, for many years, of administering a full anodyne immediately after he has been put to bed. The article which I usually employ is sulphate of morphia, of which one grain may very properly be given, if the patient be an adult. This seldom fails to prevent pain, and to induce sleep, two circumstances of immense consequence as it respects the favorable issue of the case. If rest be of any value in the treatment of inflammation, surely it ought to be of the greatest possible benefit in this disease, when it affects so tender and delicate an organ as the eye; and I know of no means so well calculated to insure this end as a good, large dose of morphia, given in the way here specified. It is especially valuable in nervous, irritable persons, and in such as are liable to suffer from nausea and severe shock after trifling accidents and operations. In regard to the relative merits of these operations, we are not in posses- sion of any statistical facts which can aid us in deciding the question. My favorite method, as before intimated, has been, for a long time, the double operation of laceration and depression, and such is my confidence in its supe- riority that I shall continue to practise it until there are more substantial reasons than I now have for abandoning it. We have already seen that no one procedure is exclusively applicable to all cases, and there can be no ques- tion that each is capable of affording excellent results in the hands of a judi- cious surgeon. Destructive inflammation will occasionally follow, no matter how careful we are; no honest man will pretend to uniform success; every- thing may go on well for a number of days, and the case be, in every respect, most promising, when, all of a sudden, some unfavorable circumstance may arise, and the eye be irretrievably lost. Such a contingency should put us upon our guard, and render us cautious in respect to our prognosis. It is far better, after every operation for cataract, to promise too little than too much. The patient should always be told that he must bide his time. DISLOCATION OF THE CRYSTALLINE LENS. Dislocation of the crystalline lens forwards into the anterior chamber, ex- hibited in fig. 186, is a rare occurrence. I have met with but two cases of it. It generally comes on spontaneously, or without any assignable cause, although sometimes it is chargeable to external violence, directly or indirectly applied. Blindness, partial or complete, is the necessary consequence of such an acci- dent, and it may easily be conceived how the resulting inflammation might destroy the eye. The following is a brief outline of the cases adverted to. Catharine Monheimer, a married woman, aged thirty-six, a native of Ger- many, had been laboring under dislocation of the lens of the left eye for three years, when I first saw her, in October, 1849. The accident happened sud- denly one night without any pain or even any unpleasant feeling, apparently while she was asleep. The next day, however, she was seized with violent pain and inflammation, which lasted for nearly two months, when it gradually subsided. It is worthy of remark that she had had no sight in that eye for seven years previously. The lens lay in the lower part of the anterior cham- ber, in close contact with the cornea and iris, and was of a conical shape, the apex looking upwards; it was opaque inferiorly, but semi-transparent above, and was so situated as almost to close the pupil. The cornea was natural, but the iris was tremulous, thrust back, or indented below, and changed in color, being much lighter than the right, which was of a grayish 334 DISEASES AND INJURIES OF THE EYE. Fig. 186. hue. The pupil was small, and im- movable. The sight was completely destroyed. The other case was that of n colored woman, aged forty-nine; the right lens, which had been dislocated for four years, without any assign- able cause, was of a dirty drab color, and occupied the anterior chamber; it rested against the posterior sur- face of the cornea, and pressed aside the iris, the pupil being contracted into a narrow, slit-like aperture. The eye was completely blind, and had been the seat of neuralgia, off and on, ever since the accident, which was followed by severe in- flammation. The proper remedy for such an occurrence is obviously extraction of the lens, with the employment of active antiphlogistic measures, to moderate and relieve the resulting Dislocation of the lens into the anterior chamber. inflammation. If the Case is One of long standing, the operation would still be proper as a means of improving the appearance of the eye, and pre- venting secondary effects. DISEASES OF THE RETINA. The retina, like the other tissues of the eye, is liable to inflammation and its various consequences, particularly effusions of fibrin, serum, and blood, leading to disorganization of its structure and to loss of function. The dis- ease, at one time, is acute and characteristic, being marked by symptoms which no one can possibly mistake ; at another, slow, chronic, and so obscure as to elude the closest scrutiny ; now transient and easily combated; now in- conceivably obstinate, and hopelessly irremediable. Considering the delicate structure of the retina, its concealed situation, the importance of its functions, and the extent and character of its connections, it is not surprising that the nature of its diseases should have been so long misapprehended, misinter- preted, and misunderstood. As these lesions are never fatal, few chances have been afforded of inspecting the eye after death, and therefore, much of what has been written about the pathology of this membrane is based rather upon conjecture than upon the results of actual observation. Now, however, that the ophthalmoscope has been introduced, we may hope soon to be able to elicit important information in regard to the nature and diagnosis of these affections, and, consequently, also respecting their treatment; already light is gleaming in the distance, and the combined researches of scientific surgeons in different parts of the world cannot fail to lead to useful revelations. If the instrument do no more than teach us the utterly hopeless nature of certain maladies, and the folly of treating them with harsh, injurious remedies, it will confer incalculable benefit; but it will, doubtless, do more; by enabling us to make out an early diagnosis in cases hitherto found impossible of recognition, it will lead to the establishment of a more rational pathology and practice. The only affections of the retina which will require notice in a work of this kind are acute and chronic inflammation. DISEASES OF THE RETINA. 335 1. Acute retinitis is rare as a pure, uncomplicated disease, but as a second- ary affection it is by no means uncommon. There are few cases of violent sclerotitis, iritis, and corneitis in which the retina does not participate, to a greater or less extent, during the progress of the morbid action. The causes of the complaint are not always obvious. It is generally said to be owing to exposure of the eye to intense light, as in looking at the sun, or at the fire of a furnace; excessive and long-continued fatigue of the organ ; and to various kinds of external injury, especially such as involve the iris and ciliary ligament. In general, only one eye is affected at the beginning, but as the disease progresses the other may also be invaded, the probability of this being so much the greater if the inflammation be very intense and protracted. Acute retinitis is sometimes observed in lying-in females, within the first ten days after parturition. I have seen several cases of this kind, in each of which the attack seemed to be associated with, or dependent upon, a rheu- matic state of the system. Very young subjects rarely suffer from this disease, except as a secondary affection. Finally, the inflammation may invade a part of the retina, or the whole membrane. The most prominent symptoms of acute retinitis are, violent pain, excessive intolerance of light, profuse lachrymation, scintillations, and various kinds of spectres, with rapid failure of sight, generally eventuating in total blindness. The pain, perhaps intermittent at the commencement, soon becomes intense and distracting ; it is deep-seated, darts about in different directions, and is often attended with intolerable hemicrania. The patient is annoyed by flashes of light, sparks, or luminous bodies, and by an endless variety of the most grotesque objects, which float before his eyes and disturb his imagination. The affected organ feels full and tense, as if it would burst, and the slightest motion or pressure is attended by an increase of the local distress. Photo- phobia and lachrymation are usually present in a marked degree, beginning early, and lasting throughout the attack. In the more violent and rapid forms of retinitis there is often total extinguishment of vision in a few hours, before there is any apparent involvement of the other structures of the eye. The pupil, in acute retinitis, is, at first, slightly contracted, sluggish, and irregular; by and by, however, it becomes dilated, and ultimately, when the disease is fully established, it is expanded to the very utmost, and totally insensible to light. A vascular zone is often perceptible at the anterior part of the sclerotica, but it is much more faint than in iritis and corneitis, and is, therefore, of great diagnostic value. W7hen the malady continues for any length of time, the other tunics of the eye participate in the inflammation ; the iris is changed in its color, the cornea is rendered hazy, and the con- junctiva and sclerotica are red and deeply injected. Suppuration of the eye is a rare occurrence. There is no disease with which acute retinitis can possibly be confounded. The distracting and intolerable pain, the flashes of light, the spectral illu- sions, the absence of the ordinary phenomena of disease in the other tissues of the eye, the motionless and dilated state of the pupil, and the rapid dimi- nution of sight, with its ultimate complete extinguishment, are unmistakable evidences of the nature of the complaint. The prognosis in this disease is most unfavorable. Even in the milder cases, complete recovery is seldom to be looked for, while, in the more violent, total blindness may be considered as inevitable. Under such circumstances, the retina is apparently completely overwhelmed by the disease, its substance being irretrievably disorganized by the inflammatory action. Wre cannot speak positively of the morbid deposits in this disease, but we may sup- pose that they consist of serum, fibrin, and blood, either alone, or variously combined. the treatment of acute retinitis must obviously be of the most vigorous 336 DISEASES AND INJURIES OF THE EYE. character; for, it need hardly be added, after what has been said respecting the rapid and destrnctive march of the disease, that, even if only a few hours are lost in indecision, the sight may be hopelessly destroyed. Copious vene- section, leeches to the temples, active purgation, and the use of antimonials and opiates, with rapid ptyalism, are the remedies mostly to be relied upon. Unfortunately, the sight is often completely annihilated before we are able to see the case, the patient, in fancied security, hoping that the inflammation will soon subside of its own accord, when, in fact, it has probably already done its worst. 2. Chronic retinitis may be a sequel of an acute attack, or it may exist as an original and independent affection, coming on in a gradual and stealthy manner, slowly, but surely, undermining structure and function. Among the more common causes of the disease are, over-exertion of the eye, long-con- tinued exposure to vivid light, external injury, and neuralgia of the ophthal- mic branches of the fifth pair of nerves. Excessive indulgence in eating and drinking, abuse of sexual intercourse, and suppression of habitual discharges, are also capable of producing the affection. A gouty and rheumatic state of the system has been known to predispose to an attack of this kind. Several years ago, a gentleman was under my care on account of chronic retinitis, contracted while travelling in a railroad car, during a long journey ; he had formerly been a martyr to rheumatism, and had just suffered from a slight attack of his old complaint, when his eye became affected. The symptoms of retinitis had existed, in a gradually ingravescent form, for nearly two months, when, almost suddenly, they disappeared upon a recurrence of severe inflam- mation in the right knee. One of the most common causes of this disease, according to my experience, is circumorbital neuralgia. In the Southwest, chronic retinitis, from this affection, is by no means infrequent. During my residence at Louisville, a period of sixteen years, I met with many cases which clearly owed their origin to this circumstance alone. The operation for cata- ract by depression is occasionally followed by chronic retinitis. The symptoms of the disease are generally strikingly characteristic. The patient complains of deep-seated pain in the eye, with neuralgic pain in the forehead, face, and temple; he is annoyed with sparks, flashes of light, or luminous bodies, and his sight progressively diminishes, growing daily more and more dim, so that at length he can, perhaps, barely distinguish light from darkness. In general, he can see objects better in bright than in cloudy weather, and at noon-day than in twilight, especially when his back is turned towards the sun. Various fantastic objects usually float before his eye; everything looks as if it were veiled in a mist, haze, or spray; now an insect, as a fly, gnat, or spider, is in the way ; now a shower of dust, or particles of dirt; now a thick cloud; now the bough of a tree, a cobweb, or gauze, or an appearance of shooting stars. If, before the sight is much impaired, the patient attempts to read/^the letters will be found to look as if they were fused together, as if they were turned upside down, or as if they were unnaturally short or unnaturally long; his eyes become immediately fatigued aod pain- ful, and, for some hours afterwards, his vision will be proportionately more dim. The pupil, at first merely-a little sluggish and somewhat dilated, be- comes gradually completely insensible to light, and expanded to the very utmost, forming merely a black, narrow ring behind the cornea; besides, it is more or less irregular in its shape, the most common deviations being the oval and angular. The interior of the eye looks dead and lustreless, with a greenish, or slightly yellowish, appearance; and the countenance has a pecu- liarly vacant stare, almost characteristic of the nature of the disease. In the more advanced stages of the complaint, the vessels of the conjunctiva are preternaturally numerous, large, and almost varicose. Of the pathology of this disease, nothing definite is known. Generally DISEASES OF THE RETINA. 337 beginning at a comparatively small point of the retina, the morbid action gradually spreads in different directions, until, at length, it involves its entire substance, from one extremity to the other. The most common alterations are, softening, deposits of fibrin and blood, and effusions of serum, with a varicose condition of the vessels of the retina and choroid. The prognosis in chronic retinitis is unfavorable. If the patient is seen early in the attack, a complete cure may occasionally be effected, although such an event is to be regarded rather as the exception than as the rule. In general, the nature of the complaint is entirely overlooked, both by the patient and the practitioner, and the consequence is that the time when, alone, treatment is likely to be of benefit is allowed to pass by in the delu- sive hope of spontaneous relief. What renders the prognosis worse in this disease is that the morbid action nearly always involves the deeper structures of the eye. The treatment of chronic retinitis must be conducted upon general prin- ciples, especially a consideration of the nature of the exciting cause, the stage of the complaint, and the condition of the patient's system. There is no question that, until very recently, this disease was usually most outrage- ously mismanaged; for, under the vague name of "amaurosis," by which it was generally known by practitioners, all kinds of remedies, of the most opposite and ridiculous nature, used to be resorted to, with no other result, commonly, than that of aggravating the local mischief and inflicting serious injury upon the sight. It was the almost universal custom to bleed, purge, salivate, and starve such patients, often reducing them literally to death's door, by the consequent exhaustion. Such a course was well calculated to ruin both the eye and system. Now, that the mischievous effects of this practice have been fully exposed, there is not a little danger of carrying the error into the opposite extreme. We are too much disposed, at the present day, to cram and stimulate. Anything like general bleeding and active purgation is only to be thought of in the event of decided plethora and great local congestion. Ordinarily, all the blood that ought to be removed, can be advantageousfy taken by leeches, or the use of a cup to each temple. The bowels should undoubtedly be kept quite free, and the best remedy for the attainment of this end is blue mass, in union with compound extract of colocynth, or a few grains of calo- mel, rhubarb and aloes. The diet should be plain and simple, but rather nutritious than otherwise, particularly if there is evidence of debility, in which case it may also be necessary to exhibit some tonic, as iron and quinine. The great remedy, however, in chronic retinitis, is mercury, given in small doses, twice in the twenty-four hours, for several weeks, or even months, with a view to its general alterative action. The effects of the medi- cine are carefully watched; for anything even like an approach to salivation must be avoided. The mercury is administered, not for the purpose of making a direct impression upon the eye, but in the hope merely of improv- , ing its condition, by improving the general health. Counter-irritation by seton, blister or issue should receive early attention; the feet should be im- mersed every night for fifteen minutes in hot mustard water; the eye should be maintained in a state of the most profound quietude; a green shade should be worn to exclude the light, and gentle exercise should be taken daily in the open air. WThen there is much pain in the branches of the oph- thalmic nerve, a large blister to the forehead often produces a most salutary effect. In such cases, too, strychnine will be useful, either alone, or in union with arsenious acid and aconite, it being understood that these articles are given in very minute doses, and only with a view to their general action. Any tendency to relapse, which is always very great in this disease, must be counteracted by perfect quietude of the eye for a long time after all morbid Vol. ii___22 338 DISEASES AND INJURIES OF THE EYE. action has apparently vanished, and by special attention to the state of the general health. Moderate exercise, a pure air, and the use of the cool or tepid shower bath, will go far in securing this result. A sea voyage proves sometimes eminently useful. 3. Amaurosis, a term much employed by ophthalmic writers, literally sig- nifies obscure vision, from whatever cause arising, but, at the present day, it is restricted to dimness of sight, produced by disease of the retina. This lesion of the retina may be purely functional, and, therefore, temporary, or it may be organic, in the worst sense of the word, and, therefore, more or less permanent. Again, amaurosis may be partial, or complete ; in the one case, the patient is still able to perceive light, and perhaps discern objects with some degree of satisfaction ; in the other, he is totally blind, the retina being perfectly insensible to the strongest light, however concentrated. It will thus be seen that the term amaurosis is used simply to denote the exist- ence of a particular symptom, and not the pathology of the disease; a dis- tinction of much practical consequence, and one which, unfortunately, is too often lost sight of by the practitioner. Amaurosis may arise from a thousand causes, many of them of the most opposite and diversified character. A mere catalogue of these causes would make a large chapter. At one time it is purely inflammatory, at another wholly asthenic ; in one case it is induced by plethora, in another by anemia; now it is purely functional, depending upon disease in other parts of the body, now entirely organic, or occasioned by the most serious structural lesion. Another circumstance, hardly less interesting in a practical sense, is that amaurosis sometimes comes on in an instant, literally in the twinkling of an eye, as when the organ is suddenly exposed to an intense light. Thus, persons have sometimes been struck down blind in gazing at the sun during an eclipse, or in looking at a bird in soaring through the air. Microscopists, artists, and other persons whose avocation demands great minuteness of sight, occasionally suffer in a similar manner. A flash of lightning has more than once produced irremediable amaurosis. Worms in the alimentary canal, the repulsion of cutaneous eruptions, the suppression of habitual discharges, de- rangement of the stomach, congestion of the brain, neuralgia of the fifth pair of nerves, inordinate sexual indulgence, the excessive use of quinine, profuse chewing, exhausting courses of mercury, and over-exertion of the eye, may all be enumerated as so many exciting causes of the disease. I recollect an instance where amaurosis was produced in an instant by the ferule of an um- brella thrust into the orbit in such a manner as to compress the ball forcibly against its bony walls. In two other cases, the disease was the result of a slightly contused and lacerated wound of the eyebrow, apparently implicat- ing the supra-orbital nerve. Compression of the brain, also, whether pro- duced by effused blood, depressed bone, or some morbid growth, often leads to amaurosis; similar effects occasionally follow concussion of this organ, though they are usually of a transient nature. Cases are met with, although they are rare, in which amaurosis observes an intermittent course, the loss of sight recurring once every twenty-four hours, very much like an attack of intermittent fever. The symptoms of amaurosis are such as characterize chronic retinitis, and need not, therefore, be described here. A dilated, motionless, and insensible state of the pupil, a peculiar lustreless expression of the eye, total blindness, and a congested and enlarged state of the vessels of the conjunctiva, with a singularly vacant stare of the countenance, are signs which can never be mis- taken. It is obviously impossible to lay down any definite rules of treatment for * lesion whose causes are so numerous and diversified as those of amaurosis. The intelligent and conscientious practitioner will not fail to make the dis- DISEASES OF THE CHOROID. 339 ease, in every case that may come under his observation, an object of special study and inquiry; often, indeed, his remedies must be addressed empirically, for, like the benighted navigator, he will frequently find himself, so to speak, without rudder and compass. Cases, however, constantly occur where the causes of the disease are so apparent as to render it impossible to mistake them, and it is to this class that he should especially direct his skill and atten- tion, since experience has shown that many of them are perfectly susceptible of cure. The old, and, perhaps, not yet entirely exploded practice of bleed- ing, purging, and salivating every patient affected with amaurosis, without any proper regard to the nature of the exciting cause, cannot be too severely censured. It affords a melancholy illustration of the folly of prescribing for the name of a disease instead of the disease itself. Undoubtedly plethora should be removed as well as debility, but this can usually be done by milder and more effective means, less likely to ruin the part and system. When the retina is totally disorganized, any treatment, however mild, must be wholly out of the question, except in so far as it may tend to improve the general health, and thus prevent a similar misfortune to the other eye, supposing that one alone is originally affected. One important use of the ophthalmoscope is to throw light upon this class of cases, and to afford information for a more rational plan of treatment. DISEASES OF THE CHOROID. The diseases of the choroid were, until a comparatively recent period, de- nied a place in the nosological tables of the internal ophthalmiae ; and there are many practitioners who still question the propriety of such a position. Their reason for such an opinion would seem, at first sight, to be well founded; but its fallacy becomes at once apparent when we reflect upon the structure of the choroid, its extraordinary nervous and vascular endowments, and its intricate relations with the retina, iris, and sclerotica. Its concealed position doubtless protects it often from morbid action, to which some of the other tunics, which are more exposed, are so obnoxious. The fact is, it is the difficulty of distinguishing these diseases that has kept them so long in the background, and has caused the scepticism here alluded to. It has only been by the most careful and patient study that we are at length enabled to diagnosticate them with any degree of satisfaction. That their more delicate shades often escape observation, even now when they are so much better understood than formerly, is unquestionable, and this circumstance should ad- monish us to push our researches still further into their history and character. The only lesion of the choroid, which will require special notice here, is inflammation. That this is rare, as an independent malady, the united testi- mony of ophthalmological writers abundantly attests; while, as a secondary disease, it is probably quite frequent, often existing as a complication of iritis, retinitis, and sclerotitis. It occurs at all periods of life, but is most common in young and middle aged persons, particularly in those whose avocation compels constant and intense application of the eyes to the purposes of minute vision. It has been asserted by the late Mr. Tyrrell that, soon after the death of the Princess Charlotte of Wales, when the whole English nation went into mourning, an immense number of cases of choroiditis oc- curred among the dress-makers of the British metropolis, on account of the immense labor imposed upon them by the mercenary conduct of those who had the control of their time and service. Many of these poor creatures, ill- fed, over-worked, and deprived of proper air, suffered from disturbance or loss of vision from this disease, brought on by excessive and long-continued concentration of the eyes upon the black material used as the conventional garb of grief. The inflammation, in many of the cases, began in the cho- 340 DISEASES AND INJURIES OF THE EYE. roid; in some it took its rise in the iris, retina, or sclerotica ; while in a third series of cases it apparently commenced simultaneously in all, or, at least, in several, of these structures. Be this as it may, it is very certain that when the choroid is at all seriously inflamed the other tunics of the eye are ex- tremely liable to become inflamed also ; whether the converse of the propo- sition is true, in an equal degree, the present state of our knowledge hardly permits us to state. Congestion and subacute inflammation of the choroid are probably the cause of the morbid sensibility of the eye so common in young men at college, and in literary persons incessantly devoted to reading and writing. Strumous subjects, and persons who have become enfeebled by ill health, privation, protracted lactation, and loss of blood, are most liable to suffer. The symptoms of acute choroiditis resemble somewhat those of retinitis, only that there is, in general, much less perception of luminous matter. The pain is deep-seated, dull, heavy,_ and throbbing, shooting about in different directions, especially towards the base of the brain, where it is often exceed- ingly severe. The eye is tender on pressure ; there is a sense of tension or fulness; and every movement of the ball is attended with an aggravation of suffering. There is commonly severe pain, of an intermittent character, around the orbit and in the temple, and the patient is harassed with intense cephalalgia, and a feeling of weight and tightness in the forehead. The sight soon grows dim, and often disappears completely within a few days from the commencement of the attack. Various fantastic objects float be- fore the eye ; at first, as little moats or specks, of a grayish, yellowish, or darkish appearance, and afterwards, as the disease augments in violence, as a thick mist, gauze, or veil. The ball of the eye is of a dull, reddish, pink, or brick-dust color, and there is generally a faint zone around the cornea, from which the vessels extend backwards over the surface of the sclerotica in fine radiating lines. The conjunctiva itself is seldom much injected. The. iris is dull and discolored, and the pupil, contracted and irregular, soon be- comes motionless, and adherent to the capsule of the lens, which, together with the lens itself, is frequently rendered opaque, either by plastic deposits, or by disease of their proper substance. Gradually the retina and vitreous humor are assailed, the latter being dissolved and broken down, and the globe, in consequence, converted into a soft, flaccid, fluctuating mass. The sclerotica, also becoming implicated, gives way at some particular point, usu- ally towards the cornea, forming a protrusion, of a bluish color, known by the name of staphyloma. Choroiditis is liable to be confounded with iritis, and, in fact, it is often difficult, even in the earlier stages of the two 'diseases, to distinguish them from each other. In general, however, a little care in the examination of the eye, and a proper inquiry into the history of the case, will serve to de- termine the diagnosis. In choroiditis, disturbance of vision is an early and prominent symptom, and always precedes any alteration in the iris; more- over, the loss of brilliancy and alteration of color of this membrane are always less conspicuous than in the latter disease, and the vascular zone around the cornea is also more faint and dull. In iritis, the sight is often comparatively little affected for some days, although the structure implicated usually undergoes very striking changes within a very short time after the establishment of the disease. Furthermore, in primitive iritis there is always a greater amount of plastic deposit in the anterior chamber, more irregularity of the pupil, and a more distinctly defined vascular zone around the cornea. When the two maladies have made considerable progress, the symptoms and appearances are generally so much alike as to defy all attempts at accuracy in diagnosis. In such an event, the only guide we can have is the history of the case. STRUMOUS DISEASES. 341 The prognosis of choroiditis is unfavorable. When the disease has made much progress before we have an opportunity of interposing our remedial measures, the chances are that the sight is already destroyed, or, at all events, so much impaired as to render its restoration a matter of impossi- bility. Hence, the importance of an early diaguosis, and of an efficient treat- ment. The treatment of acute choroiditis must, in the main, be conducted upon antiphlogistic principles, with a proper regard, however, in every instance, to the state of the constitution, the violence of the attack, and the age of the patient. A plethoric condition of the system will demand bloodletting, copiously, and, perhaps, repeatedly, with leeching, or cupping of the temple, active purgation, and the use of mercury, carried to rapid ptyalism. Re- duction of the inflammation must be attempted at all hazards, and in the shortest possible time ; a few days, or even twenty-four hours, passed in tem- porizing, may lead to hopeless blindness. The treatment is, of course, less active when the patient is feeble from previous disease or present suffering, or when the inflammation has already produced structural lesion ; here our chief reliance is upon local depletion, counter-irritation by blisters to the forehead, temple, or nape of the neck, correction of the secretions, mild aperients, and the gentle operation of mercury, with nutritious food and drink. When the disease has assumed a decidedly chronic form, a change of air, sea-bathing, and tonics, particularly iron and quinine, will aid in re- building the constitution, and contributing to the maintenance of what little vision may be left. STRUMOUS DISEASES. Strumous ophthalmia exists in various forms and degrees; sometimes as a very mild affection, at other times, as a most severe one. It may attack both eyes, or be limited to one; and it may be acute or chronic. It generally involves, simultaneously, a number of structures, especially the conjunctiva, cornea, iris, and retina. The prominent symptoms are intolerance of light, excessive lachrymation, and violent pain. The photophobia is usually very distressing. We con- stantly see cases in which the smallest ray of light is productive of the keenest suffering, and where, consequently, the patient uses every possible precaution to prevent its intrusion. For this purpose he generally, if he be a child, as is commonly the case, creeps into the darkest corner of his chamber, where he covers his eyes with his hands, or buries his head in a pillow, or, perhaps, in the lap of his mother. In this condition he often remains for hours, afraid to change his posture, lest the light should meet his eyes, and thus increase his distress. Children thus affected frequently experience an aggravation of all their suffering, even from the light of the moon and of the stars, such is the excessive sensibility of the retina. Photophobia, then, or intolerance of light, is a most important diagnostic symptom in this affection, and one which no practitioner should disregard. The lachrymation also exists in various degrees. In most cases it is, at one stage or other of the complaint, a prominent symptom. Exposure to light and cold always increases it. The tears are usually hot and scalding, and their discharge is almost always attended with temporary relief. Some- times they are so acrid as to irritate the cheeks, causing them to become red and swollen. The quantity of lachrymal fluid that is thus evacuated in the twenty-four hours may amount to several drachms. It is rare, in strumous ophthalmia, to witness a copious discharge of mucus, or of muco-purulent fluid. Even when there are excessive photophobia and great lachrymation, it is seldom that there is much secretion of this descrip- 342 DISEASES AND INJURIES OF THE EYE. tion ; often, indeed, not enough to agglutinate the edges of the lids. In this respect, scrofulous inflammation forms a striking contrast with some of the other varieties of ophthalmia, in which an immense quantity of mucus, or of mucus and pus, is discharged during the height of the morbid action, and even during its declension. There is usually, as already stated, but little redness of the conjunctiva, in this variety of ophthalmia. In ordinary inflammation, discoloration of this membrane is a constant occurrence, and so conspicuous as generally at once to attract attention. In strumous inflammation, the vessels observe a straggling arrangement; they are seldom very turgid, and they extend from the circumference of the ball inwards towards the cornea, where they are often con- gregated into little groups, or clusters, beau- tifully interlacing with each other, as in fig. 187. Wrhen the disease is violent, or of long- standing, the vessels occasionally pass over the cornea, either singly or in parallel lines, separated by narrow intervals. In ordinary ophthalmia the vessels are extremely nume- rous, and lose, so to speak, their individuality. scrofulous ophthalmia, with phiycte- Jn a w.ord> there are hundreds, where there nula; on the cornea and a fasciculus of is One in Strumous Ophthalmia. vessels running into it. Another important symptom in this form of ophthalmia is the existence of little minute vesicles at the margin of the cornea, occurring either separately or in groups, and varying in size from the smallest perceptible speck to that of an ordinary pin-head. They contain each a minute quantity of serum, and are frequently encircled by a delicate plexus of vessels, which impart to them a very beau- tiful appearance. Their shape is globular, ovoidal, or angular. Sometimes they exist partly on the sclerotica and partly on the cornea. As they are witnessed in no other form of ophthalmia, they are of great value as a diag- nostic sign. Strumous ophthalmia seldom continues long without giving rise to opacity of the cornea. This effect, like some of the others that have been mentioned, presents itself in different degrees, from the slightest haziness of the part to complete opacity. In the latter case, it is always to be greatly dreaded, inasmuch as it is generally followed by total blindness. Its occurrence should always, if possible, be prevented, not only because it is liable to im- pair the sight, but because it must necessarily, when irremovable, disfigure the eye, and injure the expression of the countenance. It need hardly be added that the immediate cause of this phenomenon is a deposit of lymph into the substance of the cornea. Ulceration of the cornea is another effect of this variety of ophthalmia, and one, in fact, of frequent occurrence. It often begins at an early stage of the disease, and may proceed, with more or less rapidity, until it extends through the entire thickness of the membrane. The most common form of the ulcer is that of a dimple-shaped depression, with smooth and rather sharp edges, the surface looking as if a piece had been scooped out of it. Gene- rally, the ulcer has a hazy appearance, but not unfrequently it does not differ in its color from that of the adjacent parts, and hence, unless the cornea is examined with great care, while the light is falling upon it at a particular angle, the disease may readily escape detection. Sometimes, several such ulcers exist upon the eye, forming either simultaneously, or in pretty rapid succession. If permitted to progress, they occasionally extend through the STRUMOUS DISEASES. 343 different layers of the cornea, as far as the anterior chamber of the eye, the humor of which may perhaps escape through the abnormal opening, or, what is more common, the opening is closed up by the membrane of the aqueous humor, or even by the iris itself. The pain attendant upon strumous ophthalmia is sometimes intense, while at other times it is very insignificant, if not wholly absent. In confirmed cases, it is always aggravated by the slightest exposure of the affected organ to the light, by medicated applications, by disorder of the bowels, by indulg- ence in eating, by rough contact, and by various other circumstances unne- cessary to be mentioned. Occasionally it is situated deeply in the ball of the eye, in the orbit, or at the base of the auterior lobes of the brain ; some- times it affects merely the lids and brows; occasionally, it is most severe in the temple, forehead, or cheek. It may be sharp, shooting, or darting; dull, heavy, or aching ; throbbing, or pulsatile ; continued, or intermittent. Not unfrequently it assumes a neuralgic character, recurring periodically, like neuralgic pain in other parts of the body. Whatever may be its nature, it is often so severe as to deprive the patient of sleep and appetite, and, indeed, of all comfort, for days and weeks together. Strumous ophthalmia is rarely attended with any tumefaction of the lids. On the contrary, these structures usually retain their normal shape and size ; but, in consequence of the excessive intolerance of light, they often present a remarkably drooping appearance, owing to the manner in which they are drawn over the eyes. When the disease is very protracted, the edges of the lids frequently become inverted, so that the cilia impinge constantly against the cornea, thereby inducing opacity of this membrane, great increase of pain, and additional inflammation. Although, in general, there is an absence of swelling of the lids, yet this symptom will occasionally be found to exist in a very marked degree. This is especially apt to happen in young children of a leucophlegmatic habit, with a thick upper lip, a tumid belly, and a soft, flabby tongue, along with great derangement of the digestive apparatus. The whole system, in such cases, seems to be surcharged with strumous dis- ease, which, in consequence, it is extremely difficult to dislodge from the eyes, which frequently become its victims. In many cases, there is an appearance of little vesicles on the cheeks, the inferior lids, round the nose, or on the lips. Their number varies from two or three to several dozens; their volume rarely exceeds that of the head of a small pin; and their contents are of a serous character. They have a whitish, almost pearly aspect, are usually discreet, though often closely grouped together, and rest upon a slightly reddish base. These vesicles, according to my observation, are most common in children of a deeply-marked strumous habit, and they seldom manifest themselves until after the inflammation has made considerable progress. I always look upon them with a feeling of sus- picion in regard to the ultimate issue of the case ; for their presence almost invariably denotes great obstinacy in the morbid action, and proportionate difficulty in effecting a prompt and permanent cure. From the symptoms which haye now been detailed, we can hardly fail to establish the diagnosis of this affection in any case that may fall under our observation. The excessive intolerance of light, the unwonted lachrymation, the absence of redness in the conjunctiva, together with the peculiar strag- gling arrangement of its vessels, the want of tumefaction, and the manner in which the lids are drawn over the ball of the eye, are signs which, once ob- served, can never be mistaken. Add to these phenomena the fact that the disease usually arises insidiously and without any assignable cause; the strumous appearance of the features; the coldness of the extremities; the tumid condition of the belly ; the formation of vesicles on the face, and vari- ous other evidences of the strumous diathesis, and all doubt respecting the 344 DISEASES AND INJURIES OF THE EYE. true nature of the case must instantly vanish. Indeed, no practitioner, un- less he is culpably ignorant of ophthalmic diseases, can possibly commit an error of this kind. t The prognosis, in this disease, must necessarily be influenced by various circumstances, as, for example, the progress and extent of the morbid action, the state of the patient's health, and the nature of our remedies. In the milder forms, and in the earlier stages of the malady, and under proper management, recovery of the affected organ may generally be reasonably pre- dicted. But, under opposite circumstances, the worst consequences may, not unfrequently, be looked for. Ulceration of the cornea often extends, despite our remedies, to a great depth, and sometimes even to complete perforation; an event which is sure to be followed by permanent impairment, if not total loss, of sight. Superficial opacity, even when it is diffused over the greater portion of the cornea, is generally readily amenable to treatment, but when it involves several of the layers of the membrane, or when a considerable period has elapsed since its formation, or, in other words, when time has been permitted for the organization of the lymph, upon the presence of which the opacity depends, then the case will necessarily be unpromising, both as it respects the future appearance of the eye and the amount of vision. It is fortunate that strumous inflammation of this organ rarely terminates in gan- grene of any of its structures. Such an event, judging from my own obser- vation, is extremely infrequent. Of the exciting causes of this disorder very little is known with any degree of certainty. Very frequently its origin is ascribed to circumstances which have no agency whatever in its production. Sometimes it is directly trace- able to external injury, as a blow, or a wound ; in many cases it is apparently brought on by long exposure of the eye to a strong light, or by excessive fatigue of the organ, induced by reading, writing, or sewing. Suppression of the cutaneous perspiration is probably another, if not a frequent, cause of the disease. In young girls, I have occasionally seen it connected with irre- gularity of the menses, but whether as a cause-or an effect has not always been apparent. Perhaps the most common cause of all is derangement of the digestive apparatus. Whenever the predisposition exists, as it always does in this affection, almost anything, however trivial, may bring on an attack. The disease may be limited to one eye, or it may occur in both, either simultaneously or successively. I do not deem it necessary here to insist upon the minute, and, as I conceive, unmeaning divisions and subdivisions of strumous ophthalmia laid down by systematic writers on the diseases of the eye. Such an arrangement can subserve no useful purpose in practice, and would be entirely out of place here. It is sufficient to say that, in nearly every instance of this complaint, there is an involvement of the conjunctiva and cornea, if not also of the sclerotica and iris, and not simply of the con- junctiva and cornea, or of one of these structures alone, as one might suppose by reading books, and neglecting observation. In all cases, the retina is either inflamed or morbidly sensitive, as is evinced by the excessive intoler- ance of light attending the malady. The age at which this disease occurs is an important circumstance in its history. It is extremely rare for it to begin after the period of puberty, and in no instance have I witnessed its outbreak in middle or advanced life. It is emphatically a malady of infancy and early childhood. According to my observation, it rarely shows itself before the age of eighteen months, or two years. It occurs in both sexes, and in every rank and condition of life, but more frequently among the poor, ill-fed, and ill-clothed, than among the re- fined and Wealthy. The offspring of the consumptive, and of those who have STRUMOUS DISEASES. 345 suffered from tubercular disease of the spine, hip, arachnoid membrane, and lymphatic ganglions, are most liable to it. Treatment.—The great remedy in the treatment of this disease is quinine, either alone or in union with other means. I am very certain, from my experience in its management, that quinine deserves to be placed at the head of all other articles in this variety of scrofulous affections, and yet, in making this remark, it is necessary to introduce a proviso, lest the young practitioner should thereby be induced to invest it with a degree of confidence to which, valuable as it is, it is not entitled. Wrhat I wish to say is simply that this medicine will, if properly administered, that is, with due regard to the patient's system and other circumstances, produce the most prompt and salutary effects; while, if these precautions be neglected, it will either prove useless or even cause mischief. There are, according to my experience, two distinct classes of strumous disease of the eye. In the one, the patient is pale and thin, with a languid circulation, and cold extremities; in the other, he is stout and robust, the cutaneous circulation being active, and the hands and feet habit- ually warm. Other points of dissimilarity readily suggest themselves, but these it is unnecessary to point out, as the distinction which I wish to esta- blish must be sufficiently apparent. Now, to treat such cases alike would be a palpable absurdity. It is only by properly discriminating between them that we can expect to arrive at a satisfactory result, as it respects the employ- ment of this important therapeutic agent. Hence, one practitioner will often mismanage a case, which another, having more judgment and more experience, will promptly cure, the disease, perhaps, disappearing as if by magic. In the commencement of my treatment in both forms of the complaint, I usually prepare the system by the exhibition of a moderately brisk cathartic of calomel and rhubarb, to clear out the bowels and correct the secretions. When there is reason to suspect that there is much acid in the alimentary canal, I generally combine with the cathartic a few grains of bicarbonate of soda. Thus, a most effectual beginning is made in the treatment of the dis- ease. If the case comes under the first division, that is, if the patient is pale and thin, and is habitually laboring under cold extremities, I now begin the use of quinine, seldom alone, but commonly in combination with sulphate of iron, tartar-emetic, and opium, in quantities proportionate to the age and strength of the individual. For a child, for example, of ten years, a. grain and a half of quinine, one grain of iron, the twelfth of a grain of antimony, and the eighth of a grain of opium, carefully mixed, will be a suitable dose, repeated every eight hours, or, if the symptoms are urgent, every six hours, or four times in the day and night. If pills or powders are offensive to the patient, the articles may be given in solution, substituting laudanum or mor- phia for the opium. When there is a highly-marked strumous diathesis, I sometimes use the iodide of iron instead of the sulphate, but in most instances I give the latter the preference. Tartar-emetic I rarely omit in any case, from the fact that it is one of the most valuable remedies we possess in the treat- ment of scrofulous disease, both of the eye and of other parts of the body. It is a powerful controller of capillary action, and at the same time a most potent sorbefacient, rendering it thus particularly applicable in all cases attended with deposits of coagulating lymph. The opium allays pain, ren- ders the eye more tolerant of light, and prevents the antimony from irritating the stomach and bowels. The quinine and iron, whether in the form of sul- phate or iodide, are powerful tonics; they improve and invigorate the diges- tive organs, increase the fibrin and coloring matter of the blood, equalize the circulation, augment the temperature of the extremities, and powerfully aid in correcting the strumous diathesis. By means of these remedies, assisted by a proper diet and due attention to the bowels and secretions, almost any •> 346 DISEASES AND INJURIES OF THE EYE. case of scrofulous ophthalmia may, in the class of patients under consideration, be effectually relieved, and that, too, in a comparatively short period. An excellent cathartic, iu these cases, is calomel in combination with rhu- barb; to which, as above mentioned, I occasionally add a few grains of soda, especially if there is reason to suspect the existence of a redundancy of acid in the alimentary canal. In a child from three to five years of age, about two and a half grains of the former, to five or six of the latter, should be given every fourth night. Occasionally the calomel may be advantageously replaced by blue mass; or, in infants, by the gray powder. When the skin is dry and inactive, the tepid bath may sometimes be em- ployed, or, what is better, the body may be sponged once a day with tepid salt water, followed by frictions with a coarse dry towel. Flannel should be worn next the surface, both in summer and winter; and the greatest attention should be paid to the preservation of the temperature of the feet. When they are habitually cold, they should be plunged, twice a day, for a few minutes at a time, into cold water, and then be well rubbed with a dry cloth. It is a great mistake, in such cases, to bathe the feet in warm water, with a view to the restoration and maintenance of their temperature. In the second class of cases, where the general health is apparently but little impaired, where the countenance is florid instead of being pallid, and where the extremities are, for the most part, warm, the quinine is most advantageously conjoined with sulphate of magnesia and tartar emetic, in the form of the saline and antimonial mixture. The following is the formula which I commonly employ under these circumstances :— I£.—Quinise sulph. Jss; Magnesise sulph. §j; Antim. et potassae tartr. gr. jss; Aquae destillatae f Jiij ; Syr. zingib. f §j; Tinct. opii gtt. xxx; Acid, sulph. arom. f^ss.—M. Of this mixture, which, considering its ingredients, may be regarded as an exceedingly elegant one, the dose is about one drachm for a child four or five years of age, repeated every four, five, or six hours. If it induce vomit- ing, or nausea beyond a few minutes, it should be diminished, or combined with more laudanum. When the inflammation is very severe, I often omit the quinine until the disease has assumed a subacute character, and in that case also I occasionally take blood freely from the arm, or by leeches from the anterior part of the temples, within an inch from the outer commissure of the lids. In the strong and robust, iron, in every form, is totally inadmis- sible. The diet, too, must be more restricted, and more active purgation is required. Indeed, the treatment should be strictly antiphlogistic, as much so as in inflammation of the eye from ordinary causes. As to counter-irritation, collyria, and salves, so much used in this com- plaint, they cannot, as a general rule, be too much or too pointedly condemned. Except in the latter stages of the complaint, in some rare circumstances, it is difficult to conceive of any case in which they would be likely to be bene- ficial. I am only speaking my real sentiments when I declare that I know of no class of remedies which have done more mischief, or which are so well calculated to fret and annoy the patient, and to support and perpetuate the morbid action. Setons are abominably filthy and painful, and should be discarded from this branch of surgery; tartar-emetic ointment and croton oil cause injurious irritation ; in short, the only eligible article of this class of remedies is a small blister behind the ear, or, what is preferable, because more easily managed and more permanent, a very small issue, in this situa- tion, made with the Vienna paste. This, when the eschar is detached, may STRUMOUS DISEASES. 347 be dressed, twice a day, with a little adhesive plaster, and will furnish a free discharge for several weeks, when, if necessary, it may easily be reopened by the application of a little more paste, or some irritating ointment. The best collyrium, undoubtedly, is a solution of nitrate of silver; but, to answer the purpose, it should be very weak, and not be used uutil the inflam- matory action is greatly diminished, when it may assist in expediting and per- fecting the cure by contracting the enlarged vessels of the conjunctiva and cornea, by allaying the morbid sensibility of the eye, and by promoting the absorption of effused lymph. The strength, at first, should rarely exceed half a grain to the ounce of water, which may be gradually increased to a grain, or even twice, thrice, or four times that quantity, according to the circumstances of the case. Sulphate of zinc, acetate of lead, Goulard's extract, and similar articles are generally worse than useless. When there are ulcers on the cornea, and they do not yield to the remedies already enumerated, they should be touched, as lightly as possible, once every other day, with the point of a camel-hair pencil wet with a solution of nitrate of silver, in the proportion of about three grains to the ounce of water; or with the nitrate of silver in substance. The former, however, is generally preferable, unless the ulcer is in a phagedenic or gangrenous con- dition, when the latter should take the place of the solution, as being more prompt and efficacious in its action. The only salve which I ever employ in this affection is the ointment of the ' nitrate of mercury, in a very dilute state ; generally in the proportion of about ten grains to the drachm of prepared lard. The ointment of the shops is entirely too strong, and cannot be used without the risk of materially augmenting the morbid action. Diluted in the manner above stated, it may be advantageously applied in all cases attended with great relaxation of the vessels of the affected part, opacity of the cornea, and adhesion of the lids. The proper way to use it is to anoint the edge of the lower lid with a small pencil, dipped in the salve, every night at bedtime. Wrhen the salve is stiff, it should be previously warmed, otherwise it will not be likely to adhere. Thus employed, a very small quantity, a portion not larger than half a grain of rice, will suffice. Some patients experience great relief from frequently bathing the forehead, face, and temples with warm water, pretty strongly impregnated with common salt; while others derive most benefit from bathing with cool, cold, or hot water. In all cases the best plan is to permit the patient to consult his own feelings in the use of this remedy. It need hardly be added that the eyes should always be carefully protected with a green shade ; but on no account should the patient be allowed to wear green glasses, or, what is still more abominable and injurious, goggles. Such a practice, indeed, cannot be too much deprecated. The same remark is ap- plicable to compresses and bandages. I have seen numerous cases in which irreparable mischief has been done by the protracted use of these articles. The true practice consists in protecting the affected organs in such a manner that, while they are sufficiently screened from the light to render the patient comfortable, they shall have the full benefit of cool air. As the morbid action declines, more and more light should gradually be admitted, until at length they receive their accustomed supply. It should never be forgotten that light is the natural stimulus of the eye, and that, by withholding this stimulus for too long a time, the organ may become morbidly sensitive ; just as the stomach becomes irritable and unable to perform its functions when it is for a long time deprived of food. Finally, I may state that I have rarely derived any essential benefit, in the treatment of any form of scrofulous ophthalmia, from iodide of potassium, so much vaunted by some practitioners. Formerly I was in the habit of 34S DISEASES AND INJURIES OF THE EYE. prescribing this article quite frequently, but it so often totally disappointed my expectations that I have, of late years, laid it entirely aside. In obstinate cases, we occasionally obtain benefit, especially in weakly children, requiring an alterant and tonic, from the exhibition of bichloride of mercury, in very minute doses, as the twentieth or twenty-fifth of a grain, in union with Hux- ham's tincture of bark. I am well aware that the salt in this prescription undergoes some chemical change ; but this renders it, perhaps, only the more efficacious. It is neither necessary nor proper to carry the remedy to the extent of ptyalism to obtain its full effects. Indeed, such an occurrence should always be carefully avoided. Cod-liver oil is frequently of great benefit, especially in the more feeble classes of cases, and should be given in such doses as the stomach will bear without nausea. WHien the debility is very unusual, the child should be permitted the free use of milk-punch, and the lighter kinds of meat. When there is hemicrania, or excessive circumorbital pain, anodynes are necessary, particularly at night, both to allay suffering and to procure sleep. Under such circumstances, some practitioners are in the habit of applying belladonna ointment to the affected parts, and in some cases I have found the remedy of service, though, in general, it has disappointed me. During the latter stages of the disease, the patient should take gentle exer- cise daily in the open air, as a means powerfully calculated to improve his general health, and to invigorate his constitution. In all cases, the greatest care should be employed to avoid exposure and indulgence of the appetite and passions. As another excellent means of guarding against relapse, a moderate use of the remedies above mentioned should be persisted in for a considerable time after all disease has apparently vanished. NEURALGIA OF THE EYE. This affection is very common in this country, especially in the South- western States, and may depend for its origin either upon local or constitu- tional causes. In the former case, it arises most generally from disease of the eye, brain, or neighboring parts, in consequence of local congestion, if not actual inflammation, provoked by external injury, the lodgment of a foreign body, the presence of a decayed tooth, the pressure of some tumor, or excessive fatigue of the eye; in the latter, it is usually developed under the influence of miasm, disorder of the digestive apparatus, exhaustion of the nervous system, or the derangement of some important secretion. A species of neuralgia of this organ not unfrequently occurs during the progress of rheumatism, gout, and tertiary syphilis. Neuralgia of the eye may exist as a primary affection, commencing in the organ itself, or it may become secondary, in consequence of an extension of disease from the adjacent structures, especially the ophthalmic branches of the fifth pair of nerves. The latter form, according to my observation, is by far the more common of the two. It is most frequent in persons of a nervous, irritable temperament, and often occurs in association with neuralgia of other parts of the body. No age is exempt from it. Of the pathology of this disorder our information is very indefinite. While in some cases it is unquestionably of an inflammatory character, as is evidenced both by the nature of the exciting cause and the peculiar features of the symptoms, in others it appears to be dependent solely upon irritation of the ophthalmic branches of the fifth pair of- nerves, or upon reflex action, the consequence of derangement of the liver, stomach, bowels, kidneys, or teeth. The disease is frequently, if, indeed, not commonly, ushered in by marked derangement of the general health, as dyspepsia, headache, constipation, flatulence, or acidity of the stomach, even when the attack depends upon a NEURALGIA OF THE EYE. 349 strictly local cause. The pain, which serves as its distinctive feature, is at first slight and transient, being of a sharp, lancinating character, dull, heavy, and aching, or like an electric shock, darting about in different directions, and recurring perhaps several times during the day and night. The eye, in the meantime, is morbidly sensitive, and intolerant of exposure and exertion. By and by, the suffering becomes more fixed and severe ; it is deeper seated and more diffused, the lids and conjunctiva often exhibit a tumid and reddish appearance, the circumorbital pain and tenderness are great, and there is always, particularly during the height of the attack, profuse lachrymation, the tears being hot and scalding. In the more violent attacks, the forehead, temple and upper part of the face are involved, the eyebrows are knit, the lids are spasmodically contracted, and the slightest ray of light is a source of intense agony. The pain, which is nearly always most severe at one spot, generally comes on gradually, increasing steadily until it reaches a certain point of intensity, when it slowly, if not suddenly, abates, or perhaps alto- gether disappears. In the miasmatic variety of neuralgia, the paroxysm, in its mode of invasion, closely resembles that of intermittent fever, the suffer- ing recurring regularly once a day or every other day, lasting a few hours, and then going off entirely, leaving, perhaps, merely a slight degree of ten- derness in the eye, orbit, temple and forehead. The constitutional symptoms vary. In general, they are very mild, even when the local suffering is unusually violent, being confined to some derange- ment of the digestive apparatus, along with more or less headache, want of appetite, and a sense of lassitude and despondency. Anything like marked fever rarely exists. It is only where the affection is very protracted, as when it depends upon organic disease of the eye, or of the ophthalmic branches of the fifth pair of nerves, that the general health is apt to become permanently impaired. Neuralgia of the eye, or of the eye and neighboring parts, is easily distin- guished by the situation and peculiarity of its pain and the history of the case. The principal affections with which it is liable to be confounded are rheumatism, gout, and tertiary syphilis. The prognosis in this affection is usually favorable, provided the case receive early and proper attention, otherwise it will be very liable to induce permanent blindness, whether it be originally seated in the eye or in the cir- cumorbital region. . The disease is, of course, unamenable to treatment when it is caused by organic disease of the brain or optic nerve. In the treatment, a primary object should be the prompt detection and removal of the exciting cause. When this has been effected, the disease generally yields to the most simple measures. Gastro-enteric disorder is rectified by emetics, mercury, antacids, and other suitable remedies; the foreign body is extracted; the decayed and worrying tooth is lifted from its socket. The miasmatic form of the malady is usually speedily relieved by quinine, in doses of from five to ten grains twice or thrice a day, either alone or in union with strychnia and arsenious acid. If the patient be bilious, as indicated by nausea, want of appetite, and aching of the back and limbs, the administration of the salt is preceded by an active emetic, or emetico-cathartic, to remove vitiated matter, and aid in restoring the secretions. Purging must not be neglected, and the diet must be properly regulated. When the affec- tion is yery obstinate, the most suitable general remedy will be a combination ot quinine, belladonna, strychnia, and arsenious acid, given in moderate doses, persevenngly continued for a number of successive weeks, with an occasional intermission of a few days. 1 he rheumatic form of the disease is best met with colchicum and mor- phia; the syphilitic, with mercury and iodide of potassium. Sometimes a l' »a«ge of air will effect a cure when everything else apparently fails. 350 DISEASES AND INJURIES OF THE EYE. During the violence of the attack, relief is sought by the exhibition of morphia and diaphoretics, sinapisms to the forehead and temple, and the im- mersion of the feet in hot water. The most reliable local remedies, in a soothing as well as curative point of view, are leeches, especially when there is marked congestion or actual in- flammation; vesication with ammonia or cantharidal collodion; frictions with Granville's lotion, or veratria ointment; the subcutaneous injection of mor- phia ; the application of electricity ; and the use of anodyne plasters, as the opium, belladonna, or stramonium. In some cases the moxa, so highly extolled by Larrey in the treatment of this affection, will be found useful, the cauterization being made over the eyebrow, along the course of the supra- orbital nerve. Excision of this nerve has occasionally been practised, but rarely with any beneficial effect. PYOPHTHALMITIS. There is a peculiar, and, unfortunately, a most destructive form of inflam- mation of the eye, originally described under the phrase of phlebitic ophthal- mitis, but which, under our improved system of nomenclature, is more appro- priately designated by the term pyophthalmitis. It occurs under a variety of circumstances, and, as the name implies, owes its origin to suppurative inflammation of the veins, or to the same causes as pyemia. It has been most frequently observed in lying-in females, in connection with puerperal fever, in erysipelas and in typhoid fever, and after severe injuries and surgical ope- rations, especially those involving the veins of the extremities. Occurring always as a secondary affection, its attack is generally, if not invariably, coincident with symptoms of pyemia, that is, a low form of fever, preceded by rigors and accompanied by excessive nervous depression, deli- rium, pains in the back and limbs, swelling of the joints, great restlessness, gastric irritability, and dryness of the mouth and tongue, the latter of which is covered with a brownish coat. The eye becomes involved at a period vary- ing, on an average, from the fourth to the tenth day, the first evidences of disease being deep-seated and excessive pains, redness and tumefaction of the conjunctiva, swelling of the lids, contraction and immobility of the pupil, and a hazy appearance of the cornea which soon runs into complete opacity. Pus is rapidly effused into the chambers of the organ, as well as among its coats, which finally slough and collapse. The only affections with which pyophthalmitis is liable to be confounded are gonorrhceal and purulent inflammation; but from these it can always readily be distinguished by the history of the case, independently of any other consideration. It must be obvious that a disease which runs its course with such frightful rapidity, and which is characterized from its inception by such excessive vio- lence, can be but little influenced by treatment, however judiciously or vigor- ously prosecuted. The most reliable means are leeching, and free division of the chemosed conjunctiva, with medicated lotions to the lids, temples, face, and forehead; active purgation; the use of the antimonial and saline mix- ture ; and puncture of the cornea to relieve the eye from tension or intra- ocular pressure. General bleeding will seldom be admissible. MALIGNANT DISEASES OF THE EYE. The only two forms of malignant diseases of the eye are encephaloid and melanosis. The variety of soft cancer, known under the name of fungous hematodes, is by no means infrequent, but as it generally occurs in combina- tion with encephaloid, and forms, in fact, merely a species of it, it does not MALIGNANT DISEASES OF THE EYE. 351 seem to me to be entitled to separate consideration. Of scirrhus, properly so termed, I have never seen an instance in this organ, and question whether there is a perfectly reliable case of it on record, notwithstanding all that has been said respecting it. 1. Encephaloid.—Encephaloid generally occurs in children from the second to the tenth year; I have seen it several times within less than six months after birth; and cases are occasionally met with of its occurrence rather late in life. The oldest patient in whom I have observed it was forty-two years of age. Both sexes are liable to it, but males probably suffer more frequently than females. Of the influence of temperament in the production of encepha- loid of the eye nothing is known. The disease always begins in the very depths of the eye, generally«in the retina or choroid, from which, as it proceeds, it gradually extends to the other structures, until, at length, they are involved in one confused and dis- organized mass. The earliest symptom is generally a yellowish, amber, golden, or buff-colored spot, far back in the organ, which, upon inspection, is found to look very much like the eye of a cat. This spot rapidly increases in volume, but finally entirely disappears, being replaced by dark matter; the pupil, at first sluggish, becomes permanently dilated and insensible to light; the lens is thrust forwards against the iris ; and the anterior chamber is com- pletely obliterated. The eye, enlarged in every direction, presents a distorted appearance; aud, the cornea at length giving way, a fungous, cauliflower- looking mass is formed, which, projecting beyond the lids, soon Fig. 188. becomes the seat of a copious, sanious, and fetid discharge, and a source of frequent and abundant hemorrhage. The patient now experiences a great deal of pain, the lymphatic ganglions in front of the ear take on disease, and the constitution exhibits all the evi- dences of the cancerous cachexia. Finally, hectic fever sets in, the body is rapidly emaciated, and death soon follows, from the joint effects of irritation and hemor- rhage, the period which inter- venes between its occurrence and the commencement of the malady varying, on an average, from six to nine months. The annexed drawing, fig. 188, from a clinical case, exhibits the appearances presented by this disease after the occurrence of ulceration. There is no disease with which it is possible to confound encephaloid; glaucoma and amaurosis bear, it is true, some resemblance to it in its earlier stages, but any doubt upon this subject may usually be dispelled by a thorough inspection of the interior of the eye, with the aid of the ophthalmoscope, which will always reveal the existence of a tumor in the one case, but the entire absence of it in the other. Besides, glaucoma and amaurosis are extremely rare in infancy, especially as simple and independent affections; hence the very fact of there being serious disease deep in the interior of the eye is cal- culated to awaken suspicion as to its malignant character. After the morbid growth has made some progress, its characters are generally too well marked to admit of mistake. The absence of black pigment will always distinguish encephaloid from melanosis. Encephaloid of the eye ; stage of ulceration. 352 DISEASES AND INJURIES OF THE EYE. Encephaloid is always fatal; if removed, however early, it is sure to recur or show itself elsewhere; if left to itself, it gradually involves the different structures of the orbit, and even the base of the brain and its membranes. The eyelids generally escape, although they are always much enlarged and infiltrated with serosity. The subjoined account of the dissection of an encephaloid eye is copied from the third edition of my Elements of Pathological Anatomy. The patient was forty-two years of age, and the tumor, which was an open, bleeding fun- gus, projected at least an inch and a half beyond the level of the lids. The entire mass, after being divested of the muscles and cellulo-adipose tissues of the orbit, all of which were quite healthy, was nearly three inches in length by five and a quarter in circumference, its weight being a little up- wards of two ounces. The eye itself was of the ordinary form and volume, but was thrown considerably out of its position by the morbid growth, which was of an irregularly oval shape, and sprung from the inner side of the scle- rotica, near its junction with the cornea. This connection, however, was rather apparent than real; for, on tracing the heterologous mass, it became evident that it had originated in the retina, which had itself almost disap- peared. The anterior surface was closely invested by the conjunctiva, which had a rough, fleecy aspect, from the morbid enlargement of its villosities- about its centre was an incrusted ulcer, three-fourths of an inch in diameter^ around which the parts were somewhat knobby, and of a bluish, livid color.' On cutting through this portion of the tumor, it was found to.consist essen- tially of vessels, some of which had been opened by the erosive process, and formed the source of the frequent hemorrhages with which the patient had latterly been affected. Posteriorly, the mass was of a much lighter com- plexion, as well as more soft, and exhibited that peculiar tnberofd arrange- ment so characteristic of encephaloid. The cornea, although still transparent, was considerably diminished in size, and adhered firmly to the iris. The sclerotica was of the natural thick- ness, extensively attached to the choroid, and of a yellowish buff color. The choroid itself was of a speckled, brownish ap- pearance ; at some points, it was completely disorganized ; and, at one part, nearly oppo- site the morbid growth, there was a thin, black layer of blood beneath it. The retina, as be- fore stated, was almost entirely destroyed; and, in place of the vitreous humor, there was a dense, solid, whitish mass, evidently the result of an effusion of fibrin. The anterior cham- ber of the eye was obliterated, and the iris transformed into a substance resembling fibro- cartilage. The optic nerve, near its entrance Encephaloid of the eye. into the sclerotica, was slightly enlarged, bulb- ous, and pervaded by encephaloid matter. The appearances of the eye are pretty well shown in fig. 189, taken from the actual specimen. In July, 1857, I removed an encephaloid eye from a little boy, aged two years, in which the morbid mass possessed an extraordinary degree of soft- ness throughout. It had been in progress nearly a twelve-month, had pro- truded slightly beyond the lids, and had involved all the soft parts of the orbit. The lachrymal gland was remarkably indurated, as well as considera- bly enlarged ; and the crystalline lens, of a yellowish color, and more than twice its natural size, had undergone the earthy degeneration. The encepha- loid matter revealed no cancer cells. MALIGNANT DISEASES OF THE EYE. 353 Melanosis of the eye. 2. Melanosis.—Melanosis of the eye, fig. 190, is much less common than encephaloid, with which it occasionally co-exists. It is generally associated with melanosis in other parts of the body, and is rarely met with before the age of thirty- five or forty. Its starting point is usually deep in the eye, but of its precise origin we have no knowledge, as no opportunities have hitherto been afforded for investigating this question, since the disease never proves fatal in its earlier stages. Judging, however, from analogy, and the close resemblance which melanosis bears, in its progress and termina- tion, to encephaloid, it is extremely probable that both products have a similar origin. Be this as it may, the first evidence of melanosis of the eye is the existence of a dark, black, or purple mass deep in the vitreous body, appa- rently in contact with the retina, and entirely devoid of the metallic lustre, so conspicuous in the other form of malignant disease. The pupil is crippled in its movements, vision is materially impaired, and the eye has lost its natural expression. As the morbid growth extends it gradually disorganizes the humors of the eye, thrusts forward the iris, obliterates the anterior chamber, and causes ulceration of the cornea, or of the cornea and sclerotica, with a consequent fungous protrusion, from which there is always a dark, fetid, and abundant discharge, with occasional slight hemorrhage. In the latter stages of the malady the ball of the eye is generally more or less lobulated, and of a characteristic black color, not uniformly but at different points of its extent, the dark hue strikingly contrasting with the white appearance of the sclero- tica. The tumor, which sometimes equals the volume of an orange, generally projects a considerable distance beyond the level of the lids. The appearances of this disease are well seen in fig. 191; the iris has been partially detached, and the mass is making its way through the sclerotica, near the cor- nea. The progress of melanosis is generally con- siderably slower than that of encephaloid, but its termination is not the less certainly fatal. The average duration of the disease is from nine to eighteen months. Some- times a case occurs where it lasts several years. ^ There is seldom much pain until ulceration sets in, when the suffering rapidly increases, and sadly tells upon the constitu- tion. Lymphatic involvement also now takes place; the disease gradually extends to the structures of the orbit; and death finally occurs from exhaus- tion, very much as in encephaloid, which it likewise resembles in its disposi- tion to relapse after extirpation. "he only remedy for encephaloid and melanosis is extirpation, and that is, unfortunately, too often of a questionable character. If done at all, it should be done early and most thoroughly. If deferred until ulceration has begun, little is to be expected from such a procedure. Under any circum- stances, however favorable, relapse is inevitable. Such is certainly the result oi my experience, confirmed a thousand times by that of the profession vol. ii.—23 Melanosis of the eyeball. 354 DISEASES AND INJURIES OF THE EYE. generally. During ray pupilage in this city, I saw Professor George McClel- lan remove this organ in three instances for these affections, and in each there was a reproduction of the malady in less than a month. The patients were children under nine years of age, and in two the symptoms and progress of the disease were such as to hold out strong inducements for the operation. I have myself extirpated the eye in nine cases, in seven for encephaloid, and in two for melanosis, and in every one, so far as I have been able to judge, I believe that I have done mischief, by hurrying the patient prematurely to the grave. In one instance I performed not less than three operations in almost as many weeks, first removing the ball, and then portions of the lids and neighboring parts, but all to no purpose. The patient died from the effects of the malady in a few months from the time of the first excision. Some years ago I saw a lad, thirteen years of age, upon whom Professor Mussey had already operated twice, with the consequence of a speedy relapse in each instance. Wrhen the case fell into my hands, some weeks after the last operation, the morbid growth had already advanced so far as utterly to preclude the propriety of further interference. The youth went home, and died in a few months after. EXTIRPATION OF THE GLOBE OF THE EYE. This operation may become necessary on account of malignant disease of the eye, especially encephaloid and melanosis. It is sufficiently easy of exe- cution, but, as it is liable to be attended by copious hemorrhage, it should not be undertaken without proper precaution. The patient being under the influence of chloroform, and the head firmly secured upon a low pillow, an incision is made from the outer canthus towards the temple, with a view of facilitating the remaining steps of the operation. The length of this incision need not exceed three-quarters of an inch. The tumor being transfixed by a double hook, or by a double ligature, the knife, a narrow and rather a sharp-pointed bistoury, is passed circularly around it, dividing the conjunctiva, and thus separating the morbid mass from the lids. The next step is to cut the muscles of the eye a short distance behind their tendinous attachments, and finally to divide the optic nerve a few lines from its entrance into the sclerotica. Should the disease, however, be of long standing, then, instead of this procedure, which is always very simple, it will be necessary to include in the dissection all the soft structures of the orbit- muscles, cellulo-adipose matter, and lachrymal gland—sometimes, indeed, even the periosteum itself, and the nerve as far back as possible. The deep dissection will be much facilitated by the use of the scissors and a pair of slender dressing-forceps. The blood, which often flows in torrents, is wiped away with a sponge mop, and when the operation is over, the cavity is stuffed with lint wet with a saturated solution of alum, a thin compress moistened with sweet oil being placed upon the lids and gently supported by a bandage. This effectually prevents further hemorrhage. Clearance of the orbit is not attempted until the establishment of the suppurative process. DISEASES AND INJURIES OF THE LACHRYMAL APPARATUS. The lachrymal organs consist of the lachrymal gland, canals, and sac, together with the nasal duct, which are all liable to inflammation and its effects, and also to some of the heterologous formations, either as primary or secondary affections. a. Lachrymal Gland.—The principal affections of this little body are in- flammation, encysted tumors, and chronic enlargement. 1. Inflammation of the lachrymal gland, technically called dacryademtu, DISEASES AND INJURIES OF THE LACHRYMAL APPARATUS. 355 is so very rare that many practitioners have doubted, though erroneously, the possibility of its occurrence. It is mostly seen in young subjects of a strumous diathesis, and is commonly produced by the effects of cold or ex- ternal injury; in disease of the globe and orbit the gland is sometimes in- volved secondarily, and this, in fact, appears to be the way in which it usually suffers, idiopathic disease being exceedingly infrequent. There are no signs by which the affection can be discriminated from other maladies in its imme- diate vicinity; but its presence may always be suspected when there is pain, more or less severe, in the situation of the gland, accompanied with swelling and tenderness on pressure. Confirmatory evidence is afforded by the absence of lachrymal secretion, or the existence of inordinate dryness of the conjunc- tiva, oedema, pain and tension of the upper lid, and displacement of the ball of the eye, which is generally pushed somewhat downwards and inwards by the pressure of the enlarged gland, as well as embarrassed in its movements. The conjunctiva always participates in the inflammation, becoming red and painful; the periosteum of the orbit is also liable to become involved, and the bone itself may ultimately be attacked. Fever and headache are among the more common symptoms, and in many cases the patient is delirious. Dacryadenitis may terminate in abscess, or pass into the chronic form, the gland remaining enlarged and tender for many months. The formation of matter is usually indicated by the occurrence of delirium, or an increase of it if it previously existed, a disposition to rigors, and aggravation of the cir- cumorbital inflammation. The treatment is rigidly antiphlogistic; by general bleeding if there be much suffering conjoined with plethora; by leeches to the outer part of the upper lid, forehead, and temple; by active purgation ; by the use of the antimonial and saline mixture; and by the application of medicated dress- ings, either in the form of light poultices or fomentations. If suppuration occur, the matter is evacuated by an early incision through the upper part of the conjunctiva, beneath the corresponding lid. The chronic form of the disease is combated by milder means; principally by purgatives, occasional leeching, and alterant tonics. Now and then the puncture made for the evacuation of the abscess is disposed to remain fistulous ; when this is the case it must be lightly touched, from time to time, with nitrate of silver, or the end of a fine probe, dipped in a weak solution of acid nitrate of mercury. 2. An encysted tumor occasionally forms in the lachrymal gland, in conse- quence, apparently, of the obstruction of one of the lachrymal ducts, and the retention of lachrymal fluid. The contents of the cyst are of a whitish color, of a thin, watery consistence, and decidedly saline to the taste; occasionally they are thick and viscid, like synovia. The tumor varies in volume from that of a pea to that of an almond ; it is irregular in shape, and bears the closest resemblance, in its appearance, to a small bladder; it consists of a single layer, and is always unilocular. In the few cases in which it has hitherto been observed it occurred in young subjects, under thirty years of age. The diagnosis of the affection is necessarily obscure, if not altogether uncertain.^ When the tumor approaches the surface, and has an elastic, or senn-elastic feel, an exploring needle, carefully inserted, may assist us in de- termining the nature of the case; but, in general, this can be done only by an incision, large enough to expose its surface. The eyeball is usually displaced forwards and inwards, but as this protrusion may be caused by other affections, such, for instance, as tumors of the orbit, entirely uncon- nected with this gland, it is evident that we can deduce no useful hints from that circumstance. Ihe treatment is conducted upon the same principles as that of encysted tumors elsewhere. The safest remedy is an injection of a very weak solution ot iodine, or the introduction of a little mercurial ointment, to excite inflam- 356 DISEASES AND INJURIES OF THE EYE. mation and an effusion of plasma. Extirpation of the sac should only be attempted when the tumor is large and indisposed to yield to other and milder means. 3. The lachrymal gland is liable to chronic enlargement, producing a condi- tion of parts similar to what occurs under similar circumstances in the tonsils, the lymphatic ganglions, and the mammary gland. Ophthalmic writers have much to say about this affection, many of them confounding it with true scir- rhus, a disease which is probably never developed in this organ. What countenances this opinion is, first, that the enlargement and induration often take place in young subjects, long before the period for the appearance of scirrhus in other situations; and secondly, that dissection, however carefully conducted, always fails to disclose the characteristic structure of this hetero- logous product. Still, I do not feel inclined altogether to deny the possibility of the occurrence of scirrhus, much less of encephaloid, in this gland; for it is unquestionable that, in not a few of the reported cases, the enlargement of this organ was carried to a prodigious extent; far, indeed, beyond what we might suppose would have happened had the disease been of a benign nature. Moreover, it is certain that the gland is liable to become affected secondarily by cancer, as is seen in encephaloid of the globe of the eye, and in epithelioma of the lids and orbit. AVe must, therefore, be in doubt respecting the real nature of these tumors. It will be a good rule to extirpate them without delay, whenever they are at all of a suspicious character, or whenever it is found that they are not amenable to the ordinary discutient means. 4. Extirpation of this body is accomplished by making an incision through the outer commissure of the lids, and raising the upper flap from the corre- sponding portion of the ball; a procedure altogether preferable to cutting through the substance of the lid, as generally advised by surgeons. The enlarged gland being thus exposed is carefully liberated with the finger or handle of the scalpel, and lifted from its bed along with any other suspicious looking structure. The edges of the cutaneous wound being approximated by suture, a light compress is placed upon the eye, and confined by adhe- sive strips. b. Lachrymal Canals.—These little passages, which convey the lachrymal secretion to the tear-bag, are liable to laceration, inflammation, obstruction, and stricture. Laceration of these tubes is one of the effects incident to injury in this region, being usually caused by a blow, or by a fracture of the nasal and maxillary bones. Wralton mentions an instance in which it was produced by a slight scratch on the inner corner of the eye in a scuffle. It is characterized by a puffy, emphysematous swelling, crackling under the finger, and gradually spreading over the cheeks and eyelids, which are sometimes completely closed. The symptoms generally disappear spontaneously in a few days. Inflammation of these passages, whether originating there, or propagated to them from the neighboring structures, is attended with thickening of the lining membrane, more or less uneasiness, muco-purulent discharge and water- ing of the eye, the tears being unable to reach their natural destination. The subjects of the disease are generally persons of a strumous predisposition, who are very prone to take cold, and to suffer from other ophthalmic affections, especially chronic conjunctivitis. Indeed, we seldom meet with inflammation of these canals without this association. The proper remedies are attention to the general health, which is often much impaired, and gentle, but steady purgation, with a leech occasionally to the inner canthus, and the use of slightly astringent injections. Obstruction of these canals may be caused in different ways; most generally by chronic thickening of their lining membrane, sometimes by the presence of inspissated mucus, or muco-fibrinous matter, sometimes by earthy concre- DISEASES AND INJURIES OF THE LACHRYMAL APPARATUS. 357 tions, and sometimes, again, by direct adhesion of their walls, or by deposits of lymph in the submucous cellular tissue. A wound of these passages is a serious accident, inasmuch as we can never hope for the complete restoration of their functions. The closure may be partial or complete, temporary or permanent; in some cases it affects merely the puncta, or orifices of the tubes. The characteristic symptom is epiphora; but the nature and situation of the obstruction can be determined only by an examination with the probe. When the obstruction is extensive, or dependent upon firm adhesions, or the presence of organized lymph, no benefit will be likely to result from treat- ment; under opposite circumstances, relief should be attempted by gradual dilatation, and mildly astringent injections, the proper instruments for per- forming these operations being Anel's probe and syringe, depicted in the annexed cuts, figs. 192 and 193. Great tact and caution are necessary in Fig. 192. — I Anel's probe. the use of these instruments, otherwise we shall be apt to increase the disease instead of diminishing it. The probe should not, at first, be introduced oftener than once every fourth or fifth day, and the operation should never be commenced without some preliminary treatment, with a view of rendering the Fig. 193. Anel's syringe. parts more tolerant of manipulation. The eye should always be well bathed immediately before, and for some time after the passage of the instrument, and if considerable irritation arise, a brisk purgative must be given, and a leech applied to the inner canthus. The dilatation may generally be greatly promoted by the daily use of some astringent injection, composed, for instance, of the eighth of a grain of nitrate of silver to the ounce of water, or a weak solution of zinc, alum, or lead. Without, however, some constitutional treatment, I am satisfied that local measures will generally afford very little benefit; and even then, under the most favorable circumstances, much time and patience will be required to effect a permanent cure in any case. Jt sometimes happens, in consequence of accident or disease, that the orifice of the inferior lachrymal canal is seriously displaced, being turned forwards or upwards, away from the ball of the eye, so as to allow the tears to flow over the edge of the lid. Wrhen this is the case, relief may be afforded by a very simple operation, suggested by Mr. Bowman, of London, consisting in the complete laying open of the canal by means of a very delicate knife, ear- ned from below upwards over a grooved director. During the after-treat- ment care must be taken to prevent the edges of the incision from growing together, by the occasional use of a probe. The object of this procedure is 358 DISEASES AND INJURIES OF THE EYE. to extend the orifice of the duct backwards to the point where the tears na- turally accumulate. When the orifice of this canal is obliterated, the canal itself remaining pervious, the same distinguished surgeon recommends that an incision should be made just below the seat of the obstruction, across the tube, which should hen be slit up on a probe. c. Lachrymal Sac.—The tear-bag is liable to laceration, inflammation, both acute and chronic, abscess, and fistule. 1. The lachrymal sac may be more or less extensively lacerated in fracture of the nasal and maxillary bones, followed by excessive swelling of the parts, with a tendency to emphysema, the formation of abscesses, and obliteration of the sac from inflammatory deposits. A case has been related by Dr. Taylor in which the rupture was occasioned by blowing the nose. To prevent these sad effects, the treatment should be prompt and vigorous, our main reliance being upon leeches and cold water-dressing, with active purgation. 2. Inflammation of the lachrymal sac, the dacryocystitis of the ophthal- mologist, commonly occurs in strumous and syphilitic subjects, either from exposure to cold, disease of the neighboring structures, or, as more generally happens, from obstruction of the nasal canal, the inferior outlet of the sac. The sac, under these circumstances, is placed in the same condition as the urinary bladder in stricture of the urethra, or chronic enlargement of the prostate gland. In either event there is retention of the natural contents of the reservoir, which, undergoing chemical decomposition, become thereby a source of inflammation, suppuration, and even ulceration. I imagine that most of the more simple cases of dacryocystitis are induced in this way. The disease may occur at any period of life, but is uncommon in infancy and childhood. The acute form of the disease is characterized by unusual violence, the symptoms, both local and constitutional, being generally much more severe than the size and importance of the affected part would seem to justify. The reason, however, is sufficiently apparent when we reflect upon the organiza- tion of the sac, and the nature of the structures which surround it. The disease begins in the form of a hard, circumscribed swelling, just below the tendon of the orbicular muscle, which, gradually increasing in size, soon be- comes the seat of the most exquisite pain, deep-seated, tensive, throbbing, and extending about in different directions ; the skin has a red, erysipelatous look, and slightly pits on pressure ; the eyelids, cheek, and nose, are deeply involved in the morbid action ; the lachrymal canals, being obstructed, no longer perform their office; there is high fever, with agonizing headache; and the patient is often violently delirious. If the excitement be not arrested, as it rarely will be when it has attained this height, suppuration will set in, thus greatly augmenting the suffering. The treatment of acute dacryocystitis is rigidly antiphlogistic. Leeching, and even venesection, may be necessary; purgatives and antimonials are freely used, along with anodynes, to allay pain and promote sleep; and the parts, painted several times a day with dilute tincture of iodine, are kept constantly wet with a strong solution of acetate of lead and opium. A small blister applied to the part is occasionally of great service. 3. The formation of abscess of the lachrymal sac is denoted by the pointed character of the swelling, by the erysipelatous blush of the skin, by the throb- bing nature of the pain, and by the sense of fluctuation, which is always pre- sent when the matter has made some progress towards the surface. In that case, too, there is often a small vesicle of the epidermis with an attenuated state of the skin, showing where the abscess, if left to itself, will ultimately open. The treatment of the disease is, obviously, by incision, large enough to afford free vent to the pent-up fluid, and the earlier the operation is per- formed the better, both for the part and system. The tendon of the orbicular DISEASES AND INJURIES OF THE LACHRYMAL APPARATUS. 359 muscle, made tense, serves as a guide to the knife, which is then carried per- pendicularly down over the most prominent part of the swelling. A very small tent is inserted to insure patency of the wound. The inflammation having subsided, the artificial opening gradually closes, though, in general, it will manifest a disposition to remain patent, especially if there is any obstruction in the nasal canal, or disease of the lachrymal bone, as may happen when the affection is of a strumous or syphilitic origin. In such a case the bone may be completely necrosed, and consequently require removal. When the sac remains open, or breaks at intervals, it discharges more or less pus, or puriform mucus, constituting what has been called muco- cele. Under such circumstances, the cure may be promoted by astringent injections, or simply washing out the sac several times a day with tepid water and soap, or common table tea. 4. Chronic dacryocystitis is often a troublesome and obstinate disease, as annoying to the practitioner as it is disagreeable to the patient. It may be a sequela of the acute form of the malady, or it may exist as an original lesion, coming on gradually and stealthily, without any evident cause, and unaccompanied by any marked symptoms. It is most common in strumous persons, in consequence of attacks of measles, scarlatina, and smallpox, and frequently lasts for months and years, meanwhile producing serious structural changes, particularly thickening of the lining membrane, and obstruction of the lachrymal and nasal ducts. Sometimes it is dependent upon disease of the pituitary membrane, caries of the bones of the nose, or the presence of a nasal polyp. The disease is recognized by a small tumor at the side of the nose just below the tendon of the orbicular muscle, and by a constant feeling of uneasi- ness of the part; there is generally some inflammation of the conjunctiva and lids, and occasionally, though not always, some discoloration of the skin in the situation of the sac. The swelling is caused by the retention of the tears and the accumulation of the mucous secretion ; two circumstances which ma- terially serve to keep up the morbid action. By pressing the tumor gently with the finger, its contents may be made to discharge themselves through the lachrymal canal, and partly, also, through the nasal duct; this, indeed, is the method usually adopted by the patient to obtain temporary relief, the operation being often performed three or four times a day. Epiphora, or watering of the eye, is generally another of the annoyances experienced by persons laboring under this affection. Chronic dacryocystitis is treated upon the same principles as the acute form of the disease, only that our remedies must be plied less vigorously. Attention to the general health is indispensable in all cases ; the secretions, which are often much at fault, must be early corrected; the diet must be properly regulated; and the bowels must be kept under the influence of mild purgatives, containing a small quantity of blue mass or calomel. Locally, the best application is a leech, renewed every six or eight days, use being made, in the interval, of the dilute tincture of iodine, painted upon the skin over the sac once every twenty-four hours. Benefit, of a very important character, will accrue from the daily use of mildly astringent injections, thrown into the sac along the lower lachrymal canal with an Anel's syringe. We cannot be too careful, however, in the use of these means, for, should they be at all irritating, we shall be sure to increase the morbid action instead of abating it. The practitioner has a great variety of articles from which to select, and he has only to be careful that he properly graduates their strength to the tolerance of the parts. When the disease is dependent, as it often is, upon partial obstruction of the nasal duct, an attempt should be made to enect clearance with the probe, used upon the same principle as in the cor- responding affection of the lachrymal canals. 360 DISEASES AND INJURIES OF THE EYE. The introduction of the probe necessarily involves a very thorough ac- quaintance with the anatomy of the lachrymal passages. The operation is usually performed upon the inferior canal, the patient being seated upon a chair with his head resting against the breast of the surgeon who stands behind him. The lower lid being made slightly tense by placing a finger over the outer commissure, the probe is inserted from above downwards, and gradually brought to a horizontal position, until the point reaches the further side of the sac; the instrument, being now raised against the superciliary arch, is passed steadily downwards, with a slight inclination backwards, along the nasal canal, into the inferior chamber of the nose, care being taken to execute the whole proceeding in the gentlest possible manner. The opera- tion is repeated from time to time, at first once every four or five days, then once every other day, and finally once every twenty-four hours, until all necessity for its employment ceases. Should this plan fail, and abscess be threatened, the sac should be laid open, and a style worn in the nasal duct. The patient being seated upon a chair, with his head supported upon the breast of an assistant, the surgeon, sitting in front of him, stretches the tendon of the orbicular muscle by placing his finger over the outer commissure, and, taking the tendon as his guide, be plunges a narrow, sharp-pointed bistoury, held, at first, almost horizontally, and then vertically, into the sac, and finishes the operation by bringing the instrument in the vertical position, and cutting from within outwards. The annexed cut, fig. 194, ex- hibits the manner in which the operation is usually done. A style, made of silver, eight lines long, and represented in fig. 195, is then conveyed into Fig. 195. Style for the nasal duct. the nasal duct, its head protruding at the orifice of the wound, where, if there be any danger of its falling into the sac, it may easily be secured by a lit- tle thread, passed through an aperture in the instru- ment, and fastened to the" side of the nose with a bit of court plaster. The style is occasionally withdrawn and cleansed. Instead of this instrument the surgeon may use a piece of catgut or unoiled sole- leather, or, what I prefer, a bougie of slippery elm, which, while it is easy of introduction, has the effect of rapid expansion, thus greatly expediting the dilatation. When the duct is firmly closed, it may be necessary, as a preliminary to the insertion of the style or bougie, to effect clearance with a common pocket probe. When the obstruction is irremovable, the proper plan is to drill a suitable opening—a pretty large one—into the lower portion of the lachry- mal bone, to allow the tears and mucus to pass into the upper chamber of the nose. Fig. 194. j INJURIES AND DISEASES OF THE LIDS. 361 5. Fistule of the lachrymal sac is nearly Fig. 196. always the result of abscess, dependent upon closure, partial or complete, of the nasal duct. It may, it is true, result from wound, but such an occurrence is quite uncommon. Disease of the lachrymal and turbinated bones, or of the pituitary membrane, and various morbid growths of the nose, may also give rise to it. The external opening is usually situated just below the tendon Of the Orbicular mUSCle, as Lachrymal fistule in its chronic stage. in fig. 196, and is subject to temporary closure. The discharge is either muco-purulent, or mucous, being of a yellowish or whitish appearance, and of a ropy consistence; the parts around are gene- rally somewhat tender and inflamed, and the tears often flow over the cheeks, in consequence of the congested condition of the lachrymal passages. As the cause of this affection is obstruction of the nasal duct, it is evident that the only remedy is its removal. This is to be accomplished in the man- ner already pointed out under the bead of chronic inflammation ; but before any measures of this kind are adopted, we should endeavor to get rid of any existing complications, and for this purpose it may be necessary to subject the patient to several weeks' preparation, by leeching, dieting, and purgation. Too much attention cannot, I am satisfied, be paid to this advice, of the benefits of which I have often had the happiest proof in the rapid progress of the treatment. When the patency of the nasal duct has been re-established, the fistule will usually close spontaneously in a few days; should it be slow in healing, the cicatrization may be promoted by the application of nitrate of silver, or a weak solution of acid nitrate of mercury. In several of my cases the orifice closed promptly, after the failure of other means, under the application of a small blister. 6. Having already spoken of the principal diseases of the nasal duct, and the means of overcoming them, in connection with inflammation and fistule, it is not necessary to enter into any formal disquisition of them here. This is the less called for, because they are of infrequent occurrence, most obscure in their diagnosis, and, in great degree, beyond the reach of remedies. INJURIES AND DISEASES OF THE LIDS. The lids are subject to various affections, some of which are peculiar to them, others common to them and other parts of the body. A very cursory survey of these lesions is all that will be necessary in a general treatise on surgery. 1. Wounds of the lids are infrequent, and must be treated on general princi- ples. A clean cut should be united by suture, with wire in preference to thread, introduced in such a manner as not to interfere with the mucous membrane, or even, if it can be avoided, the tarsal cartilage. Pins are quite out of the question, and plaster alone should never be trusted to on account of the great mobility of the parts. The nicest adaptation of the divided surfaces is to be aimed at, as any mal approximation is liable to be followed by trichiasis, entropion, or ectropion. When a lid is severed from its connections, torn through at the centre, or divided at its commissure, the edges should be well trimmed, and then united by suture, aided by adhesive strips. Occasionally a compress and bandage will be required; but, in general, the globe of the eye will afford sufficient support to the affected parts. Wrhen the lachrymal point is involved in the laceration, the greatest care should be exercised to prevent its closure. 362 DISEASES AND INJURIES OF THE EYE. A vertical fissure of the upper lid, whether congenital or accidental, must be rectified by an operation similar to that for hare-lip, apposition being maintained by the finest suture and isinglass plaster. Wounds of the eyebrows demand the same attention as similar lesions of the lids, both in regard to accuracy of adaptation and retentive measures. A disfiguring cicatrice of these parts may often be advantageously dissected out, and exchanged for a more seemly scar; but such a procedure usually requires proper preparation of the system, lest, erysipelas arising, the beauty of the result be thus marred. 2. A stye is a small, inflammatory swelling at the edge of the lid, of a furuncular nature, attended with pain, heat, and itching, with a tendency to suppuration. It is, in fact, nothing but a boil, modified by the structure of the parts in which it is developed. The matter is thick, unhealthy, and usually contained in a small slough. The disease probably has its origin in one of the bulbs of the cilia, and is most frequently met with in persons of a strumous constitution, laboring under derangement of the digestive apparatus. I have seen it much oftener in females than in males, particularly in young girls, who take but little exercise, and are subject to irregularity of the menses. Some individuals are peculiarly prone to this disease, suffering almost habitually for months together, one stye appearing after another, or each having a dis- position to assume a chronic course. The upper lid is more frequently affected than the lower. The proper practice is to encourage the suppurative process with warm fomentations, or a light elm poultice, and to puncture the swelling as soon as matter has fairly begun to form. If the stye is very painful, a leech may be applied to its outer surface, and the patient be directed to take a brisk cath- artic. When the affection becomes chronic, or has a tendency to frequent recurrence, special attention must be paid to the correction of functional derangement, by the exhibition of purgatives, alterants, and tonics, and a judicious regulation of the diet. The best local application will be a weak solution of iodine, and slight scarification, to relieve vascular engorgement. 3. Various kinds of tumors—horny, warty, sebaceous, encysted, serous, hairy, benign and malignant—form upon the lids, in their substance, or along their free edges ; but as they do not differ from similar formations in other regions, it is not necessary that I should enter into any elaborate account of their nature and treatment. Most of them are easily recognized and treated, the proper remedy being excision, performed as soon as the morbid growth acts hinderingly or disfiguringly. Those seated along the edge of the lid may usually be snipped off with the scissors, or, if the patient dreads pain, they may be removed with the ligature ; any tendency to reproduction being afterwards repressed with nitrate of silver. When the tumor occupies the substance of the lid, a horizontal incision, embracing the skin and fibres of the orbicular muscle, is made across it, when it may be seized with the tenaculum, and either dissected or dug out, as may be most convenient, care being taken, if it be encysted, not to leave any of the sac behind, nor, in any case, to injure the palpebral cartilage. The edges of the wound are approxi- mated by the interrupted suture, which is the only dressing required. One of the most common tumors in the upper lid—it does not occur in the lower—is the fatty, which often attains the size of a currant, in the course of two or three months, and is productive of more or less impediment of motion, as well as of some degree of soreness. It is almost always associated with derangement of the digestive organs, occurs at various periods of life, some- times even in young children, and generally originates in the cellular tissue between the orbicular muscle and the palpebral cartilage. It is usually some- what globular in shape, hard to the touch, and unaccompanied by discolora- tion of the skin. Its pressure sometimes causes partial absorption of the INJURIES AND DISEASES OF THE LIDS. 363 Entropion of both lids. cartilage. Laid open, it is found to consist of Fig. 197. a soft, fatty substance, frequently intermixed with a few drops of pus, and contained in an imperfect cyst. The term fatty tumor is the most appropriate one for it. The proper remedy is excision ; it never recurs, but similar growths are liable to form in its vicinity. Attention to the constitution is generally necessary to coun- teract this tendency. 4. Inversion of the lids, as seen in fig. 197, the entropion of ophthalmologists, is generally the result of severe and protracted inflammation of the eye, attended with excessive intolerance of light, compelling the patient to make constant and powerful efforts to exclude it from the retina. The consequence is that the lids are drawn with great firmness over the ball, not several times during the day, but incessantly, thus inducing relaxation of the skin and orbicular muscle, and, also, as a necessary result, inversion of the cilia. Granular and strumous diseases of the eye are, according to my observation, the most common causes of entropion; cases occasionally occur where it is produced by very slight inflammation, especially if, as not unfrequently happens, the individual has naturally a very redundant lid, or a sort of hypertrophous condition of its cutaneous and muscular tissues. Entropion sometimes affects all the lids, either simultaneously or succes- sively, as I have witnessed in a considerable number of cases; more com- monly, however, it is limited to one or two. In degree it varies from the slightest change in the natural position of the organ to the complete curling up of its inner edge, the cilia being perfectly concealed from view. In the advanced stage of the affection the skin of the lid is thrown into numerous horizontal folds, the fibres of the orbicular muscle are spread out and relaxed, the tarsal cartilage is rendered concave in its vertical diameter, and the lashes are stiff and straggling. The injurious effects which entropion exerts upon the eye may readily be imagined. The lashes, constantly pressed against the anterior part of the ball, fret and irritate the conjunctiva and cornea, keeping up inflammation, with muco-purulent discharge, profuse lachrymation, and intolerance of light. The mischief is particularly apparent in the cornea, which, in consequence of the friction of the lid, soon becomes the seat of plastic deposits, interfering with the transmission of light, and often producing total blindness. Various remedies have been suggested for the cure of this disease, but the only one which is in the least worthy of reliance is the excision of an elliptical portion of integument, extending from one extremity of the lid to the other, Fig. 198. Entropion forceps. and embracing a few of the fibres of the orbicular muscle. Much judgment is required in order accurately to proportion the amount of substance to be 364 DISEASES AND INJURIES OF THE EYE. removed; the great danger generally is that the operator takes away too little, thus favoring speedy relapse. Particular instruments, as that, for ex- ample, sketched in fig. 198, have been devised for pinching up the skin and giving the flap a proper shape ; but the scientific surgeon needs no such aid, a pair of dissecting forceps and scissors being quite sufficient for his purpose. Excision having been effected, the edges of the wound are neatly tacked together by three or four points of suture, to be removed at the end of the third day. Very little, if any, after-treatment will be required. If all the lids are inverted they may be operated upon at the same sitting, as I have done in numerous instances. 5. Ectropion, exhibited in fig. 199, the reverse of the above condition, may be caused by long-continued inflammation, attended with excessive thickening of the conjunctiva, as in granular lid ; but in the Fig> 199, great majority of cases it is produced by the con- traction of vicious cicatrices, especially by such as are the result of scalds, burns, and escharotic ap- plications. The eversion presents itself in various degrees, being sometimes very slight, and at other times so great as to turn the lid completely inside out, hanging off from the eye like a shutter. How- ever this may be, it is always accompanied by an inflamed, thickened, and indurated condition of the palpebral conjunctiva, and generally also by more or less disease of the eye, owing to the con- Ectropion of the lower eyelid. stant exposure of the ball to light and dust. In cases of long standing the ocular conjunctiva is dry and hypertrophied, and the cornea often exhibits opaque specks, ob- structing vision. The affection is most common in the lower lid, and, in its worst forms, is often attended with a remarkable elongation of the part in its horizontal diameter, so that the lid is not only everted but turned away con- siderably from the ball. Slight ectropion, depending upon inflammation, may sometimes be relieved solely by antiphlogistic means, which, by promoting the contraction of the enfeebled and relaxed structures, gradually restore the lid to its pristine posi- tion. The removal of the thickened and indurated palpebral conjunctiva, in the form of an elliptical fold, sometimes greatly facilitates the cure. When the affection has been caused by a vicious cicatrice, an extensive dissection may be necessary to effect the object, and even then success is by no means always certain, owing to the remarkable Fig. 200. reproductive tendency of the inodular tissue. I have, however, l'epeatedly effected excel- lent cures by this procedure, in apparently the most unpromising cases. The opera- tion consists in dissecting up the lid freely from its unnatural attachments, placing a well-oiled compress upon the raw surface, and making the part heal by granulation, elevation of the lid being assisted by ad- hesive plaster, or a thread passed through its edge, and secured to the forehead or cheek, according to the site of operation. If the lid is very large and ill-shaped, it may be necessary to cut out a triangular flap, fig. 200, and a very good cure is some- times effected, in the more common cases Operation for ectropion. of ectropion, simply by this means. INJURIES AND DISEASES OF THE LIDS. 365 ^^ Plastic operation on the eyelid. When the parts are much disfigured, or partially lost, whether by accident or disease, we may attempt the formation of a new lid, although we cannot flatter ourselves that our efforts will often succeed, especially if serious in- jury has been sustained by the tarsal cartilage, as in that event it will hardly be possible to obtain a good support for the new organ. The flap may be borrowed from the cheek or temple, or partly from the one and partly from the other. The adjoining cut, fig. 201, affords a good idea of the nature of the operation. 6. The lids are sometimes attached by morbid adhesions to the ball of the eye, thus not only impeding its movements but causing serious deformity. The most common causes of the occur- rence are scalds and burns, and the con- Fig. 201. tact of escharotic substances, as nitric acid and quicklime. The defect is sometimes congenital, though this must be extremely rare, as I have never seen an instance. Relief is attempted by the cautious use of the knife, the contiguous surfaces being afterwards kept apart by soft lint, and by the daily destruction of the new adhe- sions with the probe. The cure will necessarily be tedious, and require the exercise of a great deal of patience. Dr. Hays recently published the par- ticulars of several cases in which, after a thorough separation of the parts, he suc- ceeded in effecting a good cure by the inter- position of a thin silver plate, or a piece of thin tin-foil, shaped somewhat like an artificial eye, the lids being kept in close contact with the ball by means of strips of isinglass plaster. The foreign body is removed daily, the parts being well syringed before it is reinserted. The cicatrization is usually com- pleted in from three to four weeks. 7. Inversion of the eyelashes, technically called trichiasis, represented in fig. 202, may exist as an independent affection, or as a complication of en- tropion. Generally caused by chro- nic disease of the lids, especially Fig. 202. psoriasis and eczema, it sometimes comes on without any assignable cause, and at a period of life so early as almost to induce the belief that it may occasionally be congenital. In some persons the cilia are naturally very short, stiff and straggling, and when this is the case the slightest inversion of the edges of the lids may produce quite a severe trichia- sis. The lashes are generally bent in different ways, some towards the eye, some outwards, and some in the direction of the length of the lids. The constant rubbing of the faulty cilia against the ball, keeps up seri- Trichiasis. ous disease, and often leads to opa- city of the cornea, not unfrequently followed by total blindness. trichiasis, dependent upon entropion, will generally disappear the moment the hd is put in a condition to resume its proper position. When the cilia 366 DISEASES AND INJURIES OF THE EYE. alone are inverted, the only feasible remedy is excision of the part of the lid in which they are implanted, care being taken not to injure the palpebral car- tilage; the little wound will soon heal, and no deformity will ensue. When all the cilia are turned in, the procedure which I usually adopt is .to include them in two horizontal incisions, extending the whole length of the lid, from one end to the other. Nothing short of this ever answers the purpose, nor will this suffice, unless every bulb is taken away with its corresponding hair. Save the unseemly appearance caused by the absence of the lashes, it is aston- ishing what littledisfigurement such an operation produces. It has been proposed to cure this affection by inoculating the bulbs of the faulty cilia with dry tartar-emetic, with a view of causing their destruction by the resulting inflammation. I must confess I have an aversion to such a procedure. Evulsion, or drawing out the cilia by their roots with a pair of forceps, is equally objectionable; first, because the process is one of difficulty, and, secondly, because it rarely succeeds. 8. The edges of the lids are liable to an eruptive disease, which is often a source of much suffering, and the characteristic symptom of which is a distressing itching; it is evidently a species of herpes, or eczema, seated in the orifices of the Meibomian glands, and is generally known by the name of psorophthalmia, bestowed upon it by some German author. The affection is almost peculiar to young subjects, of a strumous predisposition, with light hair, eyes, and complexion. When it becomes chronic, as it is wont to do, it is a source of much annoyance, if not positive suffering, keeping the parts constantly sore, itchy, watery, and irritable. Persons thus affected are often unable to read or sew for months and years together. The disease is aggra- vated by exposure to the light, the use of stimulating food, loss of sleep, and, in short, whatever has a tendency to disturb the secretions or damage the general health. Psorophthalmia is characterized by a reddish appearance of the edges of the lids, by more or less itching, and by the presence of little bran-like scales at the roots of the cilia, accompanied by an inspissated, glutinous secretion of the Meibomian follicles, lachrymation, epiphora, injection of the conjunc- tiva, and intolerance of light. In the milder forms of the disease, some of these symptoms are either wanting, or they exist only in a slight degree, or they are altogether absent at one time, and present at another. In chronic cases, the edges of the lids, losing their angular shape, are gradually rounded off, and assume a rough, villous, or granular appearance; the mucous mem- brane is abnormally thickened, the orifices of the lachrymal canals are closed, and many of the lashes drop out for the want of support, or, rather, because of the death of their bulbs. In this stage of the complaint, the affected lid is often considerably everted, and being at the same time very red and watery, it produces that peculiar state, termed blear eye. Regarding this disease as being essentially of constitutional origin, it would be folly to attempt its subjugation by mere topical treatment. With- out entering into minutiae, it will be sufficient to remark that a steady and persistent course of purgatives, alterants, and dieting, is indispensable, in almost every case, to a satisfactory and permanent cure. Blue mass and compound extract of colocynth, in five grain doses each, every fourth or fifth night, will act sufficiently upon the bowels and secretions, without weakening the system; iodide of iron and iodide of potassium will afford a good altera- tive effect; and bread, vegetables, and milk, will be a suitable diet. Where a tonic is required, great confidence may be placed in the efficacy of iron and quinine, with a very minute quantity of opium and tartar-emetic, with a view to their soothing and alterant effects. Occasionally, a brisk emetic is serviceable, especially when there is marked disorder of the digestive organs. The most valuable topical remedies are astringent lotions and stimulating PTOSIS. 367 unguents, properly diluted, and applied by means of a camel-hair pencil. The article from which I have always derived the greatest benefit is the oint- ment of the oxide of zinc, in the proportion of one part to six of prepared lard. The ointment of red oxide of mercury, of the nitrate of silver, and of acetate of lead, are also valuable agents. Sometimes the happiest effects fol- low the application of a we%k solution of nitrate of silver in solution. The great secret, in the use of any article, is to make it sufficiently weak not to produce incited action, to apply it not oftener than once, or, at most, twice, in the twenty-four hours, and to bring it fairly in contact with every por- tion of the diseased surface. To effect the latter object, we should take care previously to remove, by means of a needle, the scaly deposits at the roots of the cilia, as well as any other matter that may have a tendency to inter- fere with the application. When the lids are very red and tender, poppy fomentations, or an elm poultice, may be necessary. Agglutination of the lids is prevented by the use of a little thick cream at bedtime. In obstinate cases, counter-irritation may be proper. PTOSIS. The term ptosis implies an inability to raise the upper lid, in consequence of some defect on the part of the elevator muscle. This defect may consist in mere atony of the muscle, in paralysis, in mechanical injury, or in hyper- trophy of the common integuments. Occasionally it is found to exist as a congenital vice. It is seldom met with simultaneously on both sides. Ptosis varies in degree from the slightest drooping of the lid to its complete closure, and always produces a corresponding defect in the sight, in consequence of the manner in which the affected structures conceal the cornea and pupil. The treatment of this affection must be regulated by the nature of the ex- citing cause. When it is dependent upon mere weakness of the elevator muscle, the most appropriate remedies will be tonics, as iron and quinine, the shower-bath, stimulating embrocations, and electricity, with change of air. In the paralytic form, the disease often disappears spontaneously, subsiding with the cause which gave rise to it. In plethoric subjects, general and local depletion, with an occasional purgative, is sometimes necessary, in addition to the use of a small blister to the forehead and eyebrow, the surface being kept raw by means of some irritating unguent. In a case of this variety of ptosis, in a young man of twenty, which was under my care some years ago, I derived signal benefit, as I supposed, from the repeated application of the moxa, and powerful vesication of the occipito-cervical region. When the affection is dependent upon lesion of the brain, no treatment, however skil- fully directed, will be of any avail. Ptosis from hypertrophy is relieved by the excision of a portion of the redundant integument, in the form of an ellipsis, the edges of the wound being afterwards approximated by several points of suture. The operation is performed in the same manner as in entropion, and great judgment is gene- rally required to determine the amount of substance to be removed. In the traumatic form, the difficulty depends upon the division of the fibres of the elevator muscle, and their consequent separation from each other, as happens, for instance, after the operation for strabismus. To afford relief, it has been proposed to cut out an elliptical portion of the integuments of the •id, and to tack together the orbicular and occipitofrontal muscles, so as to enable the latter, by the hold thus acquired, to counteract, in some degree, the action of the former. The procedure has been employed with marked success in several instances, and is worthy of further trial, though it cannot always be expected to answer the purpose as fully as could be desired. A similar plan may be adopted in the congenital variety of ptosis. 368 DISEASES AND INJURIES OF THE EYE. When the affection is irremediable, or while the proper remedies are being used for its cure, temporary relief from obstruction to vision may be afforded by holding the affected lid "out of the way with a piece of adhesive plaster, or by means of a small blunt hook, attached to a pair of spectacles. EPICANTHUS. * A very unseemly expression is sometimes imparted to the eyes by the pro- jection over them of a redundant portion of integument at the root of the nose, concealing the lachrymal caruncle and the inner part of the globe. It is always congenital, and occasionally exists in such a degree as to interfere materially with the opening of the lids, if not also with vision. Sichel and others have seen cases where it was hereditary. The treatment of epicanthus is entirely limited to the excision of the cen- tral portion of the redundant integument, in the form of an elliptical flap, the edges of the wound being afterwards approximated by the twisted suture. The result, however, is seldom satisfactory, owing to the tendency of the skin to stretch and elongate itself. In a case which I had at the Jefferson Medical Fig. 203. Epicanthus. College Clinic in 1858, in a little girl about seven years of age, little, if any, permanent benefit accrued, notwithstanding the removal of a very large flap. The character of the operation and the appearances of the affection are depicted in fig. 203. STRABISMUS. Strabismus, or squint, as it is termed in common parlance, is an aberration of the optic axes from their natural direction, by which the consent between the eyes is destroyed, and vision is more or less impaired. The resulting deformity varies in different cases, from the slightest deviation to the most disagreeable obliquity. The affected organ may be turned inwards or out- wards, upwards or downwards, according to the muscle upon the derange- ment of which the squint depends. When it is inclined inwards, it constitutes what is called convergent strabismus ; if, on the other hand, it is directed outwards, it is said to be divergent. The upward and downward obliquities have not received any particular names. , The most common form, by far, of strabismus is the convergent, in which the eye is directed inwards, or inwards and upwards. The degree of obli- STRABISMUS. 369 quity may be very slight, or so great that when the person looks directly for- ward with the sound eye, the cornea of the other shall be almost completely buried at the inner canthus. The organ, in this variety of the complaint, often inclines a little upwards, but hardly ever downwards. Divergent stra- bismus is comparatively rare; and the two other forms are almost unknown as separate and independent affections. There are few cases of strabismus in which both eyes are not implicated, though not in an equal degree. Usually one is more affected than the other; the patient, therefore, always considers the latter as his good eye, as it is the one which he habitually employs in viewing objects. It rarely happens, how- ever, that both organs become deranged simultaneously; on the contrary, one generally squints first, and, after a while, the other, the interval between the two occurrences being probably very short. The exciting causes of strabismus are various. One of the most frequent is the habit of imitation. Xearly a seventh of all the cases that occur are pro- bably thus induced. Hence, school-rooms are a fruitful source of mischief in this respect, one cross-eyed child being often the cause of strabismus in many others, simply from that practice of imitation so common in young persons. Ophthalmia, however induced, is another, and also a very common cause of the disorder, as the experience of every one can testify. Convulsions, erup- tive diseases, as measles, scarlet fever, and smallpox, hooping-cough, derange- ment of the digestive organs, injuries of the head and eyes, difficult dentition, and looking fixedly at particular objects, may all be mentioned as so many exciting causes of the affection. Xot unfrequently it comes on without any assignable reason, and in persons in the enjoyment apparently of the most perfect health. I have witnessed examples in which strabismus was con- genital, and on several occasions I have known it to occur in from three to five members of the same family. There is no evidence that the complaint is hereditary. It occurs in both sexes, and in both eyes, but whether with equal frequency or not, has not been decided. Young persons are most liable to it. Strabismus essentially consists in a permanent contraction of one of the straight muscles of the eye; of the internal, as was before stated, more fre- quently than any other. The shortening thus produced varies according to the extent of the squint, and is always accompanied by a corresponding elongation of the opposite muscle, so that it gradually loses, either wholly or in part, its antagonizing influence. The affected muscle is not only broader and thicker than the rest, but also of a deeper color; in a word, it is hyper- trophied, in accordance with a law of the economy that, in proportion as an organ is exercised, so will be its size and strength. In the few dissections which I have made of persons who died while laboring under this complaint, this condition was too manifest to escape notice, and it coincides precisely with what has been observed by others in similar cases. Of the immediate cause of strabismus we are ignorant, but the probability is that it is owing to some perverted action of the nerves which supply the muscles of the eye, rather than to any actual lesion of these muscles themselves. One of the most disagreeable effects of this disorder is the deformity which accompanies it, and which renders the individual an object of frequent remark and ridicule. Were this confined to infancy and childhood, no evil would flow from it; but when it is remembered that it continues through life, and that it is a source of constant annoyance and mortification, the influence which it exerts upon the temper of the sufferer must often be most unhappy. But there is another effect, still more deplorable, and this is the impairment of the vision of the affected eye. This defect, which is never entirely absent, always varies with the extent of the deformity and the length of time that ias elapsed since its occurrence. In some instances, especially in those of VOL. n._24 370 DISEASES AND INJURIES OF THE EYE. long standing, the sight is altogether destroyed, the retina being as insensible as in amaurosis. In another series of cases, the person is myopic, or sees objects only at a short distance. In a third series, the vision is, perhaps, double, or objects appear indistinct, or run into each other, the image painted on the retina being confused and imperfect. It is well known that strabismus has no tendency to spontaneous cure; on the contrary, it generally manifests a disposition to increase, especially in children of a nervous, excitable temperament; and the question, therefore, arises, at what period ought the surgeon to interfere ? My opinion is that the operation should be performed early; but, in coming to a conclusion on the subject, we should carefully weigh the circumstances of each case, as the condition of the patient, and the nature of the exciting cause of the complaint. If the child is otherwise healthy ; if there has been no cerebral disease; and if the squint is fully formed, there should be no hesitancy about a resort to the knife. There are valid reasons for this procedure. In the first place, the longer the deformity is permitted to persist, the greater will be the pro- bability that both eyes will ultimately require operation; secondly, as long as the deformity remains, the subject of it will be an object of remark and ridicule; and, thirdly, the invariable tendency of the affected eye is to become weaker and weaker, in proportion to its want of exercise. Besides, children bear such operations always well; they are unattended with hemorrhage and shock; and chloroform is always at hand to insure the requisite quietude during their performance. The instruments which I employ in this operation are a speculum, or lid- holder, a double, sharp-pointed hook for fixing the eye, a pair of forceps for pinching up the conjunctiva, and a pair of scissors for dividing this membrane, the ocular fascia, and the affected muscle. The lid-holder, fig. 204, is about Fig. 204. Blunt hook. five inches and a half long, quite delicate, and curved at the extremity, which is perfectly smooth and polished, and, being constructed after the manner of a fenestrated speculum, is not more than four lines wide. The hook for steadying the eye is easily understood by the annexed drawing, fig. 205. It Fig. 205. Double hook. is about five inches in length, and is furnished with a movable slide, so as to admit of the proper separation of the branches, each of which, being two Fig. 206. Toothed forceps. lines in width, terminates in a short prong as delicate as the finest needle. The forceps, fig. 206, a toothed one, should also be rather small; and the STRABISMUS. 371 Fig. 207. scissors should be long, slender, and narrow at the extremity. No knife is necessafy. If the patient is a child, or a timid adult, chloroform is given ; the body is placed recumbent Hpon a lounge, or table, the head lying horizontally, and the sound eye being protected with a thin handkerchief. Only two assistants are necessary; one of whom, standing at the head of the patient, elevates the upper lid, and holds the eye by inserting the sharp hook into the sclerotic coat, about the eighth of an inch behind the cornea; the branches should be separated about two lines, and the intervening space should correspond accu- rately with the horizontal diameter of the eye. This precaution should never be neglected, otherwise it will not be so easy to find the affected muscle. The points of the hook should be fairly implanted into the sclerotic coat, but no more. The other assistant, placed on the side of the affected eye, depresses the lower lid, and takes charge of the little sponge. The operator now pinches up a small fold of the conjunctiva, immediately behind the hook, and divides it perpen- dicularly with the scissors, fig. 207 ; he then cuts in the same direction the ocular fascia, or the sub- mucous cellular substance, and, finally, the internal Btraight muscle, the latter being severed near its point of insertion into the sclerotic coat. The moment this is accomplished, the eye, from the traction exerted upon it by the hook, springs towards the nose, and the muscle retracts within its sheath, especially if it has been thoroughly liberated from its connections. To effect this, which is a matter of para- mount importance, the scissors should be carried some distance round the eye, occasionally, indeed, nearly as far as the margins of the adjacent straight muscles. The eye will now generally move about freely in its socket, in per- fect harmony with its fellow. Should this, however, not be the case, a careful search should be instituted with the curved probe, exhibited in fig. 208, with Plan of the eye, showing the line of incision in the conjunctiva. Fig. 208. Curved probe. a view of ascertaining the cause of the difficulty, which will usually be found to be an imperfect division of the muscle, or of some of the fibrous bands ex- tending from it to the sclerotic coat. Sometimes the obliquity continues without any assignable cause, though rarely beyond a few hours. The operation being completed, the eye is bathed in cold water, to free it of blood, and the patient is confined for a few days in a dark chamber. Light diet is enjoined, and, if inflammation arise, recourse is had to antiphlogistic measures. The pain and nervous symptoms which occasionally supervene upon the operation, are best combated with anodynes. Considerable ecchy- uiosis sometimes follows the incisions, but requires no particular treatment, as it usually disappears spontaneously in a short time. Suppuration is hardly to be looked for in any case; the occurrence implies improper violence, which cannot be too much condemned. For four or five weeks after the patient eaves his room he should protect the eyes with a green shade, and avoid reading, writing, and, in short, every other occupation calculated to injure 372 DISEASES AND INJURIES OF TnE EYE. his sight. Premature use and exposure of the eyes cannot be too much de- precated, as they tend not only to prodnce inflammation, but also to jeopard the success of the operation. Soon after the operation is over, the surface of the wound becomes coated with plastic matter, which thus lays the foundation of the granulating pro- cess by which the parts are ultimately repaired. The period required for the completion of the cicatrization varies from three to six weeks. Generally it is retarded by the formation of fungous matter, which springs up at the site of the incision, and requires to be snipped off with the scissors; a pro- ceeding far preferable to the application of nitrate of silver, which is not only much more painful, but far less effectual. The extremity of the divided muscle contracts new adhesions to the ball of the eye, and thus aids in main- taining its parallelism after the cure is completed. I cannot approve of the practice, recommeuded by some surgeons, of making the patient turn the eye outwards as soon as he has recovered from the more immediate effects of the operation, for the purpose of causing it to regain its natural position in the orbit. In my earlier cases, before I had devoted much attention to the subject, I adopted this advice, but the result uniformly disappointed me. I have, therefore, long since abandoned it, per- suaded that it is founded on erroneous principles. When the eye still retains some degree of obliquity after the operation, it may positively be assumed that there has been imperfect section of the affected muscle, or of the fibrous cords connected with it. How, then, when this is the case, can we expect success? Again, the eye operated on may be perfectly straight, and yet not move in concert with its fellow. Such a result is by no means uncommon, espe- cially in the more ancient forms of the complaint, and hence the proper rule, in such an event, is to divide at once the corresponding muscle of the other eye. In children, and in cases generally of recent standing, one operation is usually quite sufficient, even when the obliquity remains for some time after. Indeed, the greatest caution should be employed even in the division of one muscle, lest the eye be permanently inclined outwards, and so the distortion be repro- duced in the opposite direction. The principal causes of failure after this operation are: first, as already stated, the imperfect division of the affected muscle and fascia; secondly, excision of a portion of the conjunctiva, eventuating in undue contraction of this membrane during the process of cicatrization ; thirdly, premature exercise and exposure of the eye; fourthly, the coexistence of epilepsy, hydrocephalus, and other cerebral diseases; fifthly, re-adherence of the muscle to an unfavorable point of the sclerotic coat, by which it is again enabled to exert a prejudicial influence over the movements of the ball; and, finally, the fact that only one operation is performed, when it is certain that both organs are affected nearly in an equal degree. Of all these causes the first and last are, I have reason to believe, the most frequent and efficient. Very recently, I had under my care a youth on whom 1 operated for double stra- bismus, whose eyes have become slightly everted from the want of accurate union of the edges of the wound, the sclerotica exhibiting its characteristic white appearance at the bottom of the incision. The effect of the operation upon vision is at first rather disagreeble than otherwise ; at least in some cases. It is only by degrees that the eye regains its functions; and occasionally, whether from long disuse of the retina, or from other causes, little or no improvement of this kind is to be looked for. Another unpleasant effect, but not a very common one, is double vision, which is evidently due to a want of consonance between the optic axes, and rarely continues beyond a few days. Finally, we must not forget to mention the peculiar prominence of the eye after this operation. This is generally well marked in every instance, and imparts to the organ a full, bold, disa- AFFECTIONS OF THE ORBIT. 373 greeable expression ; it is accompanied by a considerable separation of the lids, and is caused by the liberation of the eye from its confined position. The operation for strabismus is performed much less frequently now than it was ten years ago; chiefly because it has fallen somewhat into discredit from the frequent failures that have attended it in the hands of incompetent men. Every physician, in fact, has considered himself qualified to undertake it, no matter how slender his anatomical knowledge and practical skill. It is not surprising, therefore, that many of the cases that have been subjected to the operation should have disappointed expectation ; but these circum- stances should not discourage us, or be used to the prejudice of an operation, calculated, when properly executed, to confer so much benefit upon this class of sufferers. The results that have transpired in regard to it are eminently gratifying, and are sufficient to show that the procedure deserves to be ranked among the established resources of surgery. The sub-conjunctival operation for strabismus has had quite a number of advocates, though it has never come into general use, nor will it, I think, be likely to do so, owing to the greater difficulty of its execution. The chief reasons urged in its behalf are, that it is followed by less inflammation and less prominence of the eye, which is often so disfiguring in the ordinary procedure. Its disadvantages are that it is more troublesome, and that it requires much more care to liberate the affected muscle thoroughly from its connections with the sclerotica, thus jeoparding the result, especially in the hands of an inexperienced surgeon. As to the circumstance of its being productive of less inflammation, I consider that as a matter of very little consequence one way or the other, having never witnessed any bad effects from the ordinary procedure. The operation may be performed with a pair of scissors, or a probe-pointed bistoury, introduced through a small opening in the conjunctiva, and carefully insinuated beneath the affected muscle. Dr. Addinell Hewson, who has published an elaborate paper on Strabismus in the North American Medico-Chirurgical Review for March, 1858, executes the operation with a pair of curved scissors, furnished with a sliding blade, terminating in a sharp point. The blunt blade being passed beneath the muscle, the other is pushed on over its outer surface, when its division is effected simply by closing the instrument. A preliminary incision, horizontal, and a quarter of an inch in length, is made just below the inferior border of the muscle. AFFECTIONS OF THE ORBIT. The orbit is subject to various affections, seated either in its bony walls, their fibrous covering, or the cellulo-adipose tissue. These affections, how- ever, do not differ materially, if at all, from similar lesions in other parts of the body. One of their most disagreeable effects is that which arises from the pressure which they exert upon the ball of the eye, thereby thrusting it out of its natural position, and at the same time endangering its structure and functions. Caries and necrosis of the walls of the orbit are observed chiefly in ter- tiary syphilis; I have met with several cases of the kind, and have invariably found them troublesome and tedious. Abscess of the orbit is uncommon. It may arise from disease of the bone, or as a consequence of erysipelatous inflammation of the cellulo-adipose sub- stance. The symptoms are of the phlegmonous kind, and relief must be afforded by early evacuation. Among the more common forms of tumors of the orbit are the fatty, en- cysted, and encephaloid. A few instances have been observed in which it was the seat of melanosis and hydatids. Exostosis of the orbit is extremely 374 DISEASES AND INJURIES OF THE EYE. rare. The arterial tumor is occasionally met with, either as a congenital vice, or as a result of hypertrophy ; generally the former. It is characterized by its strong pulsation and whizzing noise, and by the atrocious pains which it produces in the eye, head, and face. The ophthalraic artery is sometimes the seat of aneurism. The treatment of these various formations must be conducted upon general principles, or according to the rules laid down for their management in dif- ferent parts of the work. DISEASES AND INJURIES OF THE EAR. 375 CHAPTER VI. DISEASES AND INJURIES OF THE EAR. Every one familiar with the history of aural surgery must be aware of the great neglect in which this department of the healing art was, until recently, held by the profession. The advances which it has made are by no means equal to those in ophthalmic surgery. There seems, indeed, to be an extra- ordinary degree of indifference on the part of practitioners and even teach- ers, in regard to the diseases of the ear. I think I am not wrong when I assert that there is a greater amount of lukewarmness respecting the study of aural surgery than that of any other branch of the science. Most men look upon it as a sort of forbidden ground ; as a subject in which they feel no interest, and with which they would rather not have anything to do. The reason of this probably is the intrinsic difficulty with which the subject is invested; the long study which is required to master the anatomy of the ear, the few opportunities which are afforded for investigating its diseases, the trouble which attends this kind of practice, and the want of success which, even in the hands of the most enlightened and scientific, so often follows our best directed efforts. Another reason, doubtless, is the little knowledge that is communicated upon these subjects in the lecture-room and in our surgical treatises. Teachers, both anatomical and surgical, absolutely seem to make it a business to slur over these matters; they talk with great minuteness and flippancy of everything else, however insignificant, but when they come to the ear they either wholly repudiate its claims to consideration, or they pass over it with a sort of railroad velocity, as if to dwell upon it with any de- gree of care were time entirely misspent. The consequence is that the pupil, upon leaving the lecture-room, knows no more about the structure and dis- eases of the ear, than he does of any other subject which he has not investi- gated. Few afterwards make up for this deficiency, and hence such cases of aural surgery as come under their observation must necessarily be neglected, or, worse, maltreated. Hence, too, the reason why this department of prac- tice, so rich and so full of interest, is, everywhere, so much in the hands of the charlatan, who, while he lives upon the credulity of the public, only deludes his victim, who is ever ready, like the drowning man, to grasp at straws. Such apathy is unquestionably highly reprehensible, if not positively crim- inal. It is surely our duty to study these diseases, in order that, when we are consulted respecting them, we may be able to treat them with the same confidence and efficiency as any other class of affections that come within the sphere of the general practitioner. This duty is the more incumbent upon us because of the great frequency of these diseases, and the disastrous re- sults by which they are so often followed. Deafness is no trifling affliction ; its existence involves not merely individual happiness, but the happiness often of families and even communities; once established, it lasts not merely for a day, a month, or a year, but as long as the person himself lasts. It is only necessary that we should devote the same amount of study and attention to these diseases that we bestow upon the other branches of surgery, and we shall soon wrest this practice from the hands of the charlatan, and place it upon the exalted footing to which its importance so clearly entitles it. 376 DISEASES AND INJURIES OF THE EAR. In the chapter which I shall devote to these diseases, a brief outline is all that my space will permit me to attempt. W7hile I shall endeavor to make it as graphic and tangible as possible, I trust that the reader will not rest satisfied until he has exhausted the subject by a thorough study of the valuable works that have appeared upon it in Great Britain, France, and Germany. Our own country is still without an original production on aural surgery. The most scientific treatises, in my judgment, that have yet been published on the subject are those of Mr. Wilde, of Dublin, and of Mr. Toynbee, of London. EXAMINATION OF THE EAR. Before I proceed to describe the diseases of the ear, it is important to make some remarks upon the proper mode of examining it, with a view to the detection and discrimination of its healthy and morbid conditions; for upon the care with which this is conducted, and the results thereby obtained, must necessarily depend, in great degree, the success of our therapeutic measures. Few practitioners have either the knowledge or the patience requisite to make a satisfactory exploration, and it is therefore not surprising that they should know so little respecting their management. In order to ascertain what the nature of the disease is, it is necessary, in the first place, to have a good light, and it need hardly be added that that afforded by the concentrated rays of the sun is better than any other. The patient being seated upon a chair, with the ear inclined towards the opposite side, facing the sun, the light should be permitted to fall directly upon the tympanal membrane, as can easily be done by pulling the auricle upwards and backwards with the thumb and forefinger of one hand, while the tragus is drawn forwards with the index finger of the other. If the sun be very bright, the examination may be conducted in a room, in front of a large window, but even then I generally prefer making it in the open air, from the fact that transmitted light is never as satisfactory as direct. The surgeon Fig. 209. Fie. 210. Fie. 211. Ear speculum. must be careful not to obstruct the passage of the sun's rays with his own head, and he should also see that no one else interferes, as two persons can never inspect the organ at the same time. A speculum need be used only when the auditory passage is unusually narrow or studded with an uncommonly large number of hairs, obstructing vision. The one which I prefer, and which will generally be found to answer every purpose for which such an instrument can be employed, is represented in fig. 209. It is very light and convenient, and may be adapted to almost any ear, however small, as its terminal extremity is not more than two lines in diameter, while its movable blades readily admit of this distance being increased to any extent com- wiides speculum. Toynbee's speculum, patible with the size of the canal. The MODE OF EXAMINING THE EAR. 377 speculum invented by Mr. Wilde, and delineated in fig. Fig. 212. 210, is also an excellent instrument, although I cannot perceive that it possesses any advantages over the other, except its more easy portability. The same remark is true of Mr. Toynbee's speculum, shown in fig. 211. The fact is that these things are very much a matter of conceit or fancy, influenced often by prejudice rather than sound judgment, or the result of correct observation. Be this as it may, I am certain, from much observation, that the eye alone will, in general, be quite sufficient for any examina- tion we may be called upon to make. There are cases, indeed, where the auditory canal is so sensitive as abso- lutely to prevent the introduction of the speculum, how- ever gently effected. In cloudy weather or at night, the examination may easily be effected with the aid of a Miller's lamp, fig. 212, consisting of a reflector and of a wax candle, inclosed in a Palmer's spring tube, six inches in length, and resting upon a base about two inches and a half in diameter. The top is closed with a cap. A speculum having been inserted into the ear, the light is thrown upon it by means of the lamp, the whole proceeding being conducted as represented in fig. 213, from Toynbee. A very light, cheap, and convenient instrument for examining the ear, both with solar and artificial light, was invented several years ago by Dr. Grant, of New Jersey. It consists, as seen in fig. 214, of a concavo-convex funnel, in which the rays are collected and thrown upon a highly polished steel mirror placed Fig. 213. Miller's lamp. Inspection of the external meatus by means of Miller's lamp and the tubular speculum. at an angle of 45°. Passing directly through this mirror is a straight tube, which is armed with a powerful lens, and which can be adjusted by means of a screw to any focus. Both the funnel and tube are coated with silver, feebly 378 DISEASES AND INJURIES OF THE EAR. 214. polished. From this mirror the rays of light are thrown, at a right angle, directly upon the tympanic membrane, which, to- gether with the adjacent parts, is thus fully illuminated, the instru- ment having been previously ad- justed in the external ear. While the light is thus playing about in the passage, the exa- miner takes a rapid survey of the appearances of the parts, noticing particularly the condition of the membrane of the tympanum, as to whether it is'transparent or opaque, red, injected, convex or concave, ulcerated, perforated, or destroyed; also the state of the auditory tube, the color and quantity of the cerumen, Fig. 215. Dr. Grant's aural reflector. Ear syringe. and, in short, everything else calculated to furnish matter of diagnostic and practical value. Should the parts be obscured, or concealed from view, by Fig. 216. Fig. 217. Hullihen's apparatus. Ear-spout, fitted on the head. the presence of pus, wax, epithelium, or hair, clearance must be effected, as a preliminary step, by syringing the tube with tepid water. A very suit- AFFECTIONS OF THE EXTERNAL EAR. 379 able instrument for this purpose is that depicted in fig. 215. It must be capable of holding at least from two and a half to three ounces of fluid, which should be thrown up with some degree of force, yet at the same time so cau- tiously as not to shock or pain the affected structures. It should be held firmly in the hand, with the nozzle, which should be inserted only a few lines, directed obliquely downwards and forwards, the water, as it regurgitates from the tube, being received into a large, flatfish basin, held under the patient's ear and chin. A convenient contrivance, combining the arrangement of a basin and syringe, for injecting the ear, was devised by the late Dr. Hullihen, of Wheeling, and is represented in fig. 216. Mr. Toynbee employs what he calls an ear-spout, fig. 217, a kind of tin gutter, fitted closely to the head, under the ear, by means of a spring. The use of the probe is not admissible in these examinations. The forceps or scoop may occasionally .be employed in the removal of solid matter. The manner of exploring the Eustachian tube will be described along with the diseases of that passage. A watch held near the ear will determine, by its ticking, perceived by the patient, the degree of hearing. The experiment should be repeated at each visit, and the result carefully noted, as it affords important information relative to the progress of the treatment. Finally, to render such an examination complete, we must carefully inspect the patient's throat and tonsils, take particular notice of the state of his voice, percuss the mastoid region, and auscultate the ear while air is being forced into it along the Eustachian tube. SECT. I.—AFFECTIONS OF THE EXTERNAL EAR. The auricle is liable to various malformations, which are of interest, both in a pathological and surgical point of view. In the first place, it may be entirely absent, either on one or both sides, without any vestige whatever of an external opening. Such a case is not necessarily attended with deafness, although audition must be much impaired. Secondly, there is occasionally an absence of the lobule of the ear; or this structure is divided, by a vertical fissure, into two portions, an anterior and a posterior; or, lastly, it is attached to the side of the head, either partially or completely. Thirdly, there may be a deficiency of the helix, this body being either wanting, or so small and flat as hardly to deserve to be considered as a distinct process. This defect is sometimes congenital, but is much oftener produced, there is reason to believe, by the pressure of the hat in early life. Fourthly, the tragus and anti-tragus are occasionally bilobed, or divided each into two portions; sometimes they are inverted towards the meatus, thereby partially closing it; and sometimes, again, they are more or less extensively united, particularly along their lower borders, producing a similar effect. Finally, excessive development of the ear may be enumerated as one of its malformations. Last winter, I had a case at the Jefferson Medical College Clinic, in an infant three months old, of supernumerary ears, in a very rudimentary state, situated immediately in front of the tragus, over the temporo-maxillary joint. In some instances the additional organs occupy the side of the neck. Some of the above defects admit of remedy by surgical operation ; others do not. Thus, a cleft lobule might be readily united by a procedure similar to that for hare-lip; an inverted tragus might be retrenched or excised ; and an abnormal adhesion might be severed by a simple dissection, care being taken, during the healing process, to keep a piece of lint interposed between the raw surfaces. In the case of supernumerary ear, above referred to, no aifhculty was experienced in effecting thorough excision. A wound of the external ear, whatever may be its shape or size, is to be 380 DISEASES AND INJURIES OF THE EAR. treated upon the same general principles as a wound in any other part of the body. The parts being properly cleansed, the edges are carefully approxi- mated with a needle and fine thread, aided, if necessary, by a few strips of isinglass plaster, which answers much better than ordinary adhesive plaster. A bandage will rarely be necessary, but should it be, it must be applied with great care and gentleness, and with the precaution of filling up the hollow between the ear and head with cotton, wool, or lint. I am aware that some surgeons object to the employment of sutures in the treatment of wounds of the ear; but I have yet to see an instance where they were productive of harm. Without their use, it would be impossible, in almost any case, to make a good cure. Last summer I had under ray charge a gentleman, who, in a fall from his carriage, tore away the entire lobule and the parts for some distance above, producing a very ugly wound, several inches in length, which promptly united, in the most beautiful manner, under the use simply of several points of the twisted suture. The dressings, in such cases, should always be made with care, any disfigurement here being highly objectionable. The lobe of the ear is occasionally the seat of a fibrous tumor. I have seen five cases of it, all in colored females, in consequence of the perforation of this body, and the wearing of a ring. The youngest of these persons was a child, three years old, who had been subjected to the operation about eighteen months previously. From what I can learn, the growth is much more common in blacks than in whites, and I believe that the exciting cause is nearly always the one here referred to. The tumor is pendulous, of tardy development, insensible, hard, and inelastic, without malignancy, although prone to recur after removal, and free from discoloration of the skin, which also retains its normal thickness and pliancy. It is generally somewhat rounded or ovoidal in its shape, and is capable of acquiring a volume equal to that of a hen's egg. In some cases it is lobulated, or, rather, bilobed. A section of it is found to be of a fibrous structure, the fibres intersecting each other in every possible direction; of a whitish color, and of a dense, almost uniform consistence. The remedy is excision, care being taken to save as much integument as possible, in order to prevent deformity. The edges of the wound are carefully approximated by several points of the twisted suture. White, chalky or plaster-like concretions, occupying the lobe of the ear, within the helix, are occasionally met with, as the result of a gouty diathesis. They present themselves in small round prominences immediately beneath the skin, and are composed of the same materials as articular tophi, uric acid crystals, very delicate, needle-shaped, and of all possible sizes, forming con- spicuous ingredients. Left to themselves, these concretions are sometimes eliminated spontaneously, a slight scar marking their exit. When they are productive of pain and irritation, they may be liberated by a small incision, aided by pressure. SECT. II.—AFFECTIONS OF THE AUDITORY TUBE. The auditory tube is liable to malformations, the introduction of foreign bodies, accumulations of wax, polypous growths, and various forms of inflam- mation. a. MALFORMATIONS. The most common malformation of this passage is occlusion of its external orifice by an extension of the common integuments, producing a condition similar to that which we occasionally see in the anus, vagina, and other mucous outlets. A person thus affected is not always deaf, although his hearing must of necessity be very defective, The cutaneous cover may be very thin, FOREIGN BODIES. 381 consisting, perhaps, merely of a sort of translucent layer, but, in general, it is quite thick and opaque ; it may be the only aberration, or it may be asso- ciated with absence of the auricle. Such a malforraation obviously admits of easy relief. All that is necessary is to make a crucial incision in the situa- tion of the natural orifice, to remove the angles of the wound, and to prevent reunion by the interposition of tents of gradually increasing sizes. But there is another case where relief is either impracticable, or where patency can be established only after much trouble and delay. This is where the occlusion is effected by fibrous, or fibro-cartilaginous matter, extending some distance down the passage, but not completely obliterating it. Here, only the most cautions and patient attention will be likely to be of any avail. The dissec- tion is made in the direction of the tube, the ear being drawn upwards and backwards during the operation. Reunion is prevented by the steady and protracted use of tents. Of course no operation is attempted where the tube is entirely impervious, or, more properly speaking, where none whatever exists. The use of a delicate exploring needle will be of great assistance in the investigation of these various conditions of the ear. Finally, children are occasionally born with their ears completely filled with the unctuous matter which covers the skin, and which is probably de- rived either from the sebaceous follicles, as a depurative secretion, or from the amniotic fluid. However this maybe, if the matter be allowed to remain, the deafness, which was at first, perhaps, only partial, may, in time, become complete; or the adventitious substance, acting as a foreign body, may excite inflammation, and ultimately lead to destruction of the tympanal membrane. Clearance is effected by means of the syringe and tepid water, aided, if neces- sary, by the scoop. A few drops of oil, or glycerine, poured upon the mass, might assist in detaching it. b. FOREIGN BODIES. Substances of various kinds find their way into the auditory tube, either by accident or design. The most common are grains of corn and coffee, beans, peas, cherry-stones, beads, pebbles, and pellets of paper, wool and cotton. I have met with several cases where the intruders were small bugs and flies. Insects sometimes deposit their larva? in the ear, being evidently attracted thither by purulent discbarges, which, if at all abundant, may afterwards serve as a nidus for the development of the new being. It is surprising that pins, which are so frequently used by females for picking and scratching the ear, do not more frequently drop into the tube than they seem to do. The effects occasioned by the presence of a foreign body in the ear vary according to its nature, size, and shape. If it be a grain of corn, bean, or similar substance, it will, if retained for a few days, not only expand under the influence of the moisture of the part, but, perhaps, even germinate, thereby causing severe pressure upon the parts in which it is impacted, and increased difficulty in respect to its extraction. No such effect, of course, will follow if the body be of an inorganic nature. Nevertheless, any sub- stance, whatever may be its character, may, by its pressure alone, induce severe pain and inflammation, eventuating in an abundant discharge of matter, excessive constitutional irritation, headache, and delirium. A large substance will, as a general rule, cause more trouble than a small one, a rough than a smooth one, a heavy than a light one, a sharp than a blunt one. A foreign body will occasionally excite ulceration of the membrane of the tympanum, and finally find its way into the middle ear. Such an occurrence, which is fortunately rare, is sure to be followed by severe suffering, if not death. 382 DISEASES AND INJURIES OF THE EAR. Cases are recorded where violent neuralgia, epilepsy, and mania were induced by the protracted sojourn of an extraneous substance in the ear. The removal of a foreign body from the ear is by no means always an easy undertaking. The difficulty, generally of itself sufficiently great, is frequently very much enhanced by the tortuous, contracted, or constricted condition of the auditory tube, to say nothing of the pain, tumefaction and discharge which are likely to be present whenever the substance has been for some time retained, and which will always greatly embarrass the proceeding. Various methods may be employed for accomplishing the object, the choice of which must be regulated by the circumstances of each individual case. If the body be relatively small to the size of the tube, and not very rough or heavy, dis- lodgment may usually be effected with the syringe, charged with tepid water, the fluid being thrown up in a full, steady, and forcible stream, with sufficient care, of course, not to injure the membrane of the tympanum. This proce- dure should always be employed when the substance lies deeply in the audi- tory passage; for, although it may not cause its expulsion, it will often bring it within reach, and thus favor extraction. During the operation, or rather, as a preliminary step to it, the ear should be drawn upwards, outwards, and backwards, so as to efface the angle of the canal. The syringe, which should hold at least two ounces, should have a long, slender nozzle, in order that the current may pass readily by the side of the foreign body. When the substance is comparatively superficial, it may frequently be seized and extracted without difficulty, the best instrument for this purpose being a pair of very delicate toothed forceps, fig. 218, or the rectangular forceps of Fig. 218. Toothed forceps. Toynbee, fig. 219. But such a procedure is not admissible when the sub- stance is smooth, hard, or deep-seated ; for, in the former case, the instrument will be likely to slip off, and FiS- 219. in the latter, it will be im- possible to give the blades the requisite degree of ex- pansion for grasping it. If, under such circumstances, the surgeon is determined to succeed, his efforts can- not fail to be productive of serious mischief. The for- eign substance will be thrust about in various directions, Toynbee's rectangular forceps. and perhaps pressed rudely against the membrane of the tympanum, until it is buried in blood, and the patient put in great agony. Cases have occurred where the surgeon, in his anxiety not to be baffled, severely lacerated the auditory tube and even the membrane of the tympanum, causing violent inflammation, followed by death. The best contrivance, as a general rule, where extrusion cannot be effected by the forceps, or a stream of water, which, however, rarely fails even here, is a small curette, such as is used by the oculist in the extraction of a cata- ract, or a very delicate probe, a little flat on the surface, and slightly bent at ACCUMULATIONS OF WAX. 383 the extremity. This being carefully insinuated between the passage and the intruder, the latter is gently dislodged, the instrument acting either as a lever or a hook, or both, according to circumstances. Fig. 220 represents two Fig. 220. The author's instrument for the removal of foreign matter from the ear. instruments which I have devised for facilitating the removal of various kinds of foreign bodies. The extremity of one is shaped somewhat like a cork- screw, and will be found useful when the substance is soft and cannot be seized in any other way. Children are often brought to us with the ear in a high state of inflamma- tion from previous attempts at extraction. When this is the case, the proper plan is to wait a short time before the attempts are renewed, measures being, meanwhile, employed to subdue the morbid action; as warm anodyne fomen- tations, the application, of a few leeches over the mastoid process, and the administration of a brisk cathartic. Allusion has already been made to the fact that a foreign body occasionally finds its way into the middle ear, through an opening in the membrane of the tympanum. Under such circumstances, dislodgment will be extremely diffi- cult, if not impossible. Deleau relates a case where, a small pebble having got into this cavity, he succeeded in effecting clearance by throwing warm water into it through the Eustachian tube. Insects are, in general, easily dislodged with the syringe. It is only when they are of large size, or much spread out, that it may be necessary to remove them with the forceps, hook, or curette. When the proper instrument is not at hand for performing the operation, the insect should be instantly destroyed with olive oil, a mixture of spirits of camphor and water, or tepid soapsuds. Finally, it is hardly necessary to add that, during the extraction of the foreign body, whatever it may be, the head should be properly supported by an assistant, and resistance counteracted by the use of an anaesthetic agent. Unless this be done, the operation, as was previously stated, will be one of great difficulty, and attended with severe pain, if not serious injury to the parts. C. ACCUMULATIONS OF WAX. This substance sometimes collects in such quantities in the auditory tube as to produce complete occlusion ; at other times, and more generally, the obstruction is only partial, attention being directed to the subject before the accumulation has made much progress. The effect, in either case, is more or less noise in the ear, generally of a buzzing, ringing, or explosive-character, and impairment of hearing on the affected side. Occasionally there is com- plete deafness. This result may depend solely upon the long disuse of the ear from the protracted retention of the secretion, or it may be produced by the pressure of the wax upon the membrane of the tympanum, eventuating in organic disease of its substance, as ulceration, or induration and thick- ening. An accumulation of wax does not necessarily imply an inordinate secretion ot this substance; on the contrary, it may be deposited unusually sparingly, jjnd yet, owing to its inspissated character, it may proceed until it completely nils the external meatus. Indeed, so long as this secretion retains its natural qualities, and no obstacle is offered to its evacuation, it is very seldom that 384 DISEASES AND INJURIES OF THE EAR. we find it disposed to remain in the ear ; but such an occurrence is very easy when it is deprived of its fluidity, whether in the act of deposition or soon afterwards. However this may be, whenever the wax is long retained it is always remarkably hard and tough, and then often contains a considerable quantity of hair and epidermic scales, the whole forming a dry, almost pul- verulent mass, accurately moulded to the auditory tube, excluding the air, and inducing pretty complete deafness. The presence of the substance is generally easily detected by its dark brown or blackish appearance, and by our inability to discover the membrane of the tympanum. Ear-wax being in great measure soluble in water, the best method of soft- ening and detaching it is to throw this fluid freely into the auditory tube with a large syringe. The water should always be used warm, and its efficacy will be much increased if it be mixed with a small quantity of soap and ether, which, by combining chemically with the wax, gradually convert it into an oleaginous mass. Many practitioners are in the habit of employing oil for this purpose, but as this substance is destitute of soluble properties, the only way in which it can prove serviceable is by lubricating the walls of the ex- ternal meatus. When the wax is not very abundant, or too firmly impacted in the tube, I am in the habit of attacking it at once with the spoon-shaped extremity of the common pocket-case director, which, on the whole, is as good an instrument as we can use. Or, instead of this, a curette, fig. 221, may be Fig. 221. Curette. employed. Care must be taken, in performing the operation, to proceed as gently as possible, picking out piece after piece, until the whole mass has been removed ; it being remembered that the long retention of this substance always renders the parts remarkably sensitive. Should any fragments remain at the sides and bottom of the cavity, they may afterwards easily be dislodged with the syringe and tepid water. Clearance having been effected, all that is necessary is to protect the ear, provided it be unusually tender, with a pel- let of cotton to exclude the air; otherwise even this precaution may be dis- pensed with. When the membrane of the tympanum is very vascular, inflamed, or ulcerated, it will be proper to apply a few leeches over the mas- toid process, to cover the ear with cloths wrung out of hot water, and to administer an anodyne diaphoretic. When the tendency to re-accumulation continues, the ear should be frequently syringed, and means taken to check the inordinate action of the ceruminous glands, upon which it depends. Several remarkable cases are recorded in works on aural surgery of persons who, after having been long deaf, have been suddenly relieved by the dis- charge of hard plugs of ear-wax while engaged in bathing, the expulsion generally taking place with a loud report, like that of a small pistol. Such an occurrence can be explained only by supposing either that the steam of the hot water, penetrating the meatus, softens the indurated mass, or, what is more plausible, that the bathing produces perspiration in the walls of the tube, thus detaching the substance, the noise being produced by the rarefac- tion of the atmosphere behind it. d. POLYPOUS AND FUNGOUS GROWTHS. Great confusion has hitherto prevailed among pathologists respecting the true distinction between polypous and fungous growths of the ear, these terms being generally applied indiscriminately to every form of tumor, whether developed within the tube or projecting from its outer orifice. I have long POLYPOUS AND FUNGOUS GROWTHS. 385 been in the habit of looking upon these morbid products as being essentially different, and in my lectures I have always described them as being divisible into two classes, one of which is similar to the tumors which we so often observe in the nose and other mucous canals, while the other consists essen- tially of a mass of granulations, bearing only a faint and distant resemblance to genuine polyps. Of polyps of the ear there are several varieties, of which the most common are the fibro-vascular, gelatinoid, and granular. Their structure is sufficiently indicated by their names. They are generally somewhat of a conical, pyri- form, or globular shape, having a small, narrow pedicle, by which they are attached to the surface from which they grow, which is usually the posterior wall of the meatus, at the site of the ceruminous glands, or in their immediate vicinity. Occasionally, though rarely, they spring from the membrane of the tympanum itself, or very low down in the tube. Their surface is commonly smooth, and of a florid, pale, or pink hue, according to the character of their structure, or, rather, the extent of their vascularity. A polyp of the ear has sometimes the form, color, and consistence of a mulberry, or of a bunch of small grapes. Their number rarely exceeds one, unless they are very small, when there may be two. As they increase in size, they gradually approach the external orifice of the ear, and sometimes partially fill up the concha, forming a hard, articular mass, several shades lighter than the part which is buried in the tube, and also much less sensitive. Polyps of the ear, of whatever structure, size and shape, are attended with more or less discharge, which is either of a thin, sanious, or truly purulent character, and generally very fetid and acrid, often eroding the surrounding surface. The hearing is always impaired, and in many cases completely de- stroyed. The nature of the tumor is easily recognized by its history and appearance. Its point of attachment is generally ascertainable with the probe, which can always be insinuated between the growth and the auditory tube, no matter what may be its age. The annexed sketch, fig. 222, represents a gelatinoid polyp, from a speci- men in my cabinet. I removed it in 1856, from the right ear of a man of twenty-six, where it had been growing for nearly three years. It was attached Fig. 222. Fig. 223. Fig. 224. to the floor of the meatus, not quite as low down as its centre, by a narrow, slender pedicle, the base protruding slightly at the outer orifice. It was of a pale, whitish color, like an oyster, somewhat elastic, insensible, and smooth on the surface, with here and there a straggling vessel ramifying beneath its vol. ii.—25 386 DISEASES AND INJURIES OF THE EAR. lining membrane. The drawing is of the natural size. Fig. 223, copied from Mr. Wilde, represents a singularly lobulated form of aural polyp. Fig. 224, from a drawing by Dr. Packard, represents the microscopical characters of a recurring fibroid polyp, which I removed from the car of a young woman at the Jefferson Medical College Clinic last winter. It occupied the whole of the auditory tube, and had already been operated upon twice. Polyps of the ear are best removed by avulsion with a pair of delicate forceps, either straight or curved, as in fig. 225, applied, if possible, close to Fig. 225. Ear forceps. their pedicle, and rotated upon their axis. If a portion of the tumor is left behind, deep in the cavity, it may be scraped away with a curette, or cut off with a pair of cornea scissors. Instruments have been devised for ligating these growths; but, excepting the ingenuity expended upon their construc- tion, they have little to recommeud them. Fig. 226 represents the aural Fig. 226. Wilde's aural canula. canula of Mr. Wilde. Caustics should never be employed for removing polyps in the ear, it being difficult so to regulate the application as to pre- vent pain and other mischief. Where there is a strong repullulating tendency, recourse may be had to the cautious use of nitrate of silver, sulphate of copper, the dilute acid nitrate of mercury, or, what is better than all, chromic acid. The second division of the subject embraces what are called fungous growth of the ear, a class of affections much more common than polyps. They con- sist, essentially, of a mass of granulations, of a soft, spongy consistence, and of a pale, florid color, which have their origin generally in an ulcerated con- dition of the auditory passage, the membrane of the tympanum, or the tube and drum together. Occasionally, the immediate cause of their production is necrosis of the petrous portion of the temporal bone, or disease of the small bones of the ear. However induced, the growth often attains a large volume, filling up the meatus, and projecting sometimes a considerable dis- tance into the concha. It is often quite sensitive, readily bleeds when rudely touched, and is always attended with a profuse, foul discharge. As these growths are always of a secondary nature, it is evident that they cannot be permanently cured until the cause, under the influence of which they are developed, has been effectually eradicated. The first object of the treatment, therefore, should be to get rid of the primary affection, whatever this may be. Meanwhile, however, any exuberant growth is removed either with the scissors, the knife, or the forceps, as may seem most convenient. INFLAMMATION OF THE AUDITORY TUBE. 387 repression being afterwards controlled by the cautious application of the ordinary escharotics. Cleanliness is an object of paramount importance in this form of the affection, and is best promoted by the frequent use of injec- tions of tepid water, with castile soap and a small quantity of the chlorides. Tumors of a malignant character sometimes grow from the auditory tube, commencing either in the soft structures, in the petrous portion of the tem- poral bone, or in the mastoid process. Whether certain forms of polyps or of fungoid excrescences, described in the preceding paragraphs, are capable of assuming this kind of action remains to be determined, but such a conclu- sion is certainly not unreasonable. However this may be, the malignant growth is, in general, easily recognized by the peculiarity of its color, which is always purple or livid, by the rapidity of its development, by its tendency to extend, not only outwardly, but laterally, in every direction, by its speedy reproduction after removal, by the almost insupportable fetor of the discharge, by the excessive pain, and, lastly, by the early involvement of the neighbor- ing lymphatic ganglions. The constitution gradually becomes affected, and the patient at length sinks under all the symptoms of the cancerous cachexia, or he dies suddenly, and perhaps unexpectedly, from effusion upon the brain. Such cases, which are fortunately rare, hold out no prospect of relief from any course of treatment of which we have any knowledge. All that can be done, therefore, is to palliate the symptoms, and smooth the-sufferer's passage to the grave. e. INFLAMMATION. The auditory tube is liable to several forms of inflammation, either of a simple or specific character, which, although infrequent, are worthy of special notice on account of the severe suffering which they entail. The most common variety of inflammation is the simple, which usually begins, so far as we are enabled to judge, in the skin and subcutaneous tissue of the tube, from which it often extends to the periosteum, and, perhaps, even to the superficial portion of the bone. I have, indeed, often thought that the disease bore a very striking resemblance, in some of its more prominent symptoms, to paronychia or whitlow. It is usually ushered in with a dull aching sensation, which is soon converted into a violent throbbing pain, attended with a feeling of weight and obstruction, and various kinds of noises in the ear. The swelling is slow, but as it proceeds it often causes complete occlusion of the tube, and affects the parts around the ear, which are always exquisitely tender, and intolerant of the slightest pressure and motion. Hence, when the disease is fully established, the patient is unable to masti- cate his food, and to lie on the affected side. Headache and constitutional disturbance occasionally attend, and there is, in most cases, a strong ten- dency to suppuration, the matter being, however, always, small in quantity, and deep-seated. The origin of this disease is not understood. It is often witnessed in per- sons who are apparently in the most robust health ; in some instances, how- ever, it seems to depend upon a disordered state of the digestive organs, growing out of over-feeding, or the intemperate use of ardent spirits, and fostered by indolent habits. Occasionally, again, it occurs as a sequela of measles, scarlatina, typhoid fever, and smallpox. When the inflammation attacks a person already much debilitated by disease, it may prove dangerous by involvement of the brain and arachnoid membrane. When an abscess forms, the matter discharges itself either into the auditory tube, or it finds an outlet in the immediate vicinity of the ear, generally just in front of the termporo-maxillary articulation. the treatment of this affection must be conducted upon general antiphlo- 3iS DISEASES AND INJURIES OF THE EAR. gistic principles. If the symptoms are violent, and the patient is robust, it may be necessary to take blood from the arra, to purge hira actively, and to subject him to the use of the antimonial and saline mixture, with anodynes to allay pain and procure sleep. In general, however, these remedies may be dispensed with, our object being gained by the application of leeches to the anterior and posterior part of the ear, anodyne fomentations, light diet, and diaphoretics, especially if we resort to an early and free incision, which is often just as necessary here as in cases of whitlow, or of the ordinary phlegmonous boil. The opening should rather be deep than extensive, and it will sometimes be well, especially in the more severe cases, to make seve- ral punctures instead of a single one. AVhen the disease is slow in disap- pearing, or when abscess after abscess forms, a course of alterative and tonic medicine will be indicated, along with a proper regulation of the diet, and change of air. The disease now described occasionally assumes an erysipelatous type, or it may possess this type from the commencement. Its nature will be denoted by the peculiar discoloration of the skin, by the tendency of the disease to spread over the surrounding parts, and by the peculiar burning, itching, or stinging character of the pain. The treatment does not vary essentially from that necessary in the preceding case, only that the inflamed surface should be painted freely with the dilute tincture of iodine, and that, if matter form, the incision should be somewhat more extensive. / HERPETIC AFFECTIONS. The auditory passage is occasionally the seat of herpetic disease, either as a primary affection, or as a propagation from the auricle, where it is by no means uncommon. It is characterized by the formation of numerous vesicles, generally more minute than the smallest pin-head, closely grouped together, if not confluent, and filled with a thin, whitish, or slightly yellowish fluid. The surface upon which the eruption rests is of a dusky reddish appearance, and the seat of intolerable itching. When the vesicles break, they are replaced by little ulcers, chaps, or fissures, discharging a thin, sanions fluid, which may be so copious as to run out upon the ear, and even upon the patient's pillow. The auditory tube is red, swollen, angry-looking, tender, and, at times, even quite painful from the great extent of disease. The suffering is increased by exposure, by the use of stimulating food, and by disorder of the alimentary canal. The affection may last for years, and finally extend to the membrane of the tympanum. Besides the itching, which is always a pro- minent symptom, the patient is troubled with noises in the ears, and with par- tial deafness. In the treatment of this affection, particular attention must be paid to the state of the genera^ health, which always exercises a remarkable influence upon its progress and duration. The secretions must be improved by a mild course of alteratives, the diet must be plain and non-stimulant, and the bow- els must be moved from time to time with vegetable cathartics. If the patient be robust, the antimonial and saline mixture will be of service; and, when the disease proves obstinate, it may be necessary to have recourse to gentle ptyalism, and the use of iodide of potassium. The best local appli- cations, at the commencement of the treatment, are leeches and the warm- water-dressing, and afterwards, when the morbid action has been somewhat moderated, weak solutions of bichloride of mercury, acetate of lead, or iodide of iron, or, what I prefer to everything else, the dilute ointment of the oxide of zinc, in the proportion of one part to three of prepared lard. HEMORRHAGE OF THE EAR. 389 g. INFLAMMATION OF THE CERUMINOUS GLANDS. The glands which secrete the wax of the ear are liable to inflammation, either as a consequence of a suppression of the cutaneous perspiration, dis- order of the digestive apparatus, the extension of some specific disease, or the presence of a foreign body. Its characteristic is an inordinate secretion of cerumen, accompanied with a sense of fulness and uneasiness deep in the auditory tube, which is at the same time perhaps considerably swollen, though rarely as much as in the more common forms of inflammation. The wax is of a pale-yellowish color, of a thin consistence, almost like water, and so abundant as to run out of the ear in considerable quantity. If it be allowed to remain, it closes up the passage, becoming thick and hard, of a dark-brownish, or blackish color, and firmly adherent to the walls of the tube. In ordinary cases there is little or no impairment of the hearing, but there is generally more or less noise in the ear, especially when the disease extends to the membrane of the tympanum, in which case there may also be consider- able deafness. The treatment of this inflammation does not differ from that of the more ordinary forms. An active purgative, with light diet, and a few leeches behind the ear, generally suffice to put a speedy stop to the morbid action. If the disease has been the result of cold, benefit will arise from the use of diaphoretics, as Dover's powder, or a combination of antimony and morphia. To clear away the wax, tepid water, containing a little soap, should be gently injected into the ear, followed by some mildly astringeut lotion, as a very weak solution of nitrate of silver, acetate of lead, or sulphate of copper and tannin. h. HEMORRHAGE. Hemorrhage of the ear is a rare occurrence. It may be the result of ex- ternal injury, or of ulceration of a tolerably large vessel, and may have its seat either in the auditory tube, in the cavity of the tympanum, or in the parts immediately around the petrous portion of the temporal bone. Cases have occurred where the bleeding was so large and unmanageable as to lead to the belief that it proceeded from the internal carotid artery, laid open by an extension of the morbid action from the ear. The blood, in these cases, gushed out of the meatus in immense quantities, and, although it could tem- porarily be controlled, yet it ultimately caused death by exhaustion. When it proceeds from, or passes through, the cavity of the tympanum, it also es- capes at the Eustachian tube, from which it is either ejected along the mouth, or, as is more common, it descends into the stomach. In fractures of the base of the skull, involving the meninges and the petrous portion of the tem- poral bone, there is often a copious discharge from the ear, at first of pure blood, and afterwards of sanguineous serum. Sometimes the bleeding is vicarious of the menstrual flux. Aural hemorrhage is to be treated upon the same principles as hemorrhage in other parts of the body; by attention to position, the exhibition of opium and acetate of lead, cold applications to the mastoid process and the back of the head, and the use of the tampon. When the blood issues from the fauces, the Eustachian tube should be plugged with the catheter, its extremity being surrounded by a bit of sponge to secure more accurate closure. 390 DISEASES AND INJURIES OF THE EAR. SECT. III.—DISEASES OF THE MEMBRANE OF THE TYMPANUM. a. WOUNDS. The membrane of the tympanum is liable to various kinds of wounds, either as the result of violence directly applied, or as concomitants of fractures of the skull. In the latter case it is probably more frequently injured than the profession are aware. It is an interesting fact to know that, when the lesion is not too extensive, it is readily repaired by an effusion of plastic matter, the process employed by nature being the same as in the healing of wounds in other parts of the body. Independently of clinical observation, which long ago established the fact, the experiments of Valsalva are perfectly con- clusive upon the subject, proving that wounds of this membrane are suscep- tible of cicatrization, even when they are accompanied by a considerable loss of substance. This distinguished medical philosopher repeatedly perforated and even lacerated the membrane of the tympanum in dogs, which, after some time, he killed, when he found that the injury had been most thoroughly repaired in every instance. Similar experiments have been performed since the time of Valsalva by physiologists and surgeons, with precisely similar results. In the operation of excising a portion of the membrane for the cure of deafness, formerly so much in vogue, the great trouble has been to prevent the opening from closing. From all these facts, then, we may deduce the interesting conclusion that wounds of this membrane, even when attended with considerable loss of substance, are, in general, easily repaired. To pro- mote this occurrence, in case of accident, the treatment should be strictly antiphlogistic, particular attention being paid to the position of the head, and free use being made of leeches behind the ear. b. RUPTURE. Rupture of the membrane of the tympanum may be produced in several , ways, as a fall upon the side of the head, a box on the ear, blowing of the nose, and the forcible introduction of a foreign body, as exhibited in the accompanying sketches, figs. 227, 228, and 229, from Toynbee. The occur- Fig. 228. Fig. 229. A fissure in the lower part of the tympanic membrane from a. box on the ear. A fissure in the posterior part of the tympanic membrane from blowing the nose. A Assure in the tympanic membrane caused by a twig. rence is generally attended with a loud noise, not unlike that caused by the discharge of a pistol, some hemorrhage, and a good deal of pain. As the edges of the rent retain their contact, the lesion is soon repaired by the inter- position of lymph, without any permanent impairment of the hearing. C. INFLAMMATION. Inflammation of the membrane of the tympanum may arise from various causes, as exposure to cold, external injury, or the presence of a foreign body. INFLAMMATION OF THE MEMBRANE OF THE TYMPANUM. 391 It is a frequent sequela of measles, scarlatina, and smallpox, and is often directly dependent for its origin upon a strumous state of the system. Infants and young children are most prone to its attacks, especially such as are natu- rally of a delicate constitution, or who have suffered from poverty and want. When this is the case, it is often induced by the most trifling causes, and fol- lowed by the most disastrous consequences, such as partial destruction of the membrane, and partial or complete deafness. Upon examining the inflamed membrane, with the aid of a strong light, it will be found to exhibit a pale rose color, which, as the morbid action ad- vances, is generally converted into a deeper hue. Small, straggling vessels are seen ramifying over the affected surface, and the part, instead of being thin and transparent, as it is in the natural state, is thick and opaque, from interstitial deposits. The inflammation often affects the adjoining parts, espe- cially the bottom of the auditory tube, and when this is the case, there is also apt to be an increase of cerumen, soon followed by suppuration, or a discharge of muco-purulent matter. Tympanitis is characterized by the existence of more or less pain, situated deep in the ear, and extending to the side of the head ; it is generally de- scribed by the patient as exceedingly sharp, aching, and distressing, and is always aggravated by loud noise, stooping, coughing, or sneezing, and by exposure of the part to the cold air. As the disease approaches the suppu- rative point, the pain generally becomes throbbing, and almost agonizing, depriving the individual both of appetite and sleep. The parts around are now more or less tender, and the movements of the jaw add greatly to the local distress. The sense of hearing is usually considerably exalted ; loud, cracking, or ringing sounds are perceived, and there is often a feeling of fluttering as if an insect were flying about in the ear. The inflammation, if at all severe, is attended with high symptomatic disorder, and occasionally with delirium. In the treatment of acute tympanitis, active antiphlogistic measures are in- dicated, and they should be employed with the least possible delay, with the ■twofold object of saving structure, and preventing cerebral involvement, two great dangers in every severe attack of this kind. If the pulse be strong and full, the pain excessive, the mind delirious, and the skin hot and dry, blood must be taken freely from the arm, the operation being followed by the appli- cation of leeches over the mastoid process, a brisk purgative, the hot foot- bath, and the antimonial and saline mixture, with a sufficiency of morphine to relieve suffering and induce sleep. Copious diaphoresis should be aimed at, and promoted by tepid drinks. The steam of hot water, directed upon the ear and the adjacent parts by means of a funnel inverted over a large pitcher, will often prove exceedingly grateful, and afford more decided com- fort than almost anything else. Its efficacy may be greatly enhanced by the addition of laudanum and powdered camphor, or camphor dissolved in alco- hol. Covering the parts with a large emollient poultice, or hot cloths, will also be productive of great amelioration. The patient's head should be con- stantly maintained in an elevated position, noise should be excluded from the apartment, and the surrounding temperature should be regulated with the thermometer, especially in cold weather. If cerebral involvement be threat- ened, leeching and counter-irritation will be necessary. In the event of there being any discharge, the syringe and tepid water may be had recourse to, but it is impossible to be too careful in their use, otherwise they will be sure to aggravate the disease instead of diminishing it. As to any direct application, the only one at all admissible, as a general rule, consists of equal parts of audanum and sweet oil, slightly warmed, and introduced into the bottom of the ear, in immediate contact with the affected surface. Irritating lotions always prove prejudicial, and cannot be too much condemned. 392 DISEASES AND INJURIES OF THE EAR. d. ABSCESS AND GANGRENE. Inflammation of the membrane of the tympanum probably terminates much more frequently in the formation of abscess than practitioners are aware; but, owing to the difficulty of examining the parts when thus affected, the occur- rence commonly escapes detection. The pus is seated in the submucous cellular tissue, and, although very small in quantity, generally leads to per- foration of the membrane, and the discharge of the small bones of the ear; its formation being ordinarily preceded by rigors and delirium. The treat- ment is antiphlogistic. If the abscess is accessible, evacuation is effected by a cataract needle, and cicatrization promoted by the cautious application of nitrate of silver, upon the extremity of a probe. Of gangrene of the membrane of the tympanum little is known. Such an event is doubtless possible, and probably occurs not unfrequently, espe- cially in scrofulous subjects, as a consequence of eruptive disease. If this were not so, how could we explain the extensive destruction of this membrane which occasionally takes place within a few days after the establishment of inflammation, the occurrence of necrosis in the temporal bone, and the almost insupportably fetid discharges which attend certain diseases of the ear? e. ULCERATION. Ulceration of the membrane of the tympanum may be an effect of ordinary inflammation, both acute and chronic ; or it may be caused by a strumous or syphilitic taint of the system, most generally the former. The erosive action may display itself in the form of little superficial abrasions, not larger, per- haps, than a small pin-head, and of a circular or oval shape; or in that of a deep and broad surface, with abrupt and well defined edges, rapidly followed by perforation of the affected part, and the discharge of some of the bones of the ear. The ulceration often proceeds until the whole membrane is destroyed, and all the adjacent parts, osseous as well as soft, are involved in the mischief, In such cases the morbid action sometimes extends to the substance of the temporal bone, and thence along to the brain and its meninges, leading to various effusions and the formation of abscesses, from which the patient sel- dom, if ever, recovers. I am satisfied, from much experience and long observation, that most cases of ulceration of the membrane of the tympanum are of a strumous nature. The subjects are generally young, delicate children, who are either the off- spring of persons who have perished from phthisis or from some allied disease, or who are themselves destined to become affected in that way. The exciting cause of the complaint is either exposure to cold or an attack of measles, scarlatina, or some other eruptive malady, whose tendency is to impoverish the blood and exhaust the powers of the system. The ulceration is frequently of a very insidious character, coming on, without any pain, during the con- valescent stage of the cutaneous disease, and continuing, with, perhaps, but little intermission, for an almost interminable period. We often meet with cases of this kind which have lasted for five, ten, and even fifteen years. The discharge is generally of a thick, cream-like consistence, of a yellowish color, verging upon greenish, and so horribly offensive as to render the patient dis- agreeable both to himself and to those around him. Exposure to cold, de- rangement of the digestive organs, and neglect of cleanliness, always aggravate it. It is often attended with fungous, or polypous growths, and is liable, unless closely watched, to be followed by inflammation of the brain and its membranes. A sudden suppression of such a discharge, especially if accom- panied by severe headache, should always be regarded with suspicion. When ulceration, by whatever cause induced, is of long standing, or of ULCERATION OF THE MEMBRANE OF THE TYMPANUM. 393 considerable extent, deafness, more or less complete, is the inevitable conse- quence. All, therefore, that can be done in such a case, is to endeavor to arrest the disease, and happy is the surgeon who can succeed in his efforts ; for it may truly be asserted that there is no affection which is more un- manageable, or more difficult to be brought under the influence of remedies. As to any improvement of the hearing, that is an occurrence hardly to be thought of. It is only when the disease is slight, and the constitution has not been impaired by previous suffering, that relief is to be looked for in this respect. The practitioner, indeed, cannot be too guarded in his prognosis. His rule of conduct should be to do all he can, but to promise nothing. The treatment of ulceration of the membrane of the tympanum must, in general, be conducted empirically. When the disease has been induced by the presence of a foreign body, or the retention of pus in consequence of some morbid growth, the removal of the exciting cause will often of itself be sufficient to effect a cure ; but fthere we have no positive information respect- ing this point, our course must, necessarily, be one of uncertainty. A care- ful examination should be made in every case, before we begin the treatment, of the condition of the parts, by washing out the ear with tepid water, thrown in gently with a large syringe. The prominent indications are, first, to allay fetor, and, secondly, to arrest the morbid action. The former is fulfilled by the cautious use of the chlorides, injected into the ear twice or thrice in the twenty-four hours ; and the latter by counter-irritation, the topical applica- tion of nitrate of silver or various astringents, and by attention to the state of the system. When the disease is of a strumous nature, or associated with debility, an alterant and tonic course will be indicated, consisting of iodide of iron and extract of cinchona, alternated with cod-liver oil, and aided by nutritious diet and exercise in the open air. The surface should be well protected, and sponged daily with tepid salt water, followed by dry friction. Too much attention cannot be paid to cleanliness, for, apart from the offensive character of the discharge, the accumulation of pus in the ear must necessarily tend to keep up the morbid action, and to increase the mischief. The nitrate of silver is undoubtedly among the best topical remedies we possess, but too much caution cannot be employed in its use. The strength of the injection should not exceed, at first, the eighth of a grain of the salt to the ounce of water, from which it may be increased to the fourth of a grain or even more, according to the tolerance of the affected surface. Another excellent article is the bichloride of mercury, used still weaker; it is particularly valuable in the scrofulous form of the disease, attended with an abundant discharge. Iodide of iron, sulphate of copper, acetate of lead, and sulphate of zinc, are also proper remedies, under similar restrictions. Whatever direct applications be employed, care must be taken not to let the discharge dry up too rapidly, lest disease should be excited in the brain and its membranes. This precaution is particularly necessary in cases of long standing, accompanied with extensive disorganization of the structures of the ear. To obviate this occurrence, and at the same time aid in arrest- ing the ulcerative action, an issue should be established behind the ear, over the mastoid process, and kept open for a long time after all disease has ap- parently vanished. W7hen symptoms of cerebral involvement arise, they must be promptly met by leeches, blisters, and such other means as will readily suggest themselves in a case of such emergency. fehould the disease be of syphilitic origin, it will be necessary, in addition 1\-a l0C^ raeans bere Pointed out, to place the patient upon the use of iodide of potassium, either alone or in conjunction with bichloride of mer- cury, in small doses, continued sufficiently long to produce slight ptyalism. lo the disease now described, the terra otorrhcea is usually applied by aural 394 DISEASES AND INJURIES OF THE EAR. surgeons; and practitioners, in prescribing for it, unfortunately too often forget that the discharge which accompanies it is merely a symptom of the affection, and not the disease itself. Another mistake which is often com- mitted is the belief that the malady upon which the discharge depends will in time disappear spontaneously, or, to use a vulgar phrase, that the patient, especially if a child, will gradually outgrow it. Such an opinion is as absurd as it is culpable, and cannot be too severely censured. The poor patient, confiding in the judgment of his professional adviser, goes on from bad to worse, until, awakening from his dream, he finds that his ear is completely disorganized, and that he is irremediably deaf. Such cases are of constant occurrence in every community; and, while they are calculated to awaken our sympathy for the sufferer, they cannot fail to excite our indignation at the practitioner, who, either through ignorance or indolence, or both, neglects to make himself acquainted with the nature and treatment of the disease. SECT. IV.—INFLAMMATION OF THE CAVITY OF THE TYMPANUM. This disease, which has been variously designated by aural surgeons, the terms being nearly all more or less objectionable, is seated in the lining mem- brane of the middle ear, which is continuous, along the Eustachian tube, with that of the fauces. As it progresses it may invade other structures, such as the fibrous layer of the tympanum, and even the labyrinth ; or, beginning in these, it may extend to and involve the mucous tissue secondarily. Un- fortunately, our knowledge of the maladies of these delicate parts of the organ of hearing is too limited to enable us to speak very positively upon the subject; their deep situation, the difficulty of exposing them, and the infrequency of their fatality, being so many reasons of the imperfection of our information. Inflammation here is probably more common than is generally imagined, and it is not at all unlikely that some of the fatal cases of disease of the base of the brain, which we meet with, from time to time, have their seat originally in the middle and internal ear. Of the causes which produce this disease, it is not always, if indeed gene- rally, possible to form a correct idea, as they are usually more than commonly obscure. The patient, if he is old enough to give an account of himself, often ascribes it to the effects of cold, in consequence, perhaps, of exposure to a shower, sitting in a draught, or bathing in cold water. He is conscious, at any rate, that he was seized soon after with pain in the ear, and he is dis- posed, consequently, to refer his suffering to that particular cause. There is no question at all that this kind of exposure is the most frequent exciting cause of internal otitis. It may also be induced, however, by external injury, by the presence of a foreign body, by irritating applications to the membrane of the tympanum, and by an extension of inflammation from the tonsils and fauces along the Eustachian tube. Children and young persons are its most common subjects, such especially as are of a strumous predisposition. Oc- casionally the disease is caused by a syphilitic state of the system; when this is the case, it is generally associated with similar disorder in other parts of the body, as the throat, nose, and bones. The affection is ushered in by pain in the ear, which is speedily followed by fever, alternating with rigors. The pain is deep-seated, and, rapidly increasing, soon amounts to intense agony, being of a tearing, boring, drag- ging, or pulsatile character ; it is aggravated by the slightest motion of the head, and darts about in different directions, as the temple, forehead, mastoid process, and teeth, which often ache most violently. Cephalalgia is generally present from the beginning, and is soon succeeded by delirium ; the patient is unable to rest for a moment in the same position, and is harassed with all INFLAMMATION OF THE CAVITY OF THE TYMPANUM. 395 kinds of noises, while the sense of hearing is in the highest possible state of exaltation; the countenance is flushed, the eyes are suffused, and there is a wildness of expression indicative of the most intense suffering. In the worst forms of the affection, the pain extends along the Eustachian tube into the throat; the whole side of the head becomes exquisitely tender; the fever increases in intensity; coma at length sets in ; and the patient expires under all the symptoms of disease of the brain and its membranes. Upon dissec- tion, matter is found in the cavity of the tympanum, and also, not unfre- quently, over the petrous portion of the temporal bone, with effusion of serum into the arachnoid sac. In protracted cases, the temporal bone is carious or partially necrosed, and separated from the dura mater by a distinct abscess. When the patient survives, the matter is sometimes suddenly discharged through the external air, followed by partial relief of the frightful suffering previously endured. The mitigation thus produced, however, is often only temporary, death being caused afterwards either by exhaustion, or, as more generally happens, by inflammation of the brain and its envelops. The period at which this event happens varies from eight or ten days to several months. In the latter case, the patient is assailed by hectic irritation ; he becomes feeble and emaciated ; his countenance exhibits a sallow, cadaverous appear- ance; there is a profuse discharge from the ear, or from the ear and the Eustachian tube; and the mind is feeble, incoherent, or fatuous. In regard to the diagnosis of this disease there is hardly a symptom which is at all worthy of reliance. Perhaps the most important is the violence of the pain, its depth, its being unreraittent, and its association with fever, rigors, and delirium. If the patient be a child, the head will be in constant motion, and the hand incessantly carried to the ear ; an adult will express himself as being in great torture. The general excitement is higher than in external otitis, the ear is more intolerant of sound, and there is always marked deli- rium, usually beginning early, and lasting until the malady disappears or proves fatal. Another point of distinction of some value is that matter forms much later than in inflammation of the membrane of the tympanum, or of this structure and of the auditory tube, in which suppuration generally takes place in from twenty-four to forty-eight hours. Finally, there is more tenderness in the mastoid and temporal regions than in external otitis, and more pain in moving the head, sneezing, coughing, and mastication. The treatment of internal otitis must be of the most prompt and vigorous character. No time must be lost in half measures, or in doubt and indeci- sion; it must be recollected that the disease is one of great danger, not merely as it respects the parts more immediately involved in the morbid action, but also the patient's life. Without entering at all into details,-which are unne- cessary, it may be stated that the great remedies in every case of the kind are general and topical bleeding, active purgation, the free use of the anti- monial and saline mixture, the hot foot-bath, and the exhibition of anodynes, in doses sufficient to allay pain and promote sleep. The best direct applica- tion is the steam of warm water, containing a considerable quantity of black drop and powdered camphor, and conducted into the ear by means of an inverted funnel. The head should, at the same time, be well covered with cloths wrung out of hot water, noise should be excluded from the apartment, and the body should be steadily maintained in the semi-erect posture. One great aim of the treatment should be to bring about early and copious dia- phoresis, experience having shown that it exerts a wonderfully controlling influence over the morbid action. As soon as proper depletion has been practised, counter-irritation should be established over the mastoid process, and, where the brain is likely to be involved, also in the nape of the neck, at nrst by means of blisters, and afterwards by issue, seton, or tartar-emetic ointment. When structural lesion is dreaded, mercury should be given in full 396 DISEASES AND INJURIES OF THE EAR. doses, with a view to its speedy constitutional effects. Should matter form in the middle ear, as denoted by the convex and opaque appearance of the membrane of the tympanum, a puncture should be made to serve as an outlet to the pent-up fluid, its escape along the Eustachian tube being generally prevented by adhesive inflammation. Wrhen the disease assumes a chronic form, our chief reliance is upon tonics, light but nutritious diet, and pyogenic counter-irritation, with the internal use of minute doses of mercury, with a view to slight but persistent ptyalism. The patient must be carefully watched, and precaution taken to protect the brain and prevent relapse. SECT. V.—DISEASES OF THE INTERNAL EAR. a. NERVOUS DEAFNESS. There is a species of deafness to which, for the want of a better expression, the term nervous is applied. The symptoms which characterize it have long been well understood, but as it respects its pathology we are still, in great degree, in conjecture. It resembles, in many of its essential fea- tures, amaurosis. It was, for a long time, attributed to paralysis of the auditory nerve, as amaurosis was attributed to paralysis of the optic nerve. That such an occurrence is possible is undeniable, but that much more im- portance has been ascribed to it than it is entitled to, is equally true. Indeed, there is reason to believe that, in the great majority of cases of what is called nervous deafness, the disease, instead of being caused by a want of power in the nerve of hearing, as a primary lesion, depends wholly upon inflammation. This has certainly been ascertained to be the fact in regard to amaurosis, and that the same circumstance obtains in relation to nervous deafness is now, I believe, generally admitted. Too much stress cannot be laid upon this view, when we consider the influence which it must exert upon the treatment of this class of affections. Under the supposition that it was, from first to last, a purely nervous disease, the most erroneous practice was pursued, and this is, perhaps, one reason, among many others, why aural maladies have been so long a specialty in the hands of the empirics. Of the exciting causes of this form of deafness, our information is not very reliable. In many of the cases that I have been consulted about the disease appeared spontaneously, without the patient being able to assign any reason whatever for its occurrence. Occasionally I have known it to come on soon after an attack of typhoid fever, attended with an unusually tardy convales- cence. Measles and scarlet fever are also sometimes followed by it. Several of the worst cases of nervous deafness that I have ever seen, occurred, appa- rently, in consequence of bathing in cold water, after the body had been overheated by exercise. Profuse and long-continued diarrhoea, protracted hemorrhages, the inordinate use of purgatives, masturbation, and abuse of sexual intercourse, have often been known to induce the affection. Another cause, and one which, according to my experience, is more than commonly operative, is chronic dyspepsia, so rife among the people of this country. The disease generally begins in one ear, and, after continuing for some time, attacks the other; or it may be confined to one ear exclusively; or, lastly, it may commence simultaneously on both sides, and proceed uniformly or other- wise, until audition is completely lost. Sometimes the disease is produced almost instantly. I saw, not long ago, a child, four years old, who went to bed perfectly well in the evening, but woke up completely deaf in the morn- ing. Sudden fright and the concussion occasioned by the firing of a cannon or even a pistol, have been known to deprive persons instantly of the faculty of hearing. Nervous deafness is sometimes hereditary. I give the following notes of a NERVOUS DEAFNESS. 397 case, which came under my observation some years ago, as an illustration of this fact:—A young man, Samuel Hirsh, a German, aged twenty-one, of Memphis, Tennessee, is partially deaf in his right ear, evidently from au affection of the auditory nerve; the disease has been coming on gradually for the last eighteen months, and is steadily increasing; it is attended with great buzzing, as well as other disagreeable noises, and with occasional headache. He has never had typhoid fever, measles, scarlatina, or smallpox. He is one of nine children. His oldest brother is thirty-five years of age, and is very deaf in both ears ; a sister, aged thirty, is quite deaf in one ear. The father is deaf in both ears, and so is a paternal aunt. The paternal grandfather is likewise deaf. The mother hears well. The first intimation which the patient usually has of his infirmity is, per- haps, derived from his friends, who, in their intercourse with him, are rendered conscious that he does not hear so well as formerly. They are obliged, in addressing him, to repeat their questions or answers more frequently than formerly, and to speak in a louder tone and more emphatic manner. Simul- taneously with this occurrence there are various noises in the ears, at first slight and occasional, but becoming gradually more and more intense and steady, until, in time, they constitute the great and absorbing symptom. In regard to the character of these sounds nothing could be more strange and diversified. Thus, in one case they resemble the ticking of a watch ; in an- other, the ringing of a bell; in a third, the buzzing of an insect; in a fourth, the chirping of a bird. In some instances they are like the rustling of the wind among leaves, the pattering of rain, the roaring of a water-fall, the motion of a saw-mill, the boiling of a tea-kettle, or the whistling of a steam- engine. These noises are generally confined to the ears, but cases occur, and they are not infrequent, in which they extend over the whole head, causing the most disagreeable and distressing feeling. Fatigue, loss of sleep, expo- sure to cold, damp states of the atmosphere, and the depressing passions, have the effect of increasing them, and of aggravating the patient's suffering, often producing fits of the most dreadful despondency. On the other hand, it is not unusual for slight improvement to occur, although it is generally very transient, lasting, perhaps, not more than a few hours, or, at most, only a few days. During this time the hearing is not only improved, but there is a considerable diminution of sound, and illusive hopes are entertained of speedy recovery. Presently, however, the symptoms recur in all their former intensity, and the disease goes on rapidly from bad to worse until the deaf- ness is complete. There are cases of this affection in which there is an entire absence of noise. They generally come on very suddenly, in consequence, often, of some affec- tion of the brain, and are of the most hopeless character, as it respects reco- very. It is probable that this variety of the disease is due to paralysis of i the auditory nerve. Nervous deafness is seldom attended with any pain in the ear or the sur- i rounding parts. The patient, in addition to the noises already described, 1 often complains of a sense of fulness in the organ, or a feeling as if the audi- tory tube had been stopped up with water; but as to actual pain, he does not experience any, except occasionally, as an intercurrent and adventitious | circumstance. The general health is variable. In many cases it is im- paired, perhaps, very materially, at the moment of the attack; but in some it is apparently as perfect and vigorous as it ever was. Some of the very worst examples of nervous deafness that I have ever witnessed occurred in persons of this description. The period which intervenes between the com- mencement of the first symptoms and the occurrence of complete deafness varies from a few weeks to a number of years. Occasionally the individual is able to hear more or less all his life, especially if he use an ear-trumpet. 398 DISEASES AND INJURIES OF THE EAR. The ear, in nervous deafness, often retains its normal appearance most per- fectly. The secretion of cerumen proceeds as before, and there is not the slightest evidence of disease in the membrane of the tympanum. Cases, however, occur in which there is a total absence of wax, and in which the drum is not only unusually dry, but more or less opaque. When touched with a probe, it is often found to be remarkably sensitive, as is the case also frequently with the parts immediately around. Among the thousand and one remedies that have been recommended, from time to time, for the relief of nervous deafness, there is not one which is worthy of the slightest reliance in a curative point of view. In my own prac- tice, I have so rarely derived any benefit from the various means that have suggested themselves to my mind, in the treatment of this affection, that I have, of late, been induced to look upon it as being generally altogether be- yond the reach of our skill; and in this sentiment most surgeons will, I am sure, fully coincide. Whatever benefit results is usually of a transient cha- racter, and is due, in great measure, if not wholly, to the effects which our remedies exert upon the condition of the general health, rather than to any improvement in the ear itself. The misfortune is that, in most cases, the affection is entirely neglected in its earlier stages, at a time when treatment might, perhaps, be of service. The patient, thinking that it is a matter of little moment, and that it will gradually vanish of its own accord, feels little inclined to apply for advice, and hence the consequence is that, when his fears become excited, it is generally too late to do him any good. When the disease supervenes suddenly, and in its more decided forms, I believe that no remedies, however judiciously employed, will be of any avail. All experi- ence goes to show that such cases are generally hopeless. Under opposite circumstances, however, I always deem it my duty to institute as rational a course of proceeding as our limited powers of observation will admit. Look- ing upon the disease as being generally of an inflammatory origin, and, there- fore, as likely to produce structural disorder, I believe that the best plan that can be adopted is to put the patient upon a very mild course of mercury, giving from a fourth to half a grain of calomel three times a day, until there is slight soreness of the gums, which should be diligently maintained for a number of weeks, care being taken to avoid everything like salivation. If plethora exist, recourse may be had to active purgation, leeching behind the ears, and even general bleeding, along with light diet, and a seton in the neck, or, what I deem more judicious, a small issue over each mastoid pro- cess. If, on the other hand, there is evidence of general debility, as happens in a plurality of such cases, the mercury must be combined with tonics, as iron and quinine, a nutritious diet, the shower bath, and daily exercise in the open air, with saline ablutions and dry frictions. I place great confidence in the use of mercury in this disease, particularly in its earlier stages, from its salutary effects in preventing structural change. When the lesion is fully established, I have never experienced any benefit from it, and have therefore, of late, ceased to prescribe it under such circumstances. In regard to direct applications, it is impossible to observe too much pre- caution. W7hen there is opacity of the membrane of the tympanum, the affected surface may be gently touched, once a day, with a little dilute mer- curial ointment, or a solution of nitrate of silver, in the proportion of half a grain of the salt to the ounce of water. Another appropriate remedy is glycerine with a small quantity of spirits of camphor. Whatever substance be employed, care must be taken that it acts as a sorbefacient, and not as an irritant; otherwise serious mischief may ensue. The treatment of nervous deafness by the introduction of the vapor of nitrons ether into the cavity of the tympanum, through the Eustachian tube is, I believe, no longer employed by any sensible practitioner, notwithstanu- DEAFNESS FROM DISEASE AND OTHER CAUSES. 399 ing the high encomiums that have been lavished upon it by Kramer and other professed aurists. From personal experience with the remedy I was led, long ago, to regard it as one of the delusions of surgical practice; a conclusion which has been fully verified by the later observations of others. Of elec- tricity and electro-galvanism, as means for relieving nervous deafness, I have not made sufficient trial to enable me to speak with certainty ; but, judging from the reports of others, I should be inclined to place no reliance upon them. b. DEAFNESS FROM DISEASE OF THE TYMPANUM AND OTHER CAUSES. Besides the form of deafness now described there are others, some of which are transient and curable, others permanent and irremediable. In order to appreciate their character, it will be necessary briefly to inquire into their causes. These will be found to be both numerous and diversified. 1. Deafness is often produced by destruction of the membrane of the tym- panum, either as an effect of ulceration, of a wound, or of the contact of some acid, introduced by design or from mischief. When the lesion is con- siderable, it is necessarily accompanied by the loss of the small bones, and by the annihilation of the sense of hearing. Injuries of the skull and brain are occasionally followed by deafness, sometimes partial, at other times com- plete. This effect is most liable to supervene upon injuries involving the base of the cranium, especially such as are attended with fracture of the petrous portion of the temporal bone and laceration of the meninges of the brain ; but it may also take place when the lesion is seated upon the side and top of the skull, and is apparently of a more trivial character. A severe box upon the ear or temple has been known to cause permanent deafness. 2. Mere concussion of the membrane of the tympanum sometimes occasions deafness. I have seen several cases where it was caused by the discharge of a cannon, a gun, and even a pistol. Artillerymen are occasionally, in an instant, deprived of the faculty of hearing during the progress of a battle, or the firing of a salute, in consequence of the sudden and violent agitation of the air. Under such circumstances, indeed, it is not uncommon to notice a considerable flow of blood from the ear. 3. Caries and necrosis of the temporal bone are a frequent cause of deaf- ness. The same effect may be induced by the pressure of a tumor upon the nerve of the ear, the long retention of hardened wax, the pressure of a foreign body upon the membrane of the tympanum, the deposit of lymph, or tubercular matter in the middle cavity of the ear, and occlusion of the Eustachian tube. 4. Violent sneezing and coughing have been known to produce deafness. Of the truth of this fact there can be no question, as several well-authenticated cases of it are upon record. 5. Another cause of deafness is frequent washing of the head in cold water, cutting of the hair very close in cold weather, or exposing the head, espe- cially when the body is overheated, to currents of cold air. 6. The inordinate use of quinine has occasionally caused complete and irre- mediable deafness in a few hours. Of this occurrence numerous cases are to be found among the inhabitants of our Southern States, where this article is often given in enormous doses. T. Deafness is sometimes produced by worms in the alimentary canal, the repulsion of cutaneous disease, and the suppression of habitual discharges. biauzani mentions the case of a woman who suffered from deafness during lour successive pregnancies. 8. Loss of hearing may be occasioned by effusions upon the base of the ram, whether the result of traumatic causes, tuberculosis, or common in- uammation. 400 DISEASES AND INJURIES OF THE EAR. 9. Deafness is sometimes dependent upon malformation or disease of the internal ear. Cases occur in which there is no trace whatever of the vesti- bule, cochlea, and semicircular canals. Occasionally the labyrinth is com- posed of a single cavity, shut off entirely from the tympanum, as in the crustaceous animals. Finally, the internal ear is sometimes occupied by scrofulous matter, serum, fibrin, or a substance resembling chalk. 10. The cause of deafness may reside in the cavity of the tympanum, which may be filled up with various kinds of materials, as mucus, lymph, pus, and blood, interfering with the transmission of sound. A substance resembling tubercle, and consisting of granules, epithelium, and oil globules, has been found in this portion of the ear, the occurrence being most common in young subjects of a scrofulous predisposition. Finally, the cavity of the tympanum may be absent; and there are cases in which there is imperfect development of the small bones of the ear. 11. There may be lesion of the auditory nerve; consisting either in imper- fect development, interstitial deposits, induration, softening, paralysis, or compression by osseous and other matter. 12. Deafness may be occasioned by lesion of the mastoid process, the cells of which are lined by a reflection of the mucous membrane of the middle ear, and which are, therefore, liable to the same kind of diseases. Inflammation, whether traumatic or idiopathic, may lead to various changes in this supple- mental portion of the ear, all more or less prejudicial to audition. It is also liable to malformations, obliteration, and scrofulous deposits. 13. Finally, deafness, partial or complete, may be caused by enlargement of the tonsils, by polypous tumors of the nose, and by various affections of the fauces. It is not necessary to enter into any formal disquisition respecting the treatment of these various kinds of deafness. Their chief interest consists in their diversity, and the consequent necessity of inquiry into their character before we attempt their removal by the use of remedies. Some of them, from their very nature, are incurable; others, for the same reason, hold out a pros- pect of relief by judicious treatment; and not a few will disappear sponta- neously, or simply by the operation of time. When the deafness depends upon the loss of the drum of the ear, the hearing may often be greatly improved by an artificial substitute, fig. 230, consisting of a circular or oval piece Fig. 230. of very thin India-rubber, as origi- nally suggested by Mr. Toynbee. it is attached to a very delicate wire rod, a little more than an inch in length, and can be very easily introduced and Toynbee's artificial tympanic membrane. withdrawn by the patient himself. It should be worn at first a few hours only a day, and then not in contact with the remnants of the tympanic membrane, lest it should occasion irritation. It is always removed at night, and the ear syringed twice a day if there be any discharge. When no such contri- vance is at hand, great comfort and advantage will be derived from the use of a little pellet of cotton-wool, moistened with glycerine, and inserted into the ear, in contact with the aperture at its bottom. Substitution may be effected once or twice a day, according to the amount of discharge. SECT. VI.—DISEASES OF THE EUSTACHIAN TUBE. The Eustachian tube, which establishes a direct communication between the middle ear and the fauces, is liable to various affections, which influence, DISEASES OF THE EUSTACHIAN TUBE. 401 to a greater or less extent, the function of audition. These affections may be thus enumerated: 1. Congenital occlusion. 2. Inflammation. 3. Me- chanical obstruction. 4. Stricture. 1. Congenital occlusion of the Eustachian tube is probably more frequent than the profession are aware. It is similar to the malformation which is met with in some of the other mucous outlets of the body, as the anus, urethra, and vagina, and may affect the entire canal, or be limited to a particular por- tion. In the latter case, the obstruction is caused either by a small membrane, not unlike a hymen, or by the presence of fibrous, fibro-cartilaginous, or car- tilaginous tissue. However induced, it is generally, if not always, a cause of deaf-dumbness, and is beyond the reach of treatment. 2. The Eustachian tube, being lined by a reflection of the mucous mem- brane of the fauces, is liable to inflammation and its various consequences, as thickening, ulceration, and even gangrene. Scrofulous children, affected with chronic disease of the tonsils, are particularly prone to suffer in this way. The inflammation of the fauces often continues for years, being constantly subject to exacerbations from the slightest exposure to cold, derangement of the digestive organs, and whatever has a tendency to excite and maintain general debility. Being kept in a state of habitual congestion, the membrane becomes gradually indurated and thickened from interstitial deposits, and thus ultimately encroaches very seriously upon the caliber of the tube. Simi- lar effects are often produced in inflammation of the throat consequent upon some of the eruptive diseases, particularly measles, scarlatina, and smallpox. The morbid action thus awakened not unfrequently extends into the Eusta- chian tube, and thence along the tympanum, where, leading to various depo- sits and alterations of structure, it may be followed by the worst effects. Ulceration of the Eustachian tube is observed chiefly in connection with constitutional syphilis, attended with destruction of the tonsils and the arches of the palate. Under such circumstances, the membranous portion of the canal may be entirely eroded, followed, during the healing process, by occlu- sion of the remainder of the passage. Gangrene of the tube is extremely rare. Inflammation of the Eustachian tube may lead to a deposit of plastic mat- ter. Such an event, however, must necessarily be uncommon, but its occur- rence has been demonstrated by dissection, and, therefore, admits of no dis- pute. When the quantity is considerable, it may cause permanent closure of the tube. Of suppuration of this passage very little is known, but the proba- bility is that it is much more common than is usually imagined. 3. Mechanical obstruction of the tube may be caused by the presence of inspissated mucus, fibrin, blood, and earthy matter. Inordinate secretion of mucus is an occasional occurrence in this tube, chiefly, we may suppose, as a consequence of chronic inflammation. When the fluid is very thick, or long retained, it may completely clog up the pas- sage, and thus seriously impair hearing. The occurrence will be more likely to happen when the mucus is intermixed with plastic matter. Fibrin alone may be a cause of obstruction, and so also may be a clot of blood, the result of hemorrhage in the internal ear. Finally, a substance resembling chalk—probably nothing but altered tuber- cular matter—is sometimes found in the Eustachian tube, closing it either partially or completely, and thus acting as a cause of deafness. 4. Stricture of the Eustachian tube is uncommon. It presents itself in various forms and degrees, but has hardly been studied with sufficient care and attention to enable us to give any satisfactory account of it. It gene- rally appears as a small, narrow band, stretched across the tube from one side to the other; or as a ring-like contraction ; or, as when it involves the osseous part of the canal, as a species of exostosis, growing inwardly, and filling up vol. n__26 402 DISEASES AND INJURIES OF THE EAR. the conduit. Sometimes the passage is obliterated nearly from one extre- mity to the other. However constituted, the obstruction is usually perma- nent, although it may not be complete. The various affections of the Eustachian tube above described can be diag. nosticated only by means of the catheter, all other attempts at arriving at a knowledge of them being vain and nugatory. It was formerly imagined that the existence of obstruction, from whatever cause arising, could be determined simply by inflation, by shutting the mouth and holding the nose; it being asserted that if the air did not penetrate the tube, it was an evidence that it was closed. Nothing, however, can be more erroneous; for there are, as is well known, many persons who cannot, by any effort they can employ, inflate this passage at all, however clear it may be. I have myself never been able to blow air into my left Eustachian tube, although my hearing has always been perfect, and the operation always promptly succeeds on the right side. Catheterism, then, is the only reliable means of diagnosis, and it is so much the more valuable, because, while it enables us to obtain important informa- tion respecting the nature of the disease, it is one of the best methods of cure. Catheterism of the Eustachian tube is quite as simple an operation as that of the bladder; but as it requires, for its successful execution, an unusual amount of practice, as well as a most accurate knowledge of the anatomy of the parts, it is evident that it can never come into general use. Besides, it is an operation which requires great delicacy on account of the exquisite sen- sibility of the Eustachian tube, as well as of the surface immediately around. For want of proper care in its performance, serious mischief has been pro- duced. Different kinds of instruments are in vogue for exploring this canal; some being straight, others curved; some flexible, others inflexible. The one which I have always been in the habit of using, and which will be found to answer the purpose most admirably, is represented in fig. 231. It is composed of Fig. 231. Catheter for the Eustachian tube. silver, and is, consequently, inflexible, being six inches in length, and having a short curve at its distal extremity, with a very smooth probe-pointed orifice. It varies in diameter from the size of a crow quill to that of a small goose quill, according to the age of the patient. In its general outline, it is some- what conical, and the ring at its large extremity corresponds with the con- cavity of the curve at the smaller one ; an arrangement which is found useful in the introduction of the instrument, as it indicates the direction of its point. The patient being seated upon a chair with the head thrown backwards against the breast of an assistant, the catheter, properly oiled and warmed, is inserted into the nose, its concavity being directed downwards towards the floor of the nostril, along which it is conveyed until it reaches the fauces. Its point is now turned upwards and outwards, so that the ring of the instru- ment shall be in an oblique position, while its body shall lie in close contact with the outer wall of the nasal fossa. All that is required now is to pass the catheter gently on, when it cannot fail to reach the tube, its entrance being denoted by a want of resistance, and a feeling as if it moved in a nar- row track. The distance to which it may be carried will depend upon its size and upon the presence or absence of mechanical obstruction. Under no circumstances, unless the instrument is uncommonly small, can it be pushed on into the middle ear. DISEASES OF THE EUSTACHIAN TUBE. 403 If now, while the catheter is in its position, air be blown through it into the tube, we shall be able to determine, at least in many cases, both the de- gree and the character of the obstruction. Thus, if the closure be partial, the fluid will readily find its way into the middle ear, very much as when we attempt inflation by shutting the mouth and nose; whereas if it be complete no such effect will follow. The presence of mucus can generally be detected by the peculiar gurgling or rustling sound which the patient perceives as the air rushes past the accumulated fluid; and soon after he will probably be conscious of a diminution of the disagreeable noises which previously dis- turbed him. If, on the other hand, the obstacle is of a solid nature, the sound produced by the inflation will be indistinct, or similar to that caused by blowing against a bone or other hard body. Fig. 232. Toynbee's otoscope. Stricture of the tube, from ordinary inflammation, may be suspected when the point of the instrument, after having passed a certain distance, refuses to Fig. 233. Application of the otoscope. e any farther. We may suppose that the obstruction is osseous, cal- >, or gristly, when the resistance is uncommonly great, and the contact 404 DISEASES AND INJURIES OF THE EAR. of the catheter elicits a sharp noise. The existence of mere deafness, or of various sounds, cannot, considered by itself, be regarded as an evidence of closure of the Eustachian tube, as it is a concomitant of different affections. Mr. Toynbee, whose vast experience in aural diseases entitles him to speak with the force of authority, employs, as a means of exploring the Eustachian tube, an instrument of his own invention, denominated an otoscope, fig. 232, consisting of an elastic tube about eighteen inches in length, each end of which is tipped with ivory or ebony. The manner of using the instrument is exhibited in fig. 233. It will be observed that one extremity rests in the ear of the surgeon, the other in that of the patient. If there be no obstruc- tion of thecanal, the surgeon will distinctly perceive a faint crackling sound, produced, apparently, by a slight vibratory movement of the tympanic mem- Fig. 234. Ear explorer. brane, when the patient makes a full and rapid expiration, or attempts to swallow his saliva, no such effects following when there is serious or com- Fig. 235. plete occlusion. When there is thickening of the mucous lining of the tympanic membrane, the noise heard during the examination will occasionally DISEASES OF THE EUSTACHIAN TUBE. 405 resemble a gentle flapping, although the Eustachian tube may be perfectly pervious. Direct exploration of the canal is effected by Mr. Toynbee by means of a common Eustachian catheter and an elastic tube, eighteen inches in length, one end of which has a flat mouth-piece of ivory, with a few deep notches in it, while the other is provided with a small steel nozzle, adapted to the further extremity of the catheter, which is not quite as large as an ordinary crow- quill. The catheter having been inserted into the Eustachian tube in the usual way, the surgeon holds it with the left hand, and places one end in his mouth, and the other in the catheter, grasping it also with the left hand. With his right hand thus at liberty, the surgeon is now to take the otoscope and introduce one end of it into the ear of the patient, who may hold it there, the other end being held by the surgeon in his own ear; or the tube may be made so tight as to remain there without being held, leaving the operator's right hand still free, as exhibited in fig. 235. The apparatus being thus adjusted, the surgeon blows very gently into the explorer, and at the same time listens attentively through the otoscope to ascertain whether the air enters the ear, and, if so, what sound it produces. If the tympanum is free, the air will rush into it in a clear stream ; but if mucus be present it will cause a peculiar gurgling, replaced by a squeak or bubbling sound, if there be, in addition, thickening of the lining membrane. Catheterism of the Eustachian tube is an important means of treatment in affections, not only of the canal itself, but of the middle ear, whether arising from mere thickening of the investing membrane, or accumulation of mucus. In the former case, the mere contact of the instrument often produces an ex- cellent sorbefacient effect, at the same time that it aids powerfully in the re- moval of the morbid sensibility of the tube, which is so generally present in inflammation. The operation may be repeated, at first, once every fourth day, and afterwards every twenty-four hours, the instrument being retained several minutes each time. It may be assisted by the inflation of air from the operator's mouth, or, after the withdrawal of the catheter, by the patient's own efforts. When more direct medication is required, the object may be attained by the injection of tepid water, slightly impregnated with some astringent arti- cle, as sulphate of zinc, acetate of lead, or of alum. Great care must be taken that the solution is as mild as possible, otherwise much harm may result. A better remedy than any of these is the nitrate of silver, in the proportion of about an eighth of a grain to the ounce of water. Whatever substance is used, great caution must be observed in regard to the repetition of the injection, which should not, on an average, be oftener than once every third or fourth day. Along with these means, special attention should be paid to the general health ; the diet should be properly regulated ; the bowels should be main- tained in a soluble condition ; and an issue should be kept up behind the ear. When the disease is obstinate, and fairly attributable to the effects of inflammation, benefit will be derived from slight and steadily continued ptyalism. Deafness caused by permanent occlusion of the Eustachian tube has been treated, in modern times, by perforation of the membrane of the tympanum. Ihe operation was proposed early in the present century by Sir Astley Cooper, and was at one period much in vogue among surgeons, although it is now obsolete. The, object was to drill a small opening into the membrane of the tympanum, in order to admit air into the middle ear, the absence from which, as was alleged, was the principal cause of the want of hearing. It having been found that the aperture thus made had a tendency in a short time to close, thereby frustrating the intention of the operation, an instrument- 406 DISEASES AND INJURIES OF THE EAR. was devised for cutting out a circular piece of the membrane. Professor Smith, of Baltimore, thought he had effected a great improvement when he invented his perforator, and for a while the most sanguine hopes were enter- tained that deafness would henceforth be a more amenable affection. These expectations, however, have not been realized, and so little confidence is now reposed in the operation that we never hear of its being executed by any one. Soon after I entered the profession, I had occasion to give it a trial in two instances, which were considered to be quite favorable to the undertaking; but, although I succeeded perfectly in each case in excising a sufficiently large piece of the membrane, not the slightest benefit followed. Of late years I have not thought proper to repeat the operation, for the reason chiefly, that, while it is painful and not altogether devoid of danger, it is hardly possible to find a well authenticated case in which it has proved beneficial. Whether the procedure will ever be revived is very questionable ; certainly not with our present views of the pathology and treatment of aural diseases. SECT. VII.—AFFECTIONS OF THE MASTOID CELLS. Disease of the mastoid cells occurs chiefly in young strumous subjects, in consequence of attacks of cold, measles, scarlatina, and smallpox. It is rarely met with after the twentieth year, and then mainly as an effect of external violence. Manifesting itself originally as an inflammation of the lining mem- brane, it may, in its progress, gradually extend to the osseous structures, on the one hand, causing caries and even necrosis; and, on the other, to the brain and its envelops, eventuating in abscess of the former, and in thickening and effusions of the latter. In the milder varieties of the disease, which is much oftener chronic than acute, there is, generally, simply an opaque, thickened, and vascular state of the lining membrane, with an abnormal secretion of mucus, to which, when the inflammation is more severe, is frequently super- added a deposit of pus. In the latter case, especially when the matter does not find a ready outlet through the wall of the auditory tube or the tympanic membrane, suppuration is liable to occur in the lateral sinus, in the brain, and in the arachnoid and pia mater, the morbid action being propa- gated along the veins of the mastoid cells. In children before the third year, the cerebrum is most prone to suffer from abscess from this cause, owing to the imperfectly developed condition of these cells, and their close proximity to this portion of the cerebral hemisphere ; but at a later period, when these cavities are pretty fully formed, the mischief is generally seated in the cere- bellum and its more immediate investments. This distinction, first clearly pointed out, I believe, by Mr. Toynbee, is practically interesting, and there- fore worthy of recollection. When the mastoid process becomes involved, the disease, which may ultimately extend to the petrous portion, if not, at times, also to the squamous, may manifest itself simply as caries, or as caries and necrosis, according to the nature and violence of the morbid action. The matter which forms in disease of the mastoid cells, whether it be limited to these cells, or found also in the lateral sinus, cerebrum, cerebellum, pia mater, or arachnoid membrane, is either of the nature of ordinary pus, or, as not unfrequently happens, is strictly of a strumous character, and often quite offensive. In the lateral sinus it is frequently associated with clotted blood. Collections of pus in the mastoid cells either destroy life by cerebral irrita- tion, or by the induction of inflammation and abscess in the brain and its envelops; or, if the patient survives, they may find a partial vent, by ulcerative action, through the auditory tube or tympanic membrane. More rarely, the fluid is discharged externally along an opening in the mastoid process. Death ^occasionally occurs, in this disease, from pyemia or purulent infection, as in OTALGIA. 407 the interesting cases related by Abercrombie, Watson, Wilde, Bruce, and others. The symptoms of inflammation of the mastoid cells are not always charac- teristic, the disease being liable to be confounded with inflammation of the middle ear and of the auditory canal. In general, it will be observed that the patient has been laboring for some time past under otalgia, or aural dis- charge, probably consequent upon some eruptive fever, and that he bears the marks of dilapidated health, or of strumous disease. The pain, which is often excessive, is referred to the mastoid process or occipital region, both of which are extremely tender on pressure; the patient is feverish, thirsty, and restless; there are buzzing noises in the ear; the head is dizzy and aches violently; and delirium usually sets in at an early stage, always followed, when matter forms, by rigors and coma, if not also by convulsions, especially if there is grave cerebral involvement. Signs of suppuration frequently appear in the auditory canal, even when the pus of the mastoid cells makes no effort to escape by that route or by the drum of the ear, both of which, however, invariably show signs of inflammation at an early period of the attack, the former being red and swollen, and the latter injected and opaque. The treatment of inflammation of these cavities must be conducted upon antiphlogistic principles, with due reference to the state of the system. Leeches and counter-irritation by blisters, with anodyne fomentations, light diet, irritating purgatives, and the antimonial and saline mixture, are our principal remedies, and the sooner they are employed the better. In chronic cases, marked by a strumous taint, a seton or issue in the nape of the neck, and the judicious use of quinia and iodide of iron, will be likely to prove beneficial. A gentle course of mercury, especially in the form of the bichlo- ride, should be tried if the disease bids fair to be unusually obstinate. When the brain is endangered by an extension of the morbid action, the tympanic membrane should be freely punctured, and the mastoid process promptly opened, to afford vent to the pent-up fluid, which is generally the direct cause of the cerebral mischief and of the caries or necrosed condition of the bone. SECT. VIII.—OTALGIA. Pain in the ear or ear-ache is of very frequent occurrence, especially in children and young persons, and may arise from a great variety of causes, as exposure to cold, inflammation of the membrane of the tympanum or of the auditory tube, gout and rheumatism, disorder of the digestive organs, and affec- tions of the teeth. Sometimes it is of a purely nervous or neuralgic character, coming and going in regular paroxysms, like neuralgic pain in other parts of the body. Children, especially such as are of a delicate constitution, are very obnoxious to severe attacks of ear-ache from exposure to cold. The suffering usually comes on in the evening, and is generally aggravated by recumbency, so that the patient is obliged to get up and walk the room, or has to be supported, if he is a child, in his nurse's arms. Ear-ache, often of a very distressing character, is a common attendant upon measles and scarlatina; and under such circumstances, as well as in many others, the pro- bability is that it is merely a symptom of ordinary inflammation of some of the structures of the ear. What corroborates this view is the fact, that the membranes of the tympanum and auditory tube usually afford evidence of the morbid action, the former being red and injected, and the latter exquisitely tender, and the seat of an inordinate secretion of cerumen. Neuralgia of the ear is most common in children, although it may occur at any period of life, and under circumstances apparently the most opposite. Its causes are various, being sometimes purely local, at other times constitu- 408 DISEASES AND INJURIES OF THE EAR. tional, while in a third series of cases they are of a mixed character. During my residence in Kentucky, where neuralgia, in all its forms, is exceedingly common, I met with several cases of this affection, which were unquestionably of a miasmatic origin. The paroxysms observed the same regularity as those of intermittent fever, recurring once in the twenty-four hours, or once every other day, lasting for some time, and then gradually disappearing; being generally preceded by chilly sensations, or even by a severe rigor, followed by a pretty copious sweat, and promptly relieved by the ordinary antiperiodic remedies. In the treatment of otalgia it is a matter of primary importance to obtain, if possible, a clear idea of the nature of the exciting cause, as upon a know- ledge of this must depend the choice of our remedies. If the teeth are at fault they must be extracted, or, at all events, put in order, before we can reasonably hope for a subsidence of the local distress ; and the practitioner who does not inquire into the condition of these organs, in such cases, is guilty of a most important dereliction. The removal of a carious tooth is often followed by instant relief, and a permanent cure. When the attack has been caused by exposure to cold, the most efficient treatment consists in a hot foot-bath and a full dose of Dover's powder, aided by warm drinks and warm applications to the ear. From three to twelve drops of laudanum, ac- cording to the age of the patient, should be introduced, tepid, into the affected organ, where it should be retained by means of raw cotton and a proper posi- tion of the head. When the distress is very violent and the ordinary remedies fail, leeches should be applied behind the ear, and the bowels be opened by a brisk cathartic, followed by an efficient diaphoretic. When the disease is of a strictly neuralgic character, as denoted by the peculiarity of the symptoms, the best remedies will be quinia, either alone or in union with strychnia, arsenious acid, and morphia. When it is de- pendent upon gout or rheumatism, colchicum will be of service. DISEASES AND INJURIES OF THE FRONTAL SINUS. 409 CHAPTER VII. DISEASES AND INJURIES OF THE FRONTAL SINUS. The affections of this cavity may be said, in general terms, to resemble those of the maxillary sinus, and of the nose. The most important are in- flammation, abscess, fractures, foreign bodies, polyps, hydatids and encepha- loid ; but, owing to their great infrequency, their diagnosis is generally very difficult, and their treatment unsatisfactory. 1. Inflammation of the frontal sinus may be provoked by external injury, as a fall or blow on the forehead ; but, in general, it is caused by the effects of tertiary syphilis, or by an extension of disease from the nose by continuity of structure through the Schneiderian membrane. However induced, it is characterized by a sense of weight and fulness, and by a dull, heavy, aching pain along the eyebrow, accompanied, in most cases, by sneezing and a dis- charge of watery mucus from the nose, with lachrymation and suffusion of the eye, more or less cephalalgia, and other evidences of indisposition, such as attend the more severe forms of coryza. An unusual amount of mucus is no doubt poured out into the sinus, and when the inflammation is at all severe, this, acting obstructingly, or not finding a ready outlet, may seriously aggravate the patient's suffering. The treatment must be by leeching over the affected sinus, active purga- tion, and diaphoretics ; aided, as the morbid action declines, by sternutatories with a view to their revulsive effect upon the mucous membrane of the nose. 2. When the inflammation passes into abscess, the occurrence will be de- noted by the increase of the local suffering, the pain assuming a throbbing, tensive, pulsatile character, and by excessive headache, delirium, and rigors, followed by high febrile disturbance. The forehead and eyebrow are swollen and tender, and, if the matter does not soon find an outlet, an erysipelatous blush will appear upon the surface, an almost unerring sign of the nature of the disease. If the case be misunderstood, or improperly treated, the morbid action may extend to the brain, or cause caries or necrosis of the walls of the sinus, as occasionally happens when the abscess is the result of tertiary syphilis. The pus may find an outlet through the nose, or through the anterior wall of the sinus, though such an event must necessarily be extremely uncommon. Occasionally, as when the quantity is unusually great, it passes into the other sinus, by breaking down the intervening septum. When it flows off by the nose the patient is apprised of the fact by the use of his handkerchief. The treatment must be conducted according to the ordinary principles of practice. If the case be urgent, as indicated by the cerebral disturbance and the erysipelatous condition of the forehead and eyebrow, the soft structures should be freely divided and a small opening made, by meaus of a suitable trephine, into the most dependent part of the sinus, which may afterwards, if necessary, be injected with anodyne and detergent lotions to promote the 3. Fractures of this cavity are uncommon. They may be caused by falls, blows, kicks, or gunshot, and must be treated upon the same general prin- ciples as fractures in other parts of the skull. AVhen the outer table is de- 410 DISEASES AND INJURIES OF THE FRONTAL SINUS. pressed, so as to occasion serious disfigurement, elevation must be attempted. either with the lever alone, or with this instrument and the trephine. Loose splinters and any foreign matter that may be present should, of course, be promptly and thoroughly removed. 4. The frontal sinus is occasionally the receptacle of foreign bodies, cither formed within, or introduced from without; more generally the latter. Thus, Bartholin speaks of having met with earthy concretions, similar to those which are sometimes found in the nose. Several authors assert that they have seen worms in it, the number, in one case, exceeding seventy; their development being doubtless due to larvae deposited in the nose, whence the maggots crept into the frontal sinus. The annals of surgery supply us with a number of examples of the lodgment of balls in this cavity in cases of gunshot wounds; and there are also several instances on record where the end of a knife-blade or scissors, broken off in its passage through the skull, was arrested in it. The presence of a foreign body in this situation must necessarily be pro- ductive of pain, a sense of weight and fulness, and probably also more or less tumefaction in the forehead and eyebrow. No diagnostic value can, however, be attached to these symptoms. When the foreign body has been introduced from without, the nature of the case may be easily determined, simply by its history. The proper remedy in these cases is, of course, extraction, a suitable open- ing being made into the anterior wall of the sinus by means of a trephine. 5. Polyps, of a gelatinoid and fibrous structure, are sometimes developed in the frontal sinus, or extend into it from the nose, forcing apart its walls, and causing more or less pain and deformity, but affording no pathognomonic signs. In time the overlying bone becomes softened and attenuated by the pressure of the tumor, crackling under the finger like parchment. Removal is effected by the knife and gouge, a crucial incision being made through the integuments of the forehead so as to admit the surgeon's finger and instru- ments. 6. Langenbeck and Brunn have each published the particulars of a case of what they call hydatids of this sinus, but which, I suppose, were really nothing but serous cysts. The tumor during the progress of its development encroaches upon the forehead and roof of the orbit, pushing the eye forward and downward, and thus occasioning serious deformity. The diagnosis must necessarily be obscure. As the disease advances, however, the anterior wall of the sinus will be rendered so thin as to yield under the pressure of the finger, and admit of the detection of fluctuation. In doubtful cases important information might be elicited by the exploring needle. The proper remedy is excision. Robert Keate, in 1819, published, in the tenth volume of the London Medico-Chirurgical Transactions, the particulars of a case of so-called hyda- tids of the frontal bone, in a girl eighteen years old, but the tumor seems to have been developed in the areolar texture, and not in the sinus, which, however, became accidentally involved during the progress of the disease. 7. Encephaloid of the frontal sinus is probably more common than is gene- rally imagined. I have myself seen only one case of it. The patient was a gentleman, upwards of sixty years of age, who, twelve months previously, had been seized, without any assignable cause, with what he supposed to be an attack of erysipelas of the forehead and face. On recovering from this, be noticed an unusual fulness over the left eyebrow, attended with great hard- ness and excessive pain. The lids continued to swell, and the left nostril, by degrees, became obstructed and the seat of a thin, sanious discharge, more or less profuse, and, at times, quite fetid. At length several openings formed upon the most prominent part of the tumor, giving vent to thick, yellowish DISEASES AND INJURIES OF THE FRONTAL SINUS. 411 pus, and readily admitting of the passage of a probe into the nose. Upon enlarging these openings, the sinus was found to be occupied by a soft, fungous mass, the overlying bone being softened and disintegrated. The morbid growth presented all the characteristics, physically and microscopi- cally, of encephaloid. The patient passed out of my hands in a few weeks, and died soon after, completely exhausted. Of scirrhus, colloid, and melanosis of the frontal sinus the annals of surgery do not, so far as known, contain a solitary example. 412 DISEASES OF THE NOSE AND ITS CAVITIES. CHAPTER VIII. INJURIES AND DISEASES OF THE NOSE AND ITS CAVITIES. The nose is subject to various affections. The most common are hemor- rhage, ulceration, polyps, hypertrophy of the mucous membrane, certain mal- formations, and foreign bodies. For examining the anterior portion of the nasal cavity, the best instrument is the bivalve ear speculum, delineated at page 316. The patient should be seated upon a chair, with the head thrown well back, Fig. 236. *n order that the light may readily penetrate the nares. If the sun is not sufficiently bright, the in- spection may be conducted with the aid of a wax taper, or, what will be better, a suitable reflector. The examination of the posterior nares and the adjacent parts may be very satisfactorily conducted with the rhinoscope, delineated in fig. 236, and de- vised by Dr. Simrock, of New York. It consists, as the drawing indicates, of two branches, one of which terminates in a speculum, while the other runs out into an oblong, concave spatula for raising the soft palate. When the instrument is properly ad- justed, it is easy to obtain a very good view of the back part of the nasal cavities, the orifices of the Eus- tachian tubes, and the posterior aspect of the velum. A strong light is, of course, required, and it need hardly be added that that of the sun is the best; but in cloudy weather, and at night, the object may be very readily attained by means of gas light thrown into the fauces with a strong concave reflector. The great advantage of this instrument is its simplicity, and the fact that it may be managed with one hand, leaving thus the other free for the application of remedies. 1. Hemorrhage.—The mucous membrane of the nose, from its great vascularity, is a frequent seat of hemorrhage. The exciting cause may be external Dr. simrock's rhinoscope. violence, as a blow, with or without fracture of the nasal bones, or mere plethora of the system, nature endeavoring to find a spontaneous outlet for the redundant fluid. Young persons, of both sexes, are particularly prone to this discharge, about the period of puberty. Occasionally the flow is vicarious of the menstrual flux. The amount of bleeding varies in different instances, from a few drachms to a number of ounces. In the latter case, and especially when the discharge is of frequent recurrence, excessive debility, and even loss of life, may be the result. The blood generally proceeds from one nostril only; very rarely from both. The milder forms of nasal hemorrhage require no special interference; nor HEMORRHAGE — PLUGGING. 413 does the practitioner interpose his authority when the discharge is vicarious, or an effort of nature to rid the system of an undue supply of blood. It is only when the discharge is very abundant, or slight, yet so frequent in its recurrence as to tend to injurious consequences, that an attempt should be made to suppress it. Writh this view perfect quietude of mind and body is enjoined, the head and shoulders are thoroughly elevated, and all stimulants, whether in the form of food or drink, are interdicted. A large bladder, par- tially filled with pounded ice, or a refrigerating lotion, is applied to the head and nape of the neck, and a lump of ice, enveloped in flannel, to the nose. Sometimes a small piece of ice may advantageously be inserted into the affected nostril, or held against the roof of the mouth. Along with these means the patient takes, every three hours, two grains of opium and two of acetate of lead, until the system has become fully impressed with the narcotic, when it may be either entirely suspended, or administered in smaller quan- tities, and at longer intervals. One of the most important indications, in this and all other hemorrhages, is to quiet the heart's action, and there is no medicine so well calculated to do this as opium. To produce the desired effect it should be given in full doses, repeated from time to time as circum- stances may require. When there is reason to believe that there is a want of coagulability of the blood, the best remedies will be perchloride of iron, or, what I like equally well, the tannate of that metal, the dose of the former being three grains, and of the latter, five or six, every three or four hours. The bowels are, of course, not neglected; and where the bleeding is con- nected with, or dependent upon, actual plethora, blood is taken freely from the arm, on the principle of derivation and direct diminution of vascular supply. Hot pediluvia, diaphoretics, and vesication of the neck are some- times eminently serviceable. In a very obstinate case of epistaxis, resisting almost every conceivable measure, even plugging, Dr. Davenport, of Iowa, promptly arrested the hemorrhage by the injection of a quantity of the undi- luted perchloride of iron. When the above measures fail, or when as much blood has already been lost as the system can bear, direct interference by obstructive means is required, and that without delay. The patient being supported upon the edge of the bed in the semi-erect posture, a double wire, very thin and flexible, and composed either of silver or iron, is passed along the floor of the nostril into the fauces, where it is to be seized with the finger introduced into the mouth. A strong double ligature, tied over a piece of soft sponge, or a roll of cotton, charpie, or patent lint, is then secured to the loop,, and drawn up into the nose by retracting the wire. The finger being still in the mouth assists in carrying the tampon round the palate and in adjusting it in the posterior orifice of the naris. The wire is now detached, and the operation completed by tying the ends of the thread over another plug in front. Both outlets being thus effectually occluded, the hemorrhage must necessarily cease as soon as the nasal cavity is filled with blood, which thus serves to compress and control the bleeding vessels. The parts are not disturbed until the end of the third day, when the tampons are removed, and the nasal cavity washed out with some mildly astringent lotion, introduced with the syringe. When no wire is at hand, the operation of plugging the nose may be per- formed with a gum-elastic catheter, a piece of whalebone, or a stick of wood; in fact, with almost anything. The best contrivance, however, of all, is that represented in fig. 231, and known as Bellocq's instrument. It consists of a silver tube, about six inches long, containing a movable rod of .nearly the ^ame length, with a steel spring surmounted by a silver knob, with a hole in [ts centre for the attachment of the ligature which holds the posterior tampon. the instrument is one of the most perfect imaginable, and should find a place 414 DISEASES OF THE NOSE AND ITS CAVITIES. in every surgeon's armamentarium. Fig. 238 exhibits the manner of apply. ing it. With any of the means now described the operation in question may always be promptly and safely performed, and the practitioner who allows his patient Fig. 237. W-—__■__—^=^3 Bellocq's canula. to bleed to death from such a cause should, provided he has had a fair oppor- tunity of exerting his skill, be held personally responsible for his life. I have seen one man, full of health, and in the prime of existence, perish from nasal hemorrhage, which might have been easily arrested by this simple procedure. Fig. 238. Plugging of the nose. Care must be taken after this operation that the plugs are not retained too long, as they would be a source of irritation and mischief, provoking the formation of matter, which would soon become excessively offensive, tainting the atmosphere, and poisoning the system. I have seen several cases where, from this cause, the patient lost his life, being seized with a low form of fever, attended with delirium, which nothing could arrest. In one of the cases there were marked symptoms of pyemia. To prevent these mishaps the plugs should be withdrawn at the end of forty-eight hours, and the nostrils be well syringed with some mildly detergent and deodorizing lotion, when, if necessary, substitution should be effected. When there is much discharge a daily renewal of the dressings may be proper. It is impossible to direct too earnest attention to this subject. 2. Ulceration.—Ulcers of the nose, chiefly of a strumous and syphilitic nature, are sufficiently common, and from their rebellious character, and fetid discharges, are often a source of great annoyance, both to the patient and the practitioner. Seated originally in the mucous membrane, they gradually ex- tend in depth, until, in many cases, they involve all the component structures, cartilage and bone, as well as fibrous tissue. The disease generally com- ULCERATION — OZiENA. 415 mences high up in the nose, beyond the reach of the eye of the observer; but not unfrequently its first effects are displayed upon the inferior turbinated bone, or the nasal septum. In the strumous variety one side alone may suffer, whereas in the syphilitic, nearly always, both are implicated. Both forms are often met with early in life, and hence it is by no means always easy to distinguish them from each other. Perhaps, the most important diagnostic characters are, that in syphilitic ulceration there is, ordinarily, greater de- rangement of the general health, more extensive involvement of structure, and more abundant discharge, than in the strumous variety. Useful information may also, commonly, be derived from the history of the case and the tempera- ment of the patient, though the latter is frequently of negative value, as scrofula and syphilis may coexist. The discharge attendant on this disease is noted for the intensity of its fetor, whence the term ozcena, by which the affection is usually designated. It is generally of a thin, sanious nature, irritating, and profuse, requiring the frequent use of the handkerchief, rendering the poor sufferer disagreeable both to himself and to his neighbors. During sleep it often descends into the fauces and the stomach, causing nausea and sometimes even vomiting. In the more aggravated forms of the affection large quantities of inspissated mucus pass off, or, collecting in the nasal cavities, form thick, brownish incrustations, which drop off every fourth, fifth, or sixth day, only to be suc- ceeded by another crop. Portions of cartilage and bone, or even entire bones, often die, and slough away. In syphilitic ulceration, more frequently than in the strumous, the ravages of the disease often extend to the proper bones of the nose and palate, and occasionally even to those of the face, eventua- ting in horrible and irremediable deformity. The treatment of ulceration and ozaena must be regulated by the nature of the exciting cause. This, therefore, should always, if possible, be determined as a preliminary step. It should not be forgotten that a bloody and fetid discharge may proceed from the nose in consequence merely of the presence of a foreign body, retained secretion, or disorder of the general health. Such cases are managed on general principles ; they require no specific remedies. But it is otherwise when the disease is dependent upon a tainted state of the system. Here, a long course of treatment, involving the exercise of much patience on the part of the sufferer, and great skill on the part of the surgeon, is usually necessary. W^here the strumous character of the malady is well settled, the different preparations of iodine, barium, and cod-liver oil are brought into requisition. If, on the contrary, there is reason to believe that the disease has been induced by syphilis, mercury and iodide of potassium should be employed, to an extent commensurate with the exigencies of each particular case. During the height of the morbid action, leeches and active purgation, with full doses of opium, may be demanded. In a majority of instances, however, stimulants, and not depletory measures, are necessary, as is evident from the pallor of the countenance, and the emaciated condition of the frame. To allay fetor, and assist in establishing healthy action in the affected parts, various lotions are employed. The best are solutions of chlorinated soda, permanganate of potassa, chloride of zinc, nitric acid, nitrate of silver, and sulphate of copper. These fluids, properly tempered, are thrown twice a day into the nostril with a large syringe, the head being held forward over a basin, and thorough contact of the liquid with the inflamed surface being effected at each operation. The rule is not to permit the injection, in any case, to ™arj;beyond a minute, and, as one article becomes inert, to substitute another. the black and yellow washes, as they are termed, and which are so useful in certain forms of syphilitic ulcers in other parts of the body, are objectionable '" this, on account of their liability to descend into the stomach, and thus 416 DISEASES OF THE NOSE AND ITS CAVITIES. lead to ptyalism. For many years past I have been in the habit of employ- ing, with signal benefit, in both varieties of the disease under consideration, a solution of sulphate of copper and tannin, in the proportion of one-fourth of a grain of the former and three grains of the latter to the ounce of water. When there is much fetor, a small quantity of chlorinated soda may be ad- vantageously added to the other ingredients. In old, obstinate cases, a rapid cure may sometimes be effected by washing out the nostril freely, twice a day, with a solution of chloride of zinc, in the proportion of about one drachm to five or six ounces of water. When the diseased spot can be reached, as it may be, when seated in the anterior and inferior part of the nose, the nitrate of silver and sulphate of copper may be applied in substance, or the sore may be touched very lightly with the dilute acid nitrate of mercury. Some of the milder unguents, as the citrine and calamine, may prove service- able by softening the scabs, and promoting healthy granulation. When there is swelling, with pain or tenderness in the nose, leeching will be serviceable. 3. Hypertrophy___Hypertrophy of the mucous membrane of the nose is observed chiefly in children and young persons of a weakly, strumous consti- tution. Its most common site is the anterior extremity of the inferior tur- binated bone; it consists of an enlarged and thickened state of the mucous tissues, dependent upon a process of hypernutrition, along with effusion of sero-plastic matter. The subjacent bone occasionally participates in the dis- ease, becoming soft, porous, and expanded. Upon looking into the nostril with the aid of a strong light, the part presents the appearance of a small tumor, of a scarlet color, and of a spongy consistence, with numerous little vessels ramifying over its surface. It is generally of slow development, and the only inconvenience which it produces is its mechanical obstruction, which is sometimes so great as to lead to considerable embarrassment of breathing in the corresponding cavity. Both nostrils occasionally suffer, though seldom in an equal degree. The only affection with which it is liable to be con- founded is polyp, but from this it is always easily distinguished by its site, scarlet color, and fixedness. The disease may continue, with perhaps little change, for years, and finally disappear spontaneously. The remedies best adapted to its cure are purgatives, and the different preparations of iodine, especially the iodide of iron, with a leech occasionally to the part, and the semi-weekly application of the solid nitrate of silver. Punctures and astrin- gent lotions are sometimes beneficial. 4. Malformations.—The most important malformation of the nose, sur- gically considered, relates to its septum. It consists of a kind of lateral curvature of the cartilaginous portion of the septum, with or without hyper- trophy of its anterior extremity. In consequence of this deviation, the corresponding cavity is diminished in size, and the opposite one propor- tionately enlarged. Cases occur in which the obstruction, thus produced, amounts almost to complete occlusion, the patient being obliged to breathe nearly entirely through the unaffected nostril. The only remedy for this affection is excision of a portion of the offending septum, care being taken to avoid perforating it. The best instrument for performing the operation is a narrow, probe-pointed bistoury, with which the necessary slicing is safely and expeditiously executed. When the obstruction is seated at the very orifice of the nostril, a tolerably extensive dissection may be required in order to effect the desired object. Congenital imperforation of the nostrils is uncommon; much more so than that of the ear, anus, urethra, or vagina. The occlusion may be caused sim- ply by a continuation of the integuments, or by the presence both of skin and of fibrous tissue. In the former case, relief is sought by a cautious incision, and the subsequent use of the bougie; in the latter, by excision, provided the obstruction does not extend too far back, in which event it should be let alone. CALCULI — FOREIGN BODIES. 411 5. Calculi.—Nasal calculi, technically termed rhinolites, are very infre- quent; they are usually situated in the inferior meatus, are of an irregular Bhape, and vary from the volume of a pea to that of a pigeon's egg. Their surface is rough, and they are of a black, gray, or brown color, their centre often consisting of some foreign body, as the root of a tooth, a bead, or a cherry-stone. Their composition is phosphate and carbonate of lime, cemented by animal matter. These calculi are usually solitary, but sometimes they are multiple, or form in each nostril. Their presence is productive of the usual symptoms of obstruction of the nose, with more or less discharge of a sanious and fetid character. Wrhen of considerable bulk, they may cause a good deal of pain and inflammation in the neighboring structures. Simple inspection of the nostril generally suffices to detect them; when this fails, a probe is introduced, which, on coming in contact with the extraneous body, produces a characteristic click, not unlike what results from the contact of a sound with a vesical calculus. Extraction is accomplished with a hook, bent probe, or polypus-forceps; or, the attempt being unsuccessful, the concretion is pushed into the fauces, a finger being previously placed there to receive it. Sometimes expulsion is effected during a fit of sneezing. 6. Foreign Bodies.—Yarious substances may find their way into the nasal cavities of children, being generally placed there as a matter of amusement. The most common of these are grains of corn, peas, beans, beads, pellets of paper, buttons, fruit stones, rags, and pieces of ribbon. If allowed to remain for any length of time, they always induce inflammation, and sometimes even ulceration of the lining membrane, with more or less pain, and a sanious, fetid discharge. In a case reported by Dr. Hays, the substance, a glass button, was retained upwards of twenty years, keeping up irritation during all that time. Their ordinary site is the anterior portion of the nostril, between the turbi- nated bone and the nasal septum, where they are often firmly impacted, and consequently difficult of spontaneous extrusion. Should the child, or an in- experienced person, attempt extraction, as too often happens in such cases, the foreign body will only be pushed farther in, and in this way it frequently passes entirely beyond the reach of the sight, being arrested, perhaps, pretty high up in the cavity, or forced against the floor of the inferior meatus. Whatever the foreign body may be, it should always, for the reasons above mentioned, be extracted as speedily as possible. If the child is sufficiently old to co-operate with the surgeon, he is requested to take a pinch of snuff, and, during the effort of sneezing which is sure to follow, expulsion is often promptly effected, especially if care be taken at the same time to occlude the sound nostril by means of the finger. If the substance obstructs the passage completely, it may often be promptly dislodged by insufflation. For this purpose, the unaffected nostril is closed by external pressure, when the sur- geon blows forcibly with his own mouth into the mouth of the patient, the current of air thus established being sufficient to cause extrusion. In gene- ral, however, the removal of the foreign body is easily enough effected with a small, flexible, blunt, double hook, a probe bent at the end, or a piece of annealed wire, formed into a loop. The patient being in a strong light with the head inclined somewhat backwards, the instrument is carried obliquely upwards, on a line with the external nose, above and behind the foreign body, which is then extruded by a kind of jerking movement of the hand. The great fault usually committed by the surgeon, in his attempts at extraction, is that he inclines the instrument too horizontally, whereby he is sure to push the intruder only farther into the nostril. In the American Journal of the Medical Sciences for April, 1860, Dr. W. «■ King, of the Navy, gives an instance of the expulsion of a cherry-stone rom the nose of a child during the action of an emetic, the mouth being tightly closed at the moment of emesis with a handkerchief. vol. ii.—27 418 DISEASES OF TnE NOSE AND ITS CAVITIES. When the extraneous substance is out of sight, it may be necessary to wash it away with a stream of water from a syriuge, or to push it into the throat, and extract it through the mouth, as in a case recently communicated to me by Dr. William II. Pancoast. The patient was an Irish servant girl, who, in stooping over a pincushion, accidentally ran a hair-pin, two inches and a half in length, into the nose. When he reached her, she was bleeding profusely, and, on expanding the nostril, he could barely discern the point of the pin, which he immediately removed with a pair of forceps, aided by the index finger. In a case mentioned to me by Dr. J. J. Moorman, of Virginia, the foreign body, a large bean, introduced a few days before and pushed far back into the nostril by the previous efforts at extraction, was propelled forward until within the reach of the forceps, by closing the mouth with the hand, so as to make the patient, a child two years old, breathe entirely through the nose. Finally, it may be proper, in order to effect extraction, if the patient is very fractious and unruly, to administer chloroform; or, if this be objectionable, to secure his body with a stout apron, as in the operation for hare-lip. 7. Polyps.—The nose is a frequent seat of polyps, more so, in fact, than any other mucous cavity of the body. Several varieties of these morbid growths have been described by authors, but without any foundation in nature; for there are, in truth, only two, the gelatinoid and fibrous, which possess sufficiently distinctive characters to entitle them to separate con- sideration. The gelatinoid polyp, fig. 239, resembles, as its name imports, a mass of jelly, or, more closely still, a common oyster. It is of a soft, spongy con- sistence, of a white, greenish color, somewhat translucent, and invested by a prolongation of the mucous membrane. Its surface, which is generally smooth, or smooth at one point and rugose at another, nearly always presents a fewr small, straggling vessels, which serve to impart to it a peculiar striated appearance. In its shape the tumor is ordinarily somewhat pyriform, its attachment being by a narrow pedicle, while the broad, bulbous portion hangs downwards and forwards into the nos- tril. It almost constantly takes its rise from the superior turbinated bone; and sometimes exists in great numbers, though occasionally it is solitary. When carefully examined, it is observed to consist of a cellulo-fibrous sub- stance, the cavities of which are occupied by a sero-albuminous fluid, much of which drains off on puncturing the investing membrane. Owing to this peculiarity of structure, the tumor is of hygrometric character, expanding in damp, foggy weather, and shrinking in dry. It is void of sensibility, breaks easily under pressure, is most common in persons after the age of forty, and frequently exists simultaneously in both nares. Its volume is usually diminu- tive. A polyp of this kind occasionally contains fibro-cartilaginous concre- tions, as in a specimen in my private collection, taken from an elderly gen- tleman. The fibrous polyp, of which the annexed cut, fig. 240, from a specimen in my collection, exhibits a well-marked example, occurs at nearly every period of life ; I have seen it in children under fourteen years of age, in adults, and in old people. More rare than the gelatinoid variety, it generally exists singly, is very prone to reappear after removal, and often exhibits a malig- nant tendency. It is ordinarily attached by a broad base to the superior Gelatinoid polyp. polyps. 419 turbinated bone, but occasionally it springs from the septum, floor, or wall of the nose. In the majority of the cases that have fallen under my notice, Fig. 240. Fibrous polyp. it was situated in the posterior part of the nostril, so as to be distinctly per- ceptible in the throat. Both sides may suffer simultaneously, but this is the exception, not the rule. The structure of the tumor is characteristic ; it is composed of fibres, of a white, glistening color, exceedingly firm and tough, closely knit together, and most intricately arranged. Interspersed among these fibres are numerous vessels, both arterial and venous, the walls of which are very brittle, and, therefore, liable to give way under the most trifling acci- dent. Owing to this circumstance, this form of polyp is the seat of frequent, and, at times, of profuse hemorrhages. For the same reason, it is always, in its recent state, of a dark red, purple, or modena color. W7hen permitted to pursue its course, the tumor may acquire an enormous bulk, descending into the throat, protruding externally, and pressing against the walls of the nasal cavities in every direction. At this stage of the disease, the features are often frightfully disfigured, presenting that peculiar appearance, seen in fig. 241, denominated "frog face." A fibrous polyp, the history of which has been admirably elucidated by Flaubert, Huguier, Nelaton, Robert, and other French surgeons, occasion- ally springs from the base of the skull, the petro-occipital suture, the inner surface of the great wing of the sphenoid bone, or even from the upper part of the spinal column, projecting, as it advances, into the nose and pharynx, and hence called the naso-pharyngeal polyp. It is of a very hard, dense texture, of a bluish or purplish color, and capable of acquiring a large bulk, its growth being rapid and uncontrollable by medicine. When extirpated it is apt to return, although now and then the operation is followed by per- manent relief. A few instances are recorded of a spontaneous cure by sloughing. The tumor is usually attached by a broad base, closely identified with the periosteum of the part from which it springs. In its progress, it may extend down into the larynx, or, separating the muscles of the pharynx, pass into the zygomatic fossa and the face, although such an occurrence is extremely uncommon. No age appears to be exempt from its attacks. The symptoms of polyp are such as attend obstruction of the nose from any other cause. The first intimation which the patient ordinarily has of the disease is a sense of fulness and weight in one of the nostrils ; he feels as if there were some fleshy substance in it, interfering with the transmission of air, and, as a necessary consequence, he makes frequent and abortive efforts to clear his nose, using his handkerchief, perhaps every half hour. Gradu- ally he observes some discharge, at first of a mucous, then of a purulent, and "nally of a sanious character, fetid, and profuse. The voice seldom remains 420 DISEASES of the nose and its CAVITIES. natural; generally it is nasal, indistinct, and even snuffling; the sleep is em- barrassed, and attended with loud snoring, the head being thrown back as in Fig. 241. Frog-face ; the polypi causing much deformity by expansion of the bones, and change of relative position in the soft parts. enlargement of the tonsils; the nose is blown with difficulty, and, during every effort of the kind, most of the contents of the nostril are forcibly pro- jected into the fauces; the sense of smell is materially impaired; and eventu- ally, as the growth spreads, the affected cavity is completely deprived of its functions. At this advanced stage of the disease, the patient occasionally experiences lachrymation from the pressure of the tumor on the nasal duct; partial deafness, from pressure on the Eustachian tube ; and slight dizziness, from pressure on the jugular vein. The symptoms above enumerated are, unfortunately, not characteristic; they may be, and often are, simulated by other affections. Thus, the person may labor under enlargement of one of the turbinated bones, hypertrophy of the mucous membrane, malposition of the nasal septum, or malignant dis- ease, either of the nose itself, or of the maxillary sinus; or, finally, there may be a foreign body in the nose, causing serious obstruction, and profuse, sanious, and fetid discharge. To make sure of the diagnosis, the polyp must be seen or felt. Protrusion at either opening of the nose at once decides the matter; but, in the absence of this, a careful inspection is made with the speculum, in a strong light, with the head inclined backwards; a grooved director is used, if necessary, to move the tumor about, and determine its size, consistence, and point of attachment. If the tumor is covered with POLYPS. 421 mucus, clearance is first effected by blowing the nose, or, this failing, by means of a pellet of cotton wrapped round the end of a probe. When the polyp lies far back it may project into the fauces, and thus satisfactorily reveal its character; should it not yet have descended, the index finger is introduced into the mouth, and carefully carried round the velum of the palate. There are several circumstances which generally serve to distinguish a gelatinoid from a fibrous polyp. In the first place, they differ essentially in their complexion ; the former being always white, like an oyster, a lump of mucus, or a mass of jelly, while the latter is of a deep red, purple, or modena color. Secondly, the gelatinoid polyp is generally smaller, and, consequently, its existence less marked in dry than in damp weather, which is not the case with the fibrous tumor, which is not affected by atmospheric vicissitudes of any kind. Thirdly, the discharge is always less profuse, less offensive, and less bloody in the gelatinoid, than in the other form of the disease ; and finally, there is rarely any involvement of the general health in the former affection, while in the latter it seldom escapes,-especially in the advanced stages. There is another circumstance which, perhaps, should not be omit- ted in this enumeration; it is, that the fibrous polyp usually grows much more rapidly than the other, and that it has a much greater tendency to en- croach injuriously and disfiguringly upon the surrounding structures. Of the causes of nasal polyps nothing is known. The disease has often been ascribed, among other circumstances, to the effects of external injury, the employment of snuff, the habit of picking the nose, and the irritation of decayed teeth; but it is very questionable whether they are capable of exert- ing such an influence. However this may be, it is certain that most growths of this class are developed without any appreciable cause. Both sexes are liable to them, but males suffer much oftener than females. Both varieties of tumor may attain a large size in a few months; or, after having made some progress, remain stationary for an indefinite period. I have seen a gelatinoid polyp attain the velume of a hen's egg in less than a year. There is no doubt that a gelatinoid polyp of the nose is occasionally ame- nable to local remedies ; but the cures thus affected are uncommon, and can- not serve as rules of practice even in ordinary cases. The best plan, there- fore, is never to waste any time in this way, but to proceed at once to the Fig. 242. Polypus-forceps. removal of the tumor. Fortunately, this is generally easily effected by tor- sion, with the forceps. The instruments which I have long used for this pur- pose are represented in the adjoining sketches, fig. 242. They are very light 422 DISEASES OF THE NOSE AND ITS CAVITIES. and slender, being seven inches and a half in length, and provided with large rings. The blades, which are nearly three inches long, are fenestrated, and grooved internally, with well serrated margins. The great fault of the com- mon polypus-forceps is that it is too short and clumsy. When the tumor is situated in the upper and back part of the nose, a curved instrument may sometimes be advantageously employed. The mode of applying the forceps is represented in fig. 243. Fig. 243. Mode of extracting a nasal polyp. The patient being seated upon a chair, in a strong light, with the head supported upon the breast of an assistant, the operator introduces the forceps as high as the origin of the tumor, which he then seizes by expanding the blades over its pedicle. Assuring himself that the instrument embraces nothing that ought not strictly to be within its grasp, he turns it gently upon its axis, or round and round, until he succeeds in detaching the morbid growth. Were he to attempt to pull it off, he might tear away not only the tumor, but, perhaps, also a large portion of mucous membrane, if not, also, even a part of one of the turbinated bones. The whole procedure should, therefore, be conducted in the most careful and gentle manner. If the first attempt is unsuccessful, or if a part of the polyp is broken off, the instru- ment is reinserted, again and again, until the object is accomplished, not a particle of the growth being left behind. If more tumors than one exist, the others are dealt with in the same way, it being desirable, if possible, to effect complete clearance at one sitting. The blood which flows during the opera- tion, and which has a tendency to conceal the polyp, is easily dislodged by blowing the nose, the sound nostril being compressed at the time to render the effort more effective. If riddance be impracticable in this wise, a stream of water, or vinegar and water, is thrown up with a large syringe. It is rarely necessary to suspend the operation on account of hemorrhage; the bleeding is usually slight, and nearly always ceases spontaneously in a few minutes. When it threatens to be copious and persistent, plugging of the nose may be proper. When the tumor is situated far back in the nose, or hangs down into the fauces, it may occasionally be broken off with the index-finger, introduced into the mouth, and carried round the palate. I promptly succeeded in re- moving, not long ago, in this way, a large gelatinoid polyp from a youth of seventeen; but I have no idea that the procedure would answer in the fibrous POLYPS. 423 polyp, or even in a gelatinoid with a broad base. In the case just adverted to, the tumor had a very narrow footstalk, attached to the posterior ex- tremity of the inferior spongy bone, and was, therefore, easily torn asunder. Nothing can be accomplished here with the forceps, however ingeniously curved and dexterously usedj there is no space for their application. When, therefore, the means just described are unavailing, removal must be effected with the double canula and a stout silver wire, represented in fig. 244. The Fig. 244. Double canula. instrument, which is four inches and a half in length, is conveyed along the floor of the nostril as far as the fauces, when the loop of the wire is properly expanded, and passed round the neck of the tumor, as near as possible to its origin. The ends of the wire are then firmly but cautiously pulled, and secured to the shoulders of the cauula. The annexed cut, fig. 245, exhibits Fig. 245. Mode of ligating a nasal polyp. the mode of applying the instrument. The strangulation is seldom effected under three or four days, and, in the meantime, it is necessary that the wire should be frequently tightened. When the polyp is nearly ready to drop off, the hnger is introduced into the fauces, and the canula is rotated on its axis, to promote the separation, lest it should take place during sleep, and thus permit the tumor to pass into the windpipe or oesophagus. In the gelatinoid iorm oi the disease, the safest and most expeditious plan is to twist off the Poiyp the moment it has been fairly embraced with the wire. I have occa- sionally succeeded in removing fibrous polyps, when situated far back on the com f -n°Se' °r at the Posterior nares, with an instrument shaped like a ^mmon chisel, not more than two lines in width, and beveled on one side at Bcrnn iff'?' 8°-aS t0 aff°rd a moderately sharP edge- The growth is easily pea ott from its connections, especially if counter-pressure be made upon 424 DISEASES OF THE NuSE AND ITS CAVITIES. it with the index-finger in the fauces. The operation, however, is generally attended with a good deal of bleeding, rendering it occasionally necessary to resort to plugging the nose. When the fibrous polyp is of extraordinary bulk, and quite inaccessible by the means now pointed out, its reraoval can be effected only by the knife, or the knife and saw. Wrhen the disease is malignant, no operation should be attempted, not even with a view to temporary alleviation ; much blood will be likely to be lost, the manipulation will be tedious and painful, and the patient may die on the table. Under opposite circumstances, the operation is performed at all hazards, and with a prospect of a favorable issue. An incision, in the form of an inverted J., is made along the junction of the nasal and maxillary bones, commencing just below the lachrymal sac, and terminating a little below the level of the nostril, the flaps being dissected up, and held asunder. No particular treatment is required after the more common operations of this kind ; there is usually very little inflammation or discharge, and in a few days the patient is able to go about his business. To prevent relapse, it is customary to inject the nose once a day with some astringent wash, as solu- tions of nitrate of silver, zinc, copper, or alum. The practice may, however, in general, be advantageously dispensed with ; it is only when there is evi- dence of persistent morbid action that it is likely to prove beneficial. In the gelatinoid variety of the affection, where the tendency to regeneration is some- times most remarkable, and also in the gregarious form of this disease, I have occasionally broken off as much as one-half, and even two-thirds of the im- plicated spongy bone, believing that this procedure was greatly preferable to the frequent repetition of the ordinary operation. For the removal of the naso-pharyngeal polyp two distinct operations have been proposed; one by Nelaton, consisting in the division of the soft and hard palate ; the other by Flaubert, of Lyons, consisting in the excision of the upper jaw, first practised by him in 1840, and now recognized as a perfectly legitimate procedure in this formidable variety of morbid growth. The former method is more particularly applicable when the tumor is situated partly in the nose and partly in the pharynx, or when it springs from the middle of the base of the skull, the superior portion of the spine, or the in- ternal surface of the pterygoid process, at the same time sending a prolonga- tion into the pharynx. It is executed by dividing, first, the soft palate in its whole length, and then, by means of the saw and pliers, so much of the hard palate as may be necessary to afford complete access to the parts, the mucous membrane having previously been raised from the bone. Flaubert's opera- tion is required when the polyp springs from the petrous portion of the temporal bone, the petro-occipital suture, or the margins of the foramina lacera. In some cases, as when the morbid growth is of extraordinary size, the entire bone is obliged to be sacrificed, whereas in others partial excision will suffice. Whatever process be adopted, the surgeon cannot fail to perceive the necessity of thorough work. With this view, after the main tumor has been removed, its base should be completely scraped away, along, if possible, with the mucous membrane and periosteum to which it was attached. To do less, would only entail a speedy recurrence of the disease. It is not surprising that operations so severe as these should occasionally be followed by fatal results, either primarily from shock and hemorrhage, or secondarily from pyemia, erysipelas, or inflammation of the brain and its envelops. 8. Encephaloid.—The nose is occasionally the seat of encephaloid; some- times by extension from the maxillary sinus, but more generally by direct development; chiefly in children and young persons; marked by the usual LIPOMA OF THE NOSE. 425 Fig. 246. local symptoms, and invariably tending to destruction. The tumor, which may spring from almost any part of the nasal cavity, is liable to be con- founded with polyp; but from this it may commonly be readily distinguished by the remarkable rapidity of its growth, by its disposition to encroach upon the surrounding structures, by the great abundance of the accompanying dis- charge, and by the early involvement of the constitution, as denoted by the cancerous cachexia. The tumor is very friable, and often bleeds profusely from the slightest injury. The horrible dis- figurement produced by this disease is well represented in fig. 246. The treatment is purely palliative, operative interference being entirely out of the question. By attention to cleanliness, a nourishing diet, and the use of opiates, the patient is rendered comparatively comfortable, and enabled to eke out his miserable existence. 9. Necrosis.—Necrosis of the turbi- nated bones and also of the vomer is suffi- ciently common as an effect of tertiary syphilis. The affection may be limited or it may involve the whole of one of these pieces. The symptoms are muco-purulent discharge, more or less abundant, excessively fetid, and a feeling of weight and soreness in the nostril. The treatment consists of deodorizing and slightly detergent injec- tions, with removal of the dead bone as soon as it is found to be sufficiently detached. When the whole turbinated bone is necrosed, it may be necessary to break or divide it, in order to facilitate extraction. Wounds.—Wounds of the nose, whether incised or lacerated, demand the nicest adaptation of their edges, and the most careful maintenance by wire sutures, introduced with a properly curved needle. Adhesive strips may be necessary to aid the approximation. Any tendency of the parts to fall in toward the nose should be counteracted by filling the nostril with a roll of lint; few cases, however, will arise requiring such interference. Encephaloid of the nose. LIPOMA OF THE NOSE. There is a curious affection of the nose—so curious generally as to excite the risibility of the observer—to which the term lipoma is applied, from the fact that it essentially consists in an accumulation of the subcutaneous adi- pose substance, along with marked hypertrophy of the integument. The drawing, fig. 247, borrowed from Liston, exhibits the disease in an extraordi- nary degree of development. The tumor has a lobulated appearance, or, more correctly speaking, it is composed of several distinct masses, having, seemingly, one common origin. The growth, which is always chronic and painless, is almost exclusively confined to elderly male subjects with a ruddy complexion and an active capillary circulation, addicted to the pleasures of the table and to alcoholic potations. The chief inconvenience which it pro- uces is of a mechanical character, obstructing vision, compressing the nostrils, and interfering with eating and drinking. Occasionally the surface becomes very red and inflamed, and may, in time, even ulcerate. The seba- 426 DISEASES OF THE NOSE AND ITS CAVITIES. Fig. 247. ceous glands 'are occasion- ally much involved in the morbid action, being enlarg- ed, obstructed, and trans- formed into distinct cysts. The only remedy for this disease, when it has attained any considerable develop- ment, is excision; when small and of recent stand- ing, removal may sometimes be effected by sorbefacient applications, especially the tincture of iodine, a change of the patient's habits, and the steady use of purgatives. Wrhen excision is determined upon, the surgeon may ex- pect^'to encounter a good deal' of hemorrhage, owing to the enlargement of the cutaneous and other vessels, but this may usually be effec- tually controlled by ligature and compression. Care should be taken not to inflict any injury upon the cartilages of the nose. Lipoma of the nose. RHINOPLASTY. The nose, in consequence of accident or disease, may be so impaired in its form and size as to require reconstruction by the aid of plastic surgery. The operation which is performed for this purpose is, accordingly, denominated rhinoplasty. The lesion for which, in this and other civilized countries, in- terference is usually demanded, is constitutional syphilis, or the joint action of syphilis and mercury, which often destroys nearly every portion of the nose, except, perhaps, a small vestige of the bridge, causing, thereby, the most hideous deformity. The horror and distress of the case are greatly in- creased when the ravages extend to the frontal sinuses, the lachrymal pas- sages, the upper lip, the ethmoid and spongy bones, and the soft and hard palate ; in the latter event, throwing the nose and mouth into one immense cavern, an occurrence which not only seriously affects the speech, but readily admits the passage of food aud drink from the latter into the former. The deformities of the nose requiring plastic interference may very pro- perly be arranged under the following heads : 1. Loss of the entire organ, bones as well as soft parts. 2. Destruction of the whole or greater portion of the cartilages, the bridge remaining intact. 3. Mutilation of the tip, as when a small piece is cut or bitten off, including a part of both wings. 4 Loss of one wing, either alone or together with the nasal column. 5. Per- foration of the nose, either on the top or at the side ; in the latter case, with or without participation of the cheek. 6. Sinking of the organ from destruc- tion of the cartilaginous septum of the nose, the soft structures being but little, if at all affected. 7. Loss of the column. 8. Mutilation of the nose and upper lip, or of the nose, lip, and cheek. For the repair of these various defects, some of the nicest processes of the art and science of surgery are required; but, even with the very best skill that can be employed in their application, success is by no means always to be looked for ; on the contrary, the surgeon will too often have occasion to RHINOPLASTY. 427 lament the occurrence of some unexpected or unavoidable event which frus- trates his hopes, and disappoints the expectations of his patient. It is, there- fore, of the greatest consequence, as stated in the general chapter on plastic surgery, that everything should be done beforehand which is calculated to insure a favorable result. If the operation be entered upon heedlessly, and without due preparation of the part and system, failure will be almost certain. The integument required for closing the chasm in the nose may be bor- rowed from the immediate vicinity of the organ, or from some distant part. In the Indian method, as the former proceeding is usually called, the flap is obtained either from the forehead, the cheek, the upper lip, or the nose itself, according to the exigencies of each particular case. In the other procedure, which bears the name of Taliacotius, in commemoration of its inventor, or "the Italian method," from the country of his nativity, the operculum is taken from the arm. The operation, however, chiefly in consequence of the tedious and painful confinement of the head and limb, is now seldom employed, although instances now and then arise in which it may be had recourse to with great advantage. When an entire nose is to be reconstructed, the Indian method certainly deserves the preference, provided it be possible to obtain the requisite amount of substance from the forehead. Supposing that everything is favorable to the operation, the first step will be to measure off the shape and size of the flap. For this purpose, the defective part should be replaced with a wax- mould, a piece of gutta percha, or a lump of dough, representing as accu- rately as possible the outline and dimensions of the original organ. A piece of soft leather is then stretched over the artificial nose, to the shape of which it is cut with great care, including the column, or central portion. Another piece of leather, one-third larger than the former, is then fashioned, this ad- dition being necessary to provide against shrinkage, which, in time, generally reaches fully this extent, if it does not exceed it. As a general rule, it may be stated, that the flap should be from two inches and three-quarters to three inches in length, by two inches and a half in width at its widest part. In this length is included the column, which should be about one inch and a quarter in length, and from six to eight lines in width, according to the breadth of the nostrils. When the column is borrowed from the upper lip, the caudiform portion of the flap is of course omitted. The pedicle of the new nose must be from six to nine lines in width, and so long as not to dis- place the left eyebrow when it comes to be twisted upon itself, which, for the sake of convenience rather than anything else, is usually from left to right. The shape and size of the flap are to be carefully mapped off, just before the operation, with tincture of iodine, the preference being always given to the central portion of the forehead, unless there are contra-indications, in which event it should be taken from one side. The shape of the flap, and the man- ner of forming it, are shown at page 429. These preliminaries having been gone through, the patient, placed re- cumbent, with the head and shoulders gently elevated, is put under the influ- ence of chloroform, it being desirable that he should be as passive as possible during the operation. A roll of lint being now inserted into each nostril, to prevent the ingress of blood, an incision is made with a very sharp, narrow scalpel, along the iodinized track. The cut on the right side, is extended down, close along the brow, to the root of the nose, while on the left side it reaches hardly as low as the level of the brow, being prolonged afterwards, if it should be deemed advisable. In performing this part of the operation, it is of the utmost importance not to interfere with the angular artery, as the vascular supply of the new nose will mainly depend upon its integrity. The parts are divided, at the first stroke of the instrument, down to the perios- teum, which is left intact. The gap in the forehead being now sponged, and 428 DISEASES OF THE NOSE AND ITS CAVITIES. the bleeding arrested by ligature, its edges are immediately brought together by several points of the interrupted suture and adhesive strips, as little being permitted to remain open as possible. The next step of the operation consists in paring the edges of the mutilated organ, and removing such redundancies as may be in the way of the new material. The skin over the bridge of the nose should also be slightly revivi- fied in order to facilitate adhesion between the contiguous surfaces. In the third step of the operation the parts are stitched together by the common interrupted suture ; or, what is preferable, by the tongue and groove suture of Professor Pancoast. In order, however, to do this properly, it is necessary that the edges of the flap should have been previously beveled off on the cuticular surface for about the eighth of an inch, as may readily be done in the act of forming it by running the knife along obliquely. The edges of the nose are beveled from without inwards, so as to form a groove for the reception of the tongue, an arrangement which thus brings together four raw surfaces. The connection is effected by passing a loop of thread with two needles first through the inner lip of the groove, then through the base of the tongue, and lastly through the outer lip of the groove, all on the same level. The ends of the thread are then tied over a thin roll of adhe- sive plaster, thereby forcing the tongue deep into the groove. The number of sutures on each side must vary from three to five, according to the extent of the wound. The annexed cuts will serve to convey a better idea of mak- ing this ingenious suture than any description, however elaborate. Fig. 248 exhibits the mode of introducing the thread, and fig. 249 the manner in which the tongue is received into the groove. Fig. 248. Fig. 249. Dr. Pancoast's tongue and groove suture. All that now remains is to fix the caudal portion of the flap, intended for the column, in its proper position, a procedure requiring great care and attention in order to secure its adhesion. For this purpose a deep transverse opening is made in the upper lip, at its junction with the natural septum of the nose, from three to five lines in length, into which the extremity of the strip, previously divested of cuticle, is firmly implanted, a few points of suture being employed to keep it in place. The lint inserted into each nostril, prior to the operation, is now replaced by a fresh tent of the same material, inclosing a small gutta-percha tube, to prevent the adhesion of the opposite surfaces, as well as to facilitate respira- tion. Narrow strips of isinglass plaster being stretched across the sides of the nose to effect more uniform approximation, the dressing is completed by applying a layer of charpie, wet with oil, along the line of suture, to pre- vent the edges from becoming dry and shrivelled. The greatest care is used that, while the contact is complete, there shall be no undue tension anywhere. The diet is light and cooling, the temperature of the room is regulated by the thermometer, and the head is well elevated by pillows. An anodyne is given immediately after the operation, and the dressing is not disturbed until the end of the third day. New tents are now introduced into the nose, and any sutures that are loose removed; otherwise they are not disturbed. It occasionally happens that the pedicle of the flap is redundant, giving the RHINOPLASTY. 429 npper part of the nose, especially on the left side, a full, unseemly appear- ance. When this is the case, the defect may be remedied by the removal of an elliptical portion of integument, care being taken not to perform the ope- ration until the organ is perfectly capable of sustaining an independent ex- istence. The adjoining sketches afford a good idea of the success which often attends rhinoplasty, when properly executed. Fig. 250 exhibits the appearance of the parts prior to the operation, and fig. 251 nearly twelve months after- Fig. 250. Fig. 251. Rhinoplasty and its effects. wards The operation was performed at the College Clinic, in 1856 with the aid of the tongue and groove suture, and the result has been, in 'every respect most gratifying, the organ remaining up to the present moment large and well shaped. It is proper to add that the flap was uncommonly large as it always should be, and that it united throughout by the first intention. ' Hie Italian operation has undergone several modifications. As originally executed by Taliacotius, and afterwards by his immediate disciples, it was a most tedious and trying procedure, well calculated to put severely to the test the patience both of the subject and the surgeon. The first step con- sisted in forming a suitable flap of integument at the inner and middle part or the left arm, over the flexor muscle, at least four inches in length by three and a half in width, its outline having been previously marked off with ink. two longitudinal incisions being made, the integument was carefully raised >o its entire extent, or as far as the two transverse lines; a piece of soft linen ffell oiled, being afterwards passed beneath it to prevent reunion. The wound, which, in the modern process, is closed by suture under the bridge was left to suppurate, and, at the end of a fortnight, the flap, now thickened', hardened, and shrunk, by exposure, and covered with granulations on its Posterior surface, was liberated at its superior extremity, which was then accurately stitched to the mutilated organ, the edges of which had been pre- viously revivified for its reception. To prevent the sutures from giving way, the limb was brought up close to the head, and maintained in that position DTan ingenious, but complex apparatus, consisting of a cap and jacket ■^de of strong drilling ; the arrangement and mode of application of which ^y be easily understood from the sketch, fig. 252, copied from the original treatise of Taliacotius. _ i 430 DISEASES OF THE NOSE AND ITS CAVITIES. Fig. 252. Taliacotius's apparatus. Another fortnight having been permitted to elapse, to afford the parts time for uniting, the flap was detached from its connection with the arm, and, after having been properly fashioned, ac- curately fixed in the position which it was destined to occupy. Taliacotius has left no statistics of his rhinoplastic operations, and we are, there- fore, left in ignorance as it regards his success. From the great care, however, with which he has described his process, and from the fact that he attended numer- ous patients from abroad, it is reasonable to conclude that his success was highly flattering. He was evidently a most in- genious and skilful surgeon, far in ad- vance of his age; and in the operation of reconstructing noses he dwells with great force and point upon the import- ance of having the adscititious parts of un- usual dimensions, thus providing against the effects of shrinkage, one of the great obstacles to the formation of a good organ. Graefe, of Berlin, modified the operation of Taliacotius, by attaching the flap at once to the mutilated nose, thus limiting the period of the constrained position of the head and limb to five or six days, this being generally found sufficient to insure adhesion between the parts. The actual value of this process, now usually known as the German method, has not been fully tested, but my opinion is, that while it answers very well in some cases, it is, on the whole, inferior to the original plan, since it lessens the chances of reunion, and admits of a greater degree of shrinkage after the operation. In the Italian procedure, the new material, from its exposed situation, acquires a better circulation, as well as a greater degree of solidity and thickness, thereby fitting it the better for the maintenance of the new relations. That excellent operator, Dr. J. Mason Warren, in one case, adopt- ing the German modification of the Italian method, took his flap from the anterior surface of the forearm, about two inches above the wrist, and suc- ceeded in effecting an admirable cure, the transplanted skin being separated on the fifth day. Small apertures, of an oval or circular form, the result of wounds, ulceration, or gangrene, are met with on various parts of the nose, and may generally be closed readily by the transplantation of a flap either from the cheek, the forehead, or even the nose itself, according to the circumstances of the case. A similar procedure will be required when there is partial destruction of the edge of the nose. When one of the wings is lost, it will generally be neces- sary to borrow the flap from the arra or forehead. WThen the nasal column is deficient, an admirable substitute may easily be obtained from the central portion of the upper lip, either by twisting the flap at its pedicle, or by evert- ing the mucous membrane, the surface of which soon assumes the character of the cuticular tissue. The nose is sometimes unseemly depressed, or caved in, in consequence of the destruction of its cartilaginous septum, without perhaps any injury of the skin, giving it more or less of an African expression. For such a defect, the only remedy is the construction of a new organ, all attempts to elevate the parts in a satisfactory manner proving useless for the want of proper support. DISEASES AND INJURIES OF THE AIR-PASSAGES. 431 CHAPTER IX. DISEASES AND INJURIES OF THE AIR-PASSAGES. Thk principal surgical affections of the air-passages are—inflammation and its effects, as oedema; croupous deposits, and ulceration; polypous growths; spasm; warty excrescences; stricture; and foreign bodies. Before I proceed to describe these lesions, it will be necessary to offer some remarks upon the proper mode of inspecting the air-passages with a view to their more ready detection. Fig. 253. EXAMINATION OF THE AIR-PASSAGES. The investigation and treatment of the maladies of the larynx and trachea have necessarily been much embarrassed for the want of proper mechanical appliances by which the interior of these structures can be brought into view, but the difficulty has, in a measure at least, been over- come by the introduction of the laryngoscope by Dr. Czermak, of Pesth, who commenced his researches in 1857, and to whom is undoubtedly due the credit of being the first to employ such an instrument upon scientific principles, although a similar idea had previously occurred to Robert Liston and Garcia. Within the last few years the subject has engaged much attention, espe- cially among European observers, as Turck, Gerhardt, and Stoerk. The laryngoscope consists of a highly polished steel mirror, fig. 253, of a square, oval, or circular shape, mounted on a flex- ible but firm rod secured in a movable handle, and, on an average, about two-thirds of an inch in diameter by one line in thickness. Previous to its introduction it should be heated to as high a temperature as is consistent with the comfort of the patient, either by holding it over the flame of a spirit lamp, or by plung- ing it in hot water, the object being to prevent the respired air from becoming condensed upon its polished surface, and so ren- dering it unfit for use. To light up the larynx and pharynx, a slightly concave glass nurror, fig. 254, resembling the ophthalmoscope, about three inches in diameter, with a small central perforation, is used. This is fitted in a light metallic frame, which is secured to a mouth- piece, by which the reflector may be held between the teeth, or, instead of this, it may be attached to a frontlet, or band encir- cling the head, the central aperture corresponding with the eye or the observer. The light of an argand lamp, concentrated upon the reflecting mirror, constitutes the best source of illumination, °™v°- but when available, the direct rays of the sun may be employed. In conducting the examination, the lamp is placed on a table a little be- th tnd to the right of the Patient> so that the flame maybe on a level with the roof of the mouth. The patient rests his hands upon his own knees, 432 DISEASES AND INJURIES OF THE AIR-PASSAGES. slightly advances his body, and throws the head a little backwards, the mouth being well opened and the tongue depressed. The observer, seated directly opposite to him, uses his left hand to support his neck and chin, or to con- trol his tongue, while with the right he introduces the laryngoscope, at the same time looking through the perforation Fig. 254. of the reflecting mirror. The light and the position of the observer and patient beino- thus properly regulated, the former warms the instrument in the manner above indicated, and requests the latter to take alternately a deep in- spiration and to sound the vowels a, e. By this procedure the velum and uvula will be raised, allowing the easy introduction of the instrument, to which a proper inclination should then be given, so that the rays of light from the reflect- ing mirror may illuminate it. The speculum, by throwing rays upon the larynx, reflects the image of the parts to the eye of the observer. With a little perseverance, any one can soon learn to bring into view the base of the tongue, the epiglottis, the vocal cords, the ventricles of the larynx, the Eustachian tubes, the posterior nares, and even the bifurcation of the trachea. It is ad- visable, however, to begin the study upon the ex- cised human larynx, or to make the examination upon one's own person, in order that the observer may gain a sufficient amount of proficiency in the use of the instruments before applying them to a patient, as well as to accustom himself to the altered position of the parts, as, in the reflected image, they are seen upside down, but in their proper position in relation to the right or left side of the body. Great care must be taken in introducing the speculum to avoid unnecessarily touching the fauces and pharynx, lest the act of swallowing or vomiting be provoked; and in some subjects the parts will be found to be so irritable that they require some preliminary train- ing, as before the operation for cleft palate, to render them tolerant of the presence of the specu- lum. Wrhen it is desired to make local appli- cations to the larynx, the self-retaining tongue depressor of Dr. Henry Church, of New York, will be found very convenient, as it leaves one Glass mirror. hand of the operator free to apply any remedy suitable to the case under inspection. The instrument of Dr. Church, here referred to, besides serving the pur- pose of a tongue depressor, is an excellent laryngoscope, readily bringing into view, when properly applied, the cavity of the larynx, the vocal cords, and the rima of the glottis. It consists, as will be seen by a reference to Bg. 255, of two pieces, connected by an arm provided with a hinge-joint, the one being a kind of reflecting spatula, while the other is a metallic plate, shaped like the lower jaw which rests in it in a sort of gutter. The spatula being introduced into the mouth, its angle of flexion is easily regulated by the screw; in this manner the tongue may not only be readily depressed hut forced forward and kept completely quiet, at the same time that the moutli LARYNGITIS. 433 may be opened and shut without the slightest inconvenience to the patient or any displacement of the instrument. Fig. 255. Dr. Church's laryngoscope and tongue depressor. 1. LARYNGITIS. Inflammation of the larynx, or of the larynx and trachea, is an exceedingly common affection, the result usually of cold, of external violence, or of the inhalation of the steam of hot water, or the fumes of irritating gases. As generally met with, the disease is most common in young children, in whom it ordinarily assumes the form of croup, which occasionally manifests an endemic cha- racter, and is extremely liable to be followed by a deposit of plastic matter, accurately moulding itself to the interior of these canals, and closely adhering to their surface. In the more aggravated cases, the de- posit extends, on the one hand, up into the throat, and, on the other, down into the bronchial tubes, thus causing great, if not fatal, mechanical obstruction to respiration. Fig. 256 exhibits this deposit as it occur- red in one of my specimens, removed from a lad who died of croup. For the relief of this affection, known as "mem- branous croup," the aid of the knife is occasionally in- voked ; generally, however, merely as a dernier resort, and, consequently, when it is too late to be of any real benefit. Now and then, it is true, a patient is saved, but, in most instances, operative interference is utterly futile, as is proved by the fact that out of 351 cases of tracheotomy, performed on account of this disease by twenty-one French surgeons, including a number of the most distinguished operators of Paris, 312 termi- nated fatally; thus affording a ratio of 8 deaths to 1 recovery. surgeons operated forty times, and lost every one of his cases. Laryngitis is sometimes caused by syphilis, generally as a tertiary lesion ; vol. n___28 False membrane of croup. One of these 434 DISEASES AND INJURIES OF THE AIR-PASSAGES. but as this affection has been described in another part of the work, it is not necessary to reconsider it here. The disease is also occasionally of a tuber- cular nature, and then nearly always passes into ulceration. Its co-existence with phthisis renders it nearly uniformly fatal. Gangrene of the larynx is exceedingly uncommon, and must almost neces- sarily terminate fatally under any mode of treatment. 2. CEDEMA. The larynx is liable to oedema. The parts which are most commonly affected are the glottis, the lips of the organ, and the epiglottis, the edges and under surface of which are usually thickened and pulpy. The disease con- sists in an effusion of serum, or serum and lymph, in the submucous cellular tissue of the parts, leading to mechanical obstruction of the tube, and serious impediment in the respiratory function. The swelling is devoid of vascu- larity, pits on pressure, and is generally most prominent round the margins of the larynx, which are often elevated into white, Fig. 257. glossy, pendulous bags, not unlike those of the epidermis after the application of a blister. Small purulent deposits are sometimes seen in it, while its surface is occasionally incrusted with patches of lymph. The swelling is of a pale straw color, reddish, mottled, or greenish, and disappears al- most completely when cut or punctured. The base of the tongue, pharynx, tonsils, uvula, and palate ordinarily participate in the morbid action, as is evinced by their inflamed condition. The mucous membrane of the larynx is heightened in color, and the lymphatic ganglions in the imme- diate vicinity of the tube are often enlarged, infil- trated, and softened. The adjoining cut, fig. 257, from a specimen in my collection, affords a good view of this disease. CEdenia of the larynx is usually insidious in its origin, and rapid in its progress, often terminating fatally in a few days. It is more common in men than in women, and is rarely observed before the cEdema of the larynx. age of puberty. In children it is sometimes in- duced by the inhalation of steam, or by drinking hot water from the spout of a tea-kettle. It often comes on suddenly, during the progress of other complaints, as scarlatina, measles, smallpox, tonsillitis, erysipelas, and typhoid fever, and is evidently of an inflammatory character, though its exciting cause is then seldom obvious. The disease is marked by embarrassment of breathing, fits of coughing, change of voice, and threatened suffocation. Most commonly, the first indi- cation is soreness of the throat, with a sense of constriction in the upper part of the larynx, as if there were a foreign body impacted in it. The voice is hoarse, sharp, hissing, or croupish ; the cough is dry, sonorous, and convul- sive; deglutition is painful; and the act of inspiration is performed with great difficulty and distress, while expiration is easy and unembarrassed. The ob- struction to the breathing seems to depend, not so much upon the diminished capacity of the larynx, as upon the man nor in which the tumid and infiltrated lips of the organ are drawn in by the air, as it rushes from the mouth into the lungs. The dyspnoea steadily increases; every respiratory muscle is called into play; the head is retroverted; the shoulders are elevated; the counte- nance is anxious and livid, from the imperfect aeration of the blood; and the 03DEMA. 435 poor patient, harassed with frequent paroxysms of suffocation, at length dies exhausted. High fever is always present in the latter stages of the malady. The distinctive signs of oedema of the glottis are, the difficulty of drawing the air into the lungs; the almost total absence of pain in the larynx; a feeling of fulness in the upper part of the throat, conveying the idea of the existence of an extraneous substance; soreness in the throat, and impediment in deglu- tition, often so great as to render it almost impossible to swallow either fluids or solids. In many cases, especially in females, in whom the distance between the lips and the affected parts is, in general, considerably less than in men, the end of the index-finger can easily be brought in contact with the elevated epiglottis and the swollen lips of the larynx. In young, restive subjects it may be necessary, in conducting the exploration, to depress the tongue with a spoon, and to separate the jaws with a piece of wood. Too much attention cannot be bestowed upon the diagnosis of this dis- ease, which is, unfortunately, often overlooked. There are few practitioners who cannot recall cases of this kind, and who have not had reason to regret their want of early discrimination, while life was still within the reach of remedies. An error of this description is the more to be lamented, because it is almost always fatal to the poor sufferer, who is sure to be suffocated by the mechanical obstruction which the swollen parts offer to the ingress of the air. The period at which death occurs from this cause varies from forty-eight hours to three, four, or five days. The treatment of oedema of the larynx consists of purgatives and emetics, and of leeches to the throat, followed by fomentations, and by blisters to the nape of the neck. General bleeding can only be required, or be proper, when the patient is young and plethoric. When the symptoms are urgent, the affected parts must be freely scarified, to afford vent to the effused fluids, the cause of the whole respiratory difficulty. For this purpose a long probe- pointed bistoury, fig. 258, with a short double-edged blade, bent at F- 258, an angle of 45°, is carried into the larynx, and moved about in such a manner as to divide the tumid and infiltrated structures at different points Of their extent. Dr. Buck's knife for oedema of the larynx. The operation, which should be performed while the patient's head is thrown back, and firmly held by an assistant, the tongue being carefully depressed, and the jaws widely separated, is followed by hardly any bleeding, and is to be repeated at longer or shorter intervals, according to the amount of relief afforded. The above treatment may often be advantageously aided by the nitrate of silver, a solution of which, in the proportion of twenty grains to the ounce of water, should be applied freely, not only to the larynx, but also to the surrounding parts, which, as before stated, are generally seriously involved in the inflammation. If these means fail, and the obstruction to the respira- tion steadily advances, our only resource is tracheotomy, an operation which has often succeeded in such cases, under circumstances apparently the most desperate. In an instance under my care in the winter of 1855, although great relief followed upon the operation, the patient, a female, fifty years of age, died on the third day, from inflammation of the lungs. The ingress of the air is promoted by the silver tube, or by means of hooks, as after tracheotomy for the removal of foreign bodies. The treatment of oedema of the larynx by incision, the only effectual method when the disease has made any decided progress, was first placed in its true light in this country, by Dr. Buck, of New York, in 1848, in a paper in the urst volume of the Transactions of the American Medical Association. The 436 DISEASES AND INJURIES OF THE AIR-PASSAGES. knife represented in the preceding cut is his invention, and is admirably adapted to the object. 3. SCALDS. Scalds of the larynx may be caused by the inhalation of steam or the contact of hot fluids, the subjects of the accident being usually very young children. Intense pain, restlessness, and difficulty of swallowing, followed by impeded respiration dependent upon oedema of the glottis, and broncho-pulmonary congestion are the characteristic symptoms of the occurrence. The mouth, tongue, and fauces are red, as well as here and there vesicated, and evidences of the effects of the hot fluid also frequently exist upon the cheeks. The epi- glottis is hard, round, and contracted, as if it had been scorched. In the worst forms of the accident, the voice is croupy, sonorous rales are heard over the chest, the countenance is of a purplish hue, the pulse is rapid and feeble, the surface is cold and damp, the eyes are rolled up, the pupils are dilated, and the patient is semi-comatose. If prompt relief be not obtained, death ensues from spasm of the larynx, or from the joint influence of spasm and inflamma- tion, the latter often extending to the bronchial tubes and substance of the lungs. The kind of treatment must depend upon the violence and extent of the injury. The milder cases will generally readily yield to the ordinary anti- phlogistic measures, as an active purgative, a mild emetic to expel the redundant mucous secretion, and leeches to the neck, or the upper part of the sternum. When the symptoms are urgent, tracheotomy is usually advised, but that the operation is rarely of any permanent benefit is clearly proved by the statistics published upon the subject, which show a sad disproportion of deaths to recoveries. Professor Bevau, of Dublin, has recently communi- cated the particulars of four cases of scalds of the larynx all successfully treated by emetics, leeches to the upper part of the sternum, and calomel, in doses of from one to two grains every half hour, until free bilious evacuations were produced. 4. ULCERATION. Ulcers of the larynx, of a common, tubercular, syphilitic, or mercurial origin, are not unfrequently met with. Commencing usually in the muci- parous follicles, or in little abscesses beneath the lining membrane, they are irregularly circular in their shape, superficial, from one to two lines in dia- meter, and surrounded by thin, grayish edges. The mucous membrane in their immediate vicinity is generally softened and abnormally red, but now and then it appears to be entirely sound. The ulcers may occur in any situa- tion ; but the parts most commonly involved are the vocal cords, the glottis, the base of the arytenoid cartilages, the ventricles of Morgagni, and the epi- glottis, the latter of which is particularly liable to suffer in secondary syphilis. Although they are ordinarily small and shallow, they sometimes occupy a large surface, or extend to a great depth, exhibiting a frightful appearance, and destroying, in their progress, muscles, ligaments, cartilages, and every- thing else that presents itself before them. The symptoms of ulceration of the larynx vary according to the nature, seat, and extent of the lesion. The syphilitic form is, in general, the most severe, but the tubercular is also not unfrequently attended with much pain and distress. When the vocal cords, the ventricles, or arytenoid cartilages are involved, there will be a sense of heat and pricking in the larynx, hacking cough, a husky, wheezing, or whistling state of the voice, aud difficulty ot breathing, along with purulent and bloody expectoration. As the disease STRICTURE. 437 progresses the voice is reduced to a mere whisper, or becomes completely extinct, severe pain is experienced in the affected parts, hectic fever super- venes, and the patient finally dies from exhaustion of the vital powers, effusion upon the lungs, or constitutional irritation. The suffering is greatly aggra- vated when the epiglottis is seriously implicated; for there is then not only dyspnoea, with cough and change of voice, but every attempt at deglutition is attended with great distress, if not with a feeling of instant suffocation. In the more advanced stages of the malady, whatever may be its character or situation, the difficulty of swallowing is often so extreme that life is essentially abridged by starvation, the patient being sometimes unable for days together to take even liquids. Ulceration of the larynx is always a dangerous disease. If the more com- mon forms are occasionally recovered from, the more aggravated nearly always prove fatal. This is particularly true of the syphilitic and tubercular varieties, very few cases of which, especially in their more advanced stages, are ever cured under any treatment. The latter is, as a general rule, even more dan- gerous than the former. Serious involvement of the muscles, ligaments, and cartilages is always denotive of great danger, whatever may be the nature of the exciting cause of the lesion. It must be obvious that the treatment of a disease, depending upon so many and such various causes, and the diagnosis of which is so obscure, cannot be conducted with much prospect of permanent relief. Indeed, experience has shown that temporary amelioration alone is usually to be looked for. When there is reason to believe that the lesion is owing to a syphilitic taint, mer- cury, iodide of potassium, nitro-muriatic acid, and other kindred articles, must be employed. In ulceration, consequent upon tubercular deposits, little or nothing is to be expected from internal remedies, beyond the beneficial influence which they may exert upon the general health. In all cases, what- ever may be the origin of the malady, permanent quietude of the affected organ is indispensable. Hence the patient must refrain from all conversation, and even, as far as practicable, from de- glutition. When there is much pain, soreness, or tender- ness in the parts, a few leeches may occasionally be applied to the front of the laryux, or the nape of the neck may be rendered raw with a blister. The best local remedy, how- ever, is a solution of the nitrate of silver, in the propor- tion of from forty to fifty grains of the salt to the ounce of water, with which the ulcerated surface should be gently but efficiently touched every third, fourth, or fifth day, according to the tolerance of the parts, in the man- ner presently to be indicated. Should suffocation be threatened, laryngotomy may be performed, and a tube worn to facilitate respiration. 5. STRICTURE. Stricture of the windpipe, fig. 259, may be induced by a deposit of fibrin in the submucous cellular tissue, or, as is more frequently the case, by the contraction conse- quent upon a wound, the healing of a large ulcer, or the death and exfoliation of a portion of one of its cartilages. Ureat diminution of the tube is occasionally produced by ^^n"^ °f ^ the pressure of an enlarged thyroid gland". The symp- toms are those of impeded respiration, gradually increasing, and surely tend- ing to the destruction of the patient. The diagnosis is established by the history of the case, and by a careful exploration of the tube with the proband 438 DISEASES AND INJURIES OF THE AIR-PASSAGES. Relief may be attempted, though with hardly any prospect of success, by dilatation with the bougie, passed from the month or from below upwards, through an opening in the trachea. The treatment is conducted on the same principle as in stricture of the urethra, oesophagus, and other outlets. When the parts are very irritable, cauterization precedes the dilatation ; and when the latter operation is impracticable, on account of the intractableness of the patient, control is effected by anassthesia. In desperate cases the trachea is laid open, and a silver tube worn. By such a procedure, a patient may some- times live in comparative comfort for many years. 6. POLYPS. Polyps of the larynx are uncommon. They are of a globular, conical, or pyriform figure, and from the size of a small bean up to that of a pigeon's egg, a nutmeg, or even a large almond. Of a pale rose, red, or grayish color, they are of a fleshy consistence, more or less elastic, and invested by a pro- longation of the mucous membrane. Microscopically examined, they are found to be composed of a fibro-cellular, fibrous, or fibro-plastic tissue, epi- thelial cells, and globules of fat. Their structure is, consequently, entirely benign. They are generally attached by a thin narrow pedicle to the ven- tricles of Morgagni, the vocal cords, the Fig. 260. margins of the larynx, or the root of the epiglottis. Now and then an instance is met with in which they spring from a very broad base. They occur in both sexes, and have been most frequently noticed in phthisi- cal subjects, after the fiftieth year. Their existence is indicated by a sense of constric- tion in the larynx, alteration and even entire extinction of the voice, croupy cough, occa- sional and gradually-increasing dyspnoea, and violent attacks of suffocation, especially when the morbid growth changes its position. One of the most reliable signs is a valvular flap- ping sound, heard and felt as the tumor moves about during respiration. Occasionally, a por- tion of the tumor, or even the entire mass, is detached and ejected ; and, when this is the case, there can, of course, be no doubt re- specting the nature of the disease. A careful exploration, both by sight and touch, will often be of essential service in determining the diagnosis. Polyp of the larynx. The annexed drawing, fig. 260, from a spe- cimen in ray collection, exhibits a well-marked growth of this kind developed in a man thirty-eight years of age, who finally died of tubercular ulceration of the larynx, in a state of profound marasmus. The tumor was about the size of a filbert, and of a fibro-cellular structure; it hung down by a rather narrow pedicle into the lower part of the tube. No suspicion of its presence had been entertained during life. Great attention has lately been paid to the study of polyps of the windpipe, principally through the writings of Professor Ehrmann, of Strasbourg, who, in an able and beautiful monograph, published in 1850, collected all the facts then known upon the subject. In this country it has also been ably treated by Dr. Green, Dr. Buck, and Dr. Willard Parker. The paper of Dr. Buck, inserted in the sixth volume of the Transactions of the American Medical WARTY EXCRESCENCES — SPASM. 439 Association, comprises a tabular view of 42 cases of morbid growths within the larynx. Of 38 cases, in which the sex is stated, 27 wrere males and 11 were females. The ages ranged from 2 years to 65, nearly one-half occur- ring in young subjects. The disease, if left to itself, is almost necessarily fatal. Of the 42 cases analyzed by the Xew York surgeon, only one was relieved by spontaneous expulsion. The majority perish from suffocation. The only remedy for these morbid growths is excision. When the tumor projects above the larynx it may be seized with a pair of polyp-forceps, and snipped off with the scissors. If, on the contrary, it is imprisoned in the tube, it will be necessary to divide the crico-thyroid ligament, together with one or both of the contiguous cartilages, so as to afford full and satisfactory access to the morbid growth. After removal, repullulation is prevented by the occasional application of nitrate of silver, or chromic acid. 7. WARTY EXCRESCENCES. Warty excrescences, fig. 261, similar to those of the vulva and penis, are sometimes found in the larynx. They are of a pale reddish or grayish color, of a soft, fleshy consistence, and of a rounded, ovoidal, or conical figure. Their surface is rough and fissured, like that of a cauli- flower; their length varies from half a line to a quarter of an inch ; and their attachment is either by a narrow pedicle or a broad base, more generally the latter. These vegetations are usually associated with thickening of the lining membrane of the tube, and are nearly always dependent upon a syphilitic taint of the system. There are no distinctive signs of the disease. The history of the case, the altered state of the voice, and the feeling of uneasiness or of constriction at the top of the larynx, must serve to guide us in our diagnosis. In an old gentleman of sixty, who was under my care with this affection some years ago, the most prominent symptom was difficulty of swallowing fluids, owing to the indu- rated and contracted condition of the epiglottis, which felt as hard as a piece of wood. Antisyphi- litic remedies, counter-irritation in front of the neck by blister, seton, or pustulation, and cauteriza- tion of the interior of the tube, constitute our chief resources in the treatment of this affection. They should be persevered in for a long time. When the excrescences are large and numerous, the obstruc- tion may be so great as to demand tracheotomy and the constant use of the silver canula. Warts in the larynx; grow- ing in the situation of the vocal cords. 8. SPASM. Spasm of the larynx, or of the larynx and trachea, may be produced by a great variety of causes, some of them directly connected with the air-pas- sages, and others indirectly, consisting, perhaps, in some disease of the brain or spinal cord, or some functional disorder of the oesophagus, stomach, bowels, or uterus. Persons are sometimes instantly suffocated from the ingress of a foreign body into the windpipe, or from its lodgment upon the rima of the glottis. In such a case, the respiration may be permanently arrested in a moment, in 440 DISEASES AND INJURIES OF THE AIR-PASSAGES. the twinkling of an eye, as effectually as from the administration of prussic acid, or a severe blow upon the head. Inebriated persons occasionally die in the same manner, during attempts at vomiting. In the exhausted condition of the system, consequent upon the inordinate use of ardent spirits, the contents of the stomach are lazily ejected, thus allowing some of the ingesta, as they proceed upwards, to lodge against the rima of the glottis, or even to descend into the windpipe. Diseases of the epiglottis, disqualifying it for the due performance of its functions, remarkably predispose to this occurrence. The effect of the passage of a drop of water into the larynx is familiar to every one. All fluids, however mild, are capable, when introduced into this tube, of exciting dyspnoea, and the most violent, spasmodic, and suffocative cough; but the impression is evanescent, for the reason that the accident does not produce mechanical obstruction to respiration. The moment the spasm subsides the breathing is re-established. All solid articles, on the contrary, whatever may be their character, will, by entering the windpipe, or resting against the mouth of the larynx, endanger life by suffocation. A person laboring under delirium tremens, and confined so as to be unable to move, may, in an effort at vomiting, instantaneously perish from the intro- duction of food into the air-passages. Many such cases, it is to be feared, occur without the real cause of dissolution being known. Suffocation is occasionally produced by the sudden ingress of blood into the windpipe. This sometimes happens during operations upon the mouth and throat, and even during the performance of tracheotomy itself. Violent, and, indeed, fatal effects are occasionally produced by the impac- tion of foreign bodies in the pharynx and oesophagus. In most cases, the bad effects are caused by the spasm which the extraneous substance induces in the muscles of the larynx ; but occasionally they proceed from sheer mechani- cal obstruction. In the treatment of spasmodic affections of the air-passages, careful inquiry must be made into the nature of the exciting cause, for it is only by doing this that the practitioner can hope to devise a rational plan of cure. The general health, if at fault, must be amended, the secretions corrected, and all sources of irritation, local and general, removed. As means of immediate or temporary relief, the most suitable remedies are antispasmodics, particularly chloroform, morphia, and valerian, with anodyne fomentations to the neck, or, what is generally more efficacious, cloths wrung out of iced water. If the case is urgent, threatening suffocation, the only resource is laryngotomy. 9. PARALYSIS. Paralysis of the larynx and trachea may be caused by disease or accident; in the latter case usually by a blow or fall, eventuating in contusion of the muscular fibres of the tube, so as to disqualify it, in part, if not completely, for the exercise of its functions. The lesion is sometimes purely sympathetic, depending upon disorder of the brain, spinal cord, or digestive apparatus; and in this event, relief must obviously be sought in a correction of the ante- cedent evil. W7hen caused by external violence, the symptoms may be of so urgent a character as to demand immediate recourse to bronchotomy. 10. FISTULE. Fistule of the windpipe is occasionally congenital; most generally, however, it is caused by wounds refusing to heal in consequence of the overlapping of their edges, or the presence of some extraneous substance, as a piece of ne- crosed fibro-cartilage. Its size varies, of course, in different cases; usually, CAUTERIZATION OF THE AIR-PASSAGES. 441 however, it is very diminutive, perhaps hardly as large as an ordinary pin's head. Its edges have a red, raw appearance, and there is usually a small quantity of mucous discharge, at once indicative of the real nature of the lesion. When a fistule of the trachea has continued for a long time, the tube above the opening is very apt to become contracted, thus interfering materially with the cure of the case. The treatment of this affection consists in paring the edges of the opening, both in the tube and in the integument, and in approximating them by seve- ral points of the interrupted suture. The milder cases occasionally yield to gentle cauterization with the solid nitrate of silver. 11. HERNIA OF THE TRACHEA. The trachea is liable to protrusion of its lining membrane between two of its rings, constituting what has been, ridiculously enough, called "bronchial hernia." It is usually caused by severe straining ; either suddenly, as occa- sionally happens in violent labor from forcibly holding the breath, or gra- dually, in consequence of loud and habitual efforts with the voice. The tumor which is thus formed is remarkable for its softness, and varies from the size of a pea to that of a pigeon's egg, increasing during exertion and diminishing under pressure. It produces no particular inconvenience, except what re- sults from the disfigurement which it occasions. The proper remedy is steady, systematic compression, which, if it does not produce a cure, will, at all events, have the effect of preventing its farther increase. 12. CAUTERIZATION OF THE AIR-PASSAGES. The treatment of affections of the air-passages by cauterization has attracted great attention within the last few years, both in this country and in Europe, chiefly through the exertions and influence of Dr. Horace Green, of New York. Unfortunate in the manner of its introduction, it has met with much opposition and even obloquy, and there are not wanting many able practi- tioners who altogether deny its practicability, alleging that the instrument employed for the purpose, when it descends beyond a certain point, is always thrust into the oesophagus instead of passing on into the air-tubes. On the other hand, the treatment has received the approval of some of the highest authorities in the profession, and there is reason to believe that it has already rendered important service in a class of diseases which, until its adoption, were generally found to be of a very hopeless character. The operation of mopping the windpipe is unquestionably not an easy one, but that it can be executed by any one of ordinary tact, and possessed of a correct knowledge of the anatomy of the parts, my observation abundantly attests. That the instrument is often passed down the oesophagus by awkward and ignorant practitioners is, I think, equally true. Experience is in this, as in every other operation requiring delicacy and skill, of vast benefit, and there is no doubt that he who enjoys it in the greatest degree is, all other things being equal, most likely to succeed in cauterizing the air-passages with facility and success. Cauterization of the larynx is particularly indicated in chronic affections of this tube, whether simple, syphilitic, or tubercular, or dependent upon the presence of warty excrescences. It is also very efficient in acute inflammation, especially in that variety of it denominated membranous croup. Aphonia, caused by disease of the larynx, is likewise a suitable case for its employment. The article with which the cauterization is effected is the crystallized nitrate of silver, in the form of solution, in the proportion of from twenty to lorty grains to the ounce of water. When ulceration is present, or when the 442 DISEASES AND INJURIES OF THE AIR-PASSAGES. medicine has ceased to produce the desired effect, the strength of the solution may be considerably increased ; but for ordinary purposes this is unnecessary. The solid article is, of course, never employed, as it is not only too severe, but might do incalculable mischief if it were to break off, and fall into the windpipe. The probang with which the application is made consists of a thick whale- bone rod, fig. 262, furnished with a stout handle, and bent to an angle of Fig. 262. Sponge-probang for the larynx. nearly 45°, the curved extremity being surmounted by a small round piece of sponge, of great softness and delicacy, and firmly attached by means of a strong thread, to guard against its coming off. The whole instrument is about ten inches in length. The sponge being slightly moistened with the caustic solution, the patient, seated upon a chair, is requested to open his mouth as widely as possible, and take a full inspiration, followed by a gentle expiration, thus placing the parts in the best condition for the easy introduc- tion of the instrument, and the prevention of spasmodic cough. While this is being done, the surgeon depresses the tongue, and carries the probang over the top of the epiglottis, and thence suddenly on, over the lower sur- face of that cover, downwards and forwards through the mouth of the larynx into the interior of that tube. A momentary contact is all that is necessary. The operation is generally followed by some cough, but this soon passes off, leaving the part and system comparatively comfortable. When the spasm is unusually great, threatening suffocation, I have found the best remedy to be the inhalation of a little chloroform, which usually affords almost instantane- ous relief. The operation in chronic disease should not be repeated oftener than once every third or fourth day ; in acute affections, on the contrary, it may be necessary to perform it once or even twice a day. Injections of nitrate of silver may be practised when the disease is situated in the trachea aud bronchia beyond the reach of the probang. The parts having been thoroughly educated as in the previous case, and the patient's head being retracted, and the tongue depressed, a narrow gum-elastic catheter, about thirteen inches in length, is inserted into the mouth of the larynx, and thence passed rapidly on into the windpipe, leaving only about two inches and a half of the tube projecting beyond the front teeth. The nozzle of a small syringe is then introduced into the catheter, and the fluid thrown in as quickly as possible, lest the procedure should provoke violent coughing, and thus prove abortive. The strength of the solution should vary from ten to thirty grains to the ounce, to be gradually increased with the tolerance of the parts; and the quantity injected should not at any time exceed a drachm and a half, one third, or less, of this being quite sufficient at the beginning of the treatment. The operation, which is often followed by severe spasm, and which requires unusual dexterity for its successful execution, may be repeated once every third, fourth, or fifth day, according to the exigencies of the case. When the object is merely to medicate the larynx, or the larynx and upper part of the trachea, the operation may be performed with the instrument delineated in fig. 263, devised by Mr. Erichsen. It consists of a silver tube, perforated at the end, and provided with a piston having a sponge attached to its lower surface. The syringe, charged in the usual manner, is passed INTRODUCTION OF TUBES. 443 into the pharynx, or between the lips of the glottis, and the fluid is thrown into the air-passages in a number of fine jets. Fig. 263. ^jjggaMjt Erichsen's laryngeal syringe. When the fauces and air-passages are very irritable, or the patient is uncom- monly timid or unmanageable, it will be well, as suggested by Dr. Green, to institute a kind of preliminary treatment, consisting in the frequent applica- tion of the finger and of various instruments to the tongue and throat, so as to educate the parts for the approaching ordeal, in the same manner as prior to the operation of staphylorraphy. If the fauces are inflamed, they should at the same time be occasionally touched with nitrate of silver. 13. INTRODUCTION OF TUBES. The introduction of tubes into the windpipe becomes necessary whenever that canal is opened for the purpose of promoting the ingress of the air, in cases of mechanical obstruction, however induced. The only exception to this rule is, or should be, when the respiratory difficulty is occasioned by the presence of a foreign body in the air-passages, and where, consequently, a tube, worn in the trachea, might interfere with the expulsion of the substance. Tubes of this kind are generally made of silver ; they should possess the qualities of lightness and of accurate adaptation to the parts which they are destined to serve. Their length varies from an inch and a half to two inches and a quarter, according to the stature of the patient, and their diameter should be such as to admit of easy introduction, without at all encroaching upon the surface of the windpipe. Their shape is cylindrical, with a slight antero-posterior curvature, the concavity of which is directed forwards. The superior extremity of the instrument is provided with two rings, for the pas- sage of tapes, which, being tied at the back part of the neck, secure it firmly in its place. Most instruments of this kind are now made double, as seen in fig. 264, the inner one, which is nearly a fourth of an inch longer than the outer, being so constructed as to admit of easy removal for the purposes of cleanliness. This is a matter Fig- 264. of paramount importance, as the tube soon becomes clogged with thick, tough, adherent mucus, thus rendering frequent withdrawal absolutely indispensable. Meanwhile, the outer instrument, or sheath, being retained, the in- troduction of the inner is thereby much facili- tated ; so that, in fact, the operation may readily be intrusted to any intelligent nurse, a great convenience, both in city and country prac- tice. The two tubes are fastened together by a button. The breathing orifice should Trachea tube. always be carefully covered over with a piece ot gauze to prevent the ingress of flies and other extraneous substances. " hen a tube is intended to be worn in the larynx, it will generally be necessary to remove an elliptical section of the crico-thyroid membrane, in 444 DISEASES AND INJURIES OF THE AIR-PASSAGES. order to afford sufficient room for its accommodation. Occasionally, the object may be attained by a large crucial incision. The length of time during which such an instrument should be worn must, of course, depend upon circumstances, or, more properly speaking, the neces- sity which led to its introduction. In some instances it may be dispensed with in a very short time, while in others it may require to be retained for years, if not during the remainder of life. In case of acute disease the tube should not be removed until all danger of suffocation is passed, as the wound, generally, rapidly contracts, and might thus lead to a return of dyspnoea. Whenever the patient wishes to speak, he must place his finger upon the orifice of the instrument. When bronchotoray is performed for the relief of croup, diphtheria, and similar affections, the windpipe should not be sucked, with a view of pro- moting respiration, without the precaution of washing out the mouth and throat well, immediately after, with a strong solution of chlorinated soda, or some other disinfecting fluid, for the purpose of promptly neutralizing the poison contained in the secretions of the parts. For the want of such pre- caution, several valuable practitioners have recently lost their lives, while a number of others have suffered severely without fatal consequences. 14. FOREIGN BODIES. The air passages are liable to the intrusion of a great variety of substances, referable to four distinct classes, the vegetable, animal, mineral, and mixed, the latter comprising such as are partly vegetable and partly animal, partly animal and partly mineral, or partly mineral and partly vegetable. Of these different substances, those which most commonly enter the air-passages, at least in this country, are grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Bits of meat, bone, and gristle are also very frequent in- truders. Pieces of coin, pins, buttons, and similar articles are extremely liable to be entrapped in the windpipe, in consequence, apparently, of the foolish habit, so common everywhere, of holding such substances heedlessly in the mouth. I have been made acquainted with quite a number of cases, one of which fell under my own observation, in which the foreign body was a cockle-bur, represented in fig. 265. Substances of extraordinary size sometimes pass into the air-tubes. Thus, in a case of a child between three and four years of age, communicated to me by Dr. Zebra Foote, of Indiana, the foreign body, a brass pen-holder, was three inches and a half in length by three lines Fig. 265. Fig. 266. Cockle-bur. Ear of grass. in diameter. It had descended into the left bronchial tube, where it was found after death, nine months after the accident, surrounded by thick matter. Several cases have been reported of the accidental inhalation of ears of rye, wheat, barley, and grass, as in fig. 26G. Worms, especially the lumbricoui FOREIGN BODIES. 445 variety, have been known to creep into the windpipe; and at least one case has occurred of death from the introduction of a leech into the sinus of the larynx. Gautier gives an instance of death from the inhalation of a small fish. In my Treatise on Foreign Bodies in the Air-Passages, a number of cases are mentioned in which teeth, both natural and artificial, were inhaled. In several of the cases, the artificial teeth were connected together by metal, as in fig. 267. In this instance, the substance was retained for thirteen years, and was found, on dissection, in the right thoracic cavity, into which it had passed by ulceration. Mr. Xunn has published the particulars of the case of Fig. 267. Fig. 268. Artificial teeth. Puff dart. a man who drew a puff dart, represented in fig. 268, into his windpipe. Occa- sionally, the entrapped substance has been a bullet, as in two instances, re- ported to me by Dr. Maxwell, of Indiana, and by Dr. Stitt, of Kentucky. Two, three, and even four foreign substances occasionally enter the air- tubes, eithes simultaneously or successively. Dr. Sipe, of Missouri, has com- municated to me the particulars of the case of a child, who, when the larynx was opened, ejected not less than a dozen fragments of parched corn. Dr. Mount, of Cincinnati, met with an instance, in an infant five weeks old, who, after the operation of laryngo-tracheotomy, expelled four pieces of unburnt coffee, three immediately, and the other and largest one the next day. Sometimes the substances are of a dissimilar character. Thus, in a case observed by Professor Van Buren, of Xew York, the child, upon the windpipe being opened, coughed up a water-melon seed and the shank of a plum. Situation.—The foreign body may be arrested in different portions of the windpipe, or it may remain loose, and move up and down the canal during the expulsion and introduction of the air. Occasionally, it is stopped at the very entrance of the larynx; but, more frequently by far, it passes into the interior of this tube, and lodges in one of its ventricles. It is not often arrested in the trachea, or, if arrested there, it does not long remain. Instead of this, after having passed the larynx, it generally, either at once or at a very early period, descends into one of the bronchial tubes, from which, however, during a violent expiratory effort, it may again be impelled upwards, not only into the trachea, but even into the larynx. A needle, piu, bit of bone, or, in short, any sharp and slender body, might be permanently retained in the trachea, in consequence of its extremities becoming implanted in its walls; so also might a cockle-bur, a piece of meat, a lump of cheese, or a piece of sponge. A solid or heavy body, as a bullet, pebble, shot, or grain of corn, will, on the contrary, be almost certain to pass at once into the bronchial tubes, in obedience simply to the laws of gravity. When a foreign body passes into the bronchial tubes, its tendency is to lodge in the right; a circumstance which has long been known, and variously explained. Thus, it has been supposed to be owing to the differences in the capacity and direction of the two tubes, the right being larger than the left and placed more horizontally. The real cause, however, would seem to be the "dge, or spur, in the lower part of the trachea, the position of which, towards 446 DISEASES AND INJURIES OF THE AIR-PASSAGES. the left of the mesial plane, has the effect of throwing the foreign body, as it descends, over towards the right side, an effect still further favored by the greater diameter of the passage. Sometimes, each bronchial tube contains a foreign body; and occasionally, again, although rarely, the substance is forced on beyond the primitive division into a secondary one. The glottis, although by far the most common, is not the only, avenue by which foreign bodies may reach the windpipe; occasionally they enter the tube from without, either by penetrating the skin and muscles of the neck, as in the remarkable instance observed by De La Martiniere, in which a little boy, in cracking a whip, forced a brass pin into the windpipe; or they may be pushed into the passage from the oesophagus, in consequence of the attempts made to extract them from this canal, as in the case which occurred to Dr. Eve. Again, foreign bodies may enter the lungs through the walls of the chest, instead of passing into them by the more natural and common route of the glottis. Expansion.—When the foreign body is of a vegetable or animal nature, it is liable to imbibe some of the moisture of the surface with which it lies in contact, and thus increase in volume. The heat of the part no doubt also contributes to this result. The degree of expansion, which may be produced under the joint influence of these causes, varies too much to admit of precise statement. Beans, peas, and grains of corn, seem to be particularly prone to increase in bulk ; sometimes a great deal even in a very short time. Occa- sionally the substance exhibits signs of germination. On the other hand, there are certain bodies which are incapable of thus expanding, as melon, orange, pear, and similar seeds, beef, cartilage, tendon, apple, cabbage, turnip, and other vegetable matter. It is probable that the particular situation of the foreign body has some influence upon the change of bulk and consistence wrought upon it during its sojourn in the windpipe. A substance impacted in one of the bronchial tubes would be likely, I think, to experience this change in a greater degree, as well as more rapidly, than one lodged in the trachea, or larynx. The ex- tent of contact should also be taken into account; and, finally, the character and quantity of the secretion excited by the presence of the extraneous body. When a foreign body is long retained, especially in one of the bronchial tubes, it not unfrequently becomes incrusted with various kinds of matter, as inspissated mucus, mucus and lymph, lymph alone, or carbonate and phos- phate of lime. Pathological Effects.—The foreign substance may produce various changes in the structures with which it lies in contact, as well as in those in its neigh- borhood. Occasionally, though rarely, remote parts, as the lungs, trachea, and larynx, become affected, either primarily or secondarily, in consequence of the irritation thus induced. One of the most common of these effects is inflammation of the mucous membrane, generally, however, of limited extent. When the foreign body is bulky, and creates great inconvenience, or is retained for a long time, the morbid action becomes diffused, often spreading a considerable distance be- yond the part originally affected, and leading to deposits of lymph, if not also to softening. In chronic cases, the mucous membrane is liable to be- come thickened, indurated, and deeply congested. Ulceration is uncommoo. Sometimes, though rarely, the foreign substance is partially surrounded by lymph, which thus serves to fix it in its situation. When the extraneous substance is retained in the bronchial tubes, serious disease is liable to occur in the lungs, especially inflammation, which some- times involves an entire lobe, if not the whole of the corresponding organ; sometimes, indeed, the mischief extends even to the other lung, or both vis- cera may suffer simultaneously. Occasionally abscesses form, and continue FOREIGN BODIES. 447 to discharge for an indefinite period; they generally occur at the seat of the obstruction, or in its immediate vicinity, but sometimes at remote points. Their contents are of an unhealthy character, being more or less fetid, tinged with blood, and intermixed with mucus. The pulmonary tissues around them are usually densely hepatized, and deeply discolored. Sometimes, again, the foreign substance, especially if retained for any length of time, induces a deposit of tubercular matter in the tissues immediately adjoining it. Pulmonary emphysema is another effect, but also a very rare one, and the same remark is true of cedenra of the larynx. The bronchial lymphatic ganglions are also liable to suffer. The most common alterations are enlargement, preternatural vascularity, and softening of their substance. Suppuration is infrequent. The morbid action some- times extends to the pleura, leading to effusion of serum and lymph, exten- sive adhesions, and also, occasionally, to the formation of pus. It is a singular fact that all these pathological changes may occur, to a greater or less extent, in cases where the obstruction is exclusively seated in the larynx or in the upper portion of the trachea. In a few instances the heart and pericardium have been found inflamed, but whether from an extension of the morbid action from the respiratory organs, or from embarrassment in the pulmonary and cardiac circulation has not been determined. When abscesses form after this accident, whether as a consequence of simple pneumonia or of the softening of tubercular deposits, the matter gene- rally passes into the bronchial tubes, whence it is afterwards discharged by coughing or expectoration. Occasionally it points externally at one of the intercostal spaces, where it sometimes forms an opening, through which the foreign body ultimately escapes. Dr. John L. Atlee has communicated to me the particulars of a case in which he ruptured a large abscess in the lung in an attempt at extracting the foreign body. When the substance is long retained, it may excite ulceration of the bronchial tube, and finally drop into the pleural cavity, causing fatal inflammation. Symptoms.—The symptoms which follow and accompany this accident may be divided into those which take place at the moment of the introduction of the foreign body, and those which arise in consequence of its sojourn in the air- passages. This distinction, although recognized by most writers, has not received the consideration to which its importance, practically speaking, entitles it. The moment a foreign substance, however small, touches the windpipe, it excites severe distress and coughing, on account of the spasmodic action of the muscles of the larynx. We have a familiar illustration of this in the suffering which occurs when a drop of water, a crum of bread, or a particle of salt accidentally slips into the glottis. Instantly the most violent distress is excited, which generally continues until the intruder is dislodged from a situa- tion which nature never intended it to occupy, and where it could not remain long without causing serious structural mischief. But these symptoms are, in general, slight and transient compared with those that attend the intro- mission of a foreign body, properly so called. In the latter case, the patient is usually in imminent danger of suffocation, and he may, indeed, regard him- self as being very fortunate if he escapes with his life. In the great majority of instances, he is seized with a feeling of annihilation ; he gasps for breath, looks wildly around, coughs violently, and almost loses his consciousness. His countenance immediately becomes livid, the eyes protrude from their sockets, the heart beats tumultuously, the body is contorted in every possible manner, and froth, or froth and blood, issue from the mouth and nose. Now and then he grasps his throat, utters the most distressing cries, or falls down in a state of insensibility. Sometimes he vomits, especially if the accident occurs 448 DISEASES AND INJURIES OF THE AIR-PASSA(iES. after a full meal; and the relief occasionally experienced from this source is very great. In some instances, again, there is an involuntary discharge of feces and even of urine. A considerable quantity of pure blood is occasionally thrown up during the violent coughing immediately consequent upon the accident. The duration of the first paroxysm varies from a few seconds to several minutes, or, in severe cases, as when the foreign body is arrested in the larynx, even to several hours. Writh the restoration of the respiration, the features resume their natural appearance, and the patient recovers his con- sciousness and power of speech. The voice, however, frequently remains somewhat altered, the breathing is more or less embarrassed, and the indivi- dual is harassed with frequent fits of coughing, often attended with a recur- rence of all, or nearly all, the original symptoms. Thus the case may pro- gress for an indefinite period, until the foreign body is expelled, or until it produces death by disease of the air-passages. Should the obstruction be kept up, even if it be only for a few days, the patient will be in twofold danger; for he will not only be liable to be suffo- cated at any moment by the foreign body passing up into the larynx, during a paroxysm of coughing, but the probability is that the lungs, resenting its presence, will take on inflammation, which no skill, however well directed, can always effectually arrest. Occasionally there is almost an entire absence of symptoms. The foreign body seems to be in a state of latency, causing little or no inconvenience. Thus, in a case reported by Louis, the patient, after the first few minutes, did not experience any bad symptoms for an entire year. At the end of that time, he coughed up a cherry-stone, followed by such a copious expectoration as to kill him in three days. The cough is usually spasmodic, sudden, short, and uncontrollable, lasting from a few seconds to half an hour or more. During its existence the pa- tient frequently experiences a sense of tickling in the throat, with soreness and pain in the respiratory tubes and at the top of the sternum ; the coun- tenance is suffused and even livid; the brain is oppressed by sanguineous determination; and if the paroxysms be violent and protracted, there is sometimes a discharge of blood from the nose and mouth. Sometimes the cough is of a croupy character, and when this is the case, it may be very difficult to ascertain the true nature of the affection, or to determine whether the symptoms really depend upon disease of the larynx, or upon the presence of a foreign body. The cough, after having existed for a short time, may disappear, and never recur. It is occasionally influenced by the patient's posture. Thus, he may be perfectly free while sitting up, or lying down, but the moment he rises, or moves his body, he may be seized with a violent paroxysm. The voice is variously affected. Generally it is natural, or so nearly natu- ral as to render it difficult, if not impossible, to detect the change. Occa- sionally, however, it is remarkably altered, both in quality and strength. Sometimes it is croupy, hoarse and low, sharp and sibilant, or as if cracked. Now and then it is reduced to a mere whisper, or entirely extinct. These alterations may occur immediately after the accident, or not until the foreign body has set up irritation in the vocal cords. Sometimes the power of speech is temporarily lost, and then returns, either suddenly or gradually, without any assignable cause. The expectoration is ordinarily of a thin, sero-raucous appearance, and varies in quantity from a few drachms to several ounces in the twenty-four hours, according to the frequency and violence of the cough. Not unfre- quently it is very thick and ropy, more or less opaque, and remarkably abun- dant. Occasionally it is of a dirty, rust-colored aspect, or tinged with blood. FOREIGN BODIES. 449 When cavities form around the foreign body, whether in consequence of gan- grene, or the softening of tubercular matter, the expectcTration may be almost insupportably offensive. Sometimes the patient throws up blood, either pure or mixed with frothy matter. The quantity is usually very small, not exceeding a few drachms. The accident may occur immediately after the introduction of the foreign substance, or not until serious structural changes have taken place in the lungs. The pain which follows this accident is subject to much diversity, depend- ing upon various circumstances. Generally it is very slight, at all events until the resulting inflammation has produced serious structural lesion. In its character, it may be sharp and pricking, or dull, heavy, and aching; it may be limited to the seat of the foreign body, or it may pervade the tra- chea, larynx, bronchial tubes, and lungs, if not also the throat, oesophagus, and muscles of the chest. It is generally accompanied with a sense of con- striction, tightness, or suffocation, and is liable to be aggravated whenever the patient coughs, or there is the slightest change in the situation of the foreign body. It may also be stated, as a general rule, that the pain will be greater when the foreign substance is large and rough than when it is small and smooth. The pain occasionally remains fixed for a long time at one spot, and then suddenly shifts to another. It appears to be most apt to become fixed when the foreign body is impacted, or immovable. Sometimes the pain remains at its original site long after the extrusion of the foreign substance. Instead of pain, the patient occasionally experiences a feeling of soreness. This may occur at various points of the respiratory apparatus, and is, per- haps, more frequently present than the practitioner is aware, owing to the want of a thorough examination, or the fact that the patient is not always able to indicate the nature of his suffering. No substance can remain for any length of time in the air-passages without causing more or less serious disturbance in the respiratory functions. The patient has hardly escaped from the immediate effects of the accident before his life is endangered by inflammation, which, if not promptly subdued, may speedily prove fatal. This effect, which is always to be dreaded in every case of the kind, devolves upon the attendant the absolute necessity of fre- quent examinations of the chest, both by auscultation and percussion. One of the most remarkable circumstances after this accident is that, while the patient can freely inspire, he often finds it almost impossible to expire. This is particularly the case when the foreign body lies in one of the bronchial tubes, which may be thus almost completely closed, neither allowing the air to enter nor to pass out of it. Nevertheless, as the other canal remains free, inspiration may be carried on with considerable vigor, whereas every attempt to expel the air from the obstructed lung will be attended with great suffering and a feeling of exhaustion. If, under such circumstances, the ear be applied to the chest, the respiratory murmur on the affected side will be found to be either entirely inaudible, or but faintly appreciable, while on the sound side it will either be perfectly natural, or more or less puerile, if not characterized by various rales. Whenever this happens, the thorax will be found everywhere perfectly clear, on percussion; the reverse being, of course, the case when there is hepatization from disease, or excessive engorgement of the pulmonary tissues, as will necessarily occur in nearly every instance, within a short time after the foreign body has reached the air-pas- sages. Occasionally, the air, as it rushes by the foreign body, produces sounds so peculiar that they may be regarded as pathognomonic of the nature of the affection. Thus, in a case observed by Mr. McNamara, of tmblin, the noise resembled that produced by blowing through a whistle, the foreign substance, a plum-stone, being perforated at the middle. Occa- vol. ii.—29 450 DISEASES AND INJURIES OF THE AIR-PASSAGES. sionally the substance, as it plays up and down the windpipe, produces a peculiar flapping s<3hnd. Finally, the symptoms may be of an asthmatic character. The posture of the patient varies. Generally he finds it most agreeable to sit up ; for as soon as he attempts to lie down he is seized with an increase of erabarrassraent of breathing, with a disposition to cough and a feeling of suffocation. During sleep he is consequently obliged to be propped up in bed, or to get what rest he may be able to obtain in a chair. Sometimes, however, he lies best on his back, or on one side. The general health is variously affected; sometimes slightly, sometimes severely, sometimes, again, not at all. In most cases, however, even in those in which the foreign substance is not retained beyond a few days, the system is feverish, and the patient suffers from want of appetite and sleep, attended with an anxious expression of the features. If the irritation continue, inflam- mation of the lungs and air-tubes soon takes place, with an aggravation of the cough, emaciation, and loss of strength. Diagnosis.—As these accidents occur most frequently in infants and chil- dren, who can but ill express their feelings, one of the first duties of the practitioner is to inquire, most carefully and circumstantially, into the history of every case that may be brought under his observation. Yery frequently some time elapses before he can reach the patient, or it may be that, although the interval between the occurrence and his visit may be very short, the first symptoms may have entirely disappeared, and the patient act and feel as if nothing had taken place. Now, it is just in such cases as these that errors are most liable to happen ; for the reason that the professional attendant, seeing that there is apparently nothing the matter, allows his mind to be lulled into a state of security, frequently not less injurious to himself than destructive to his patient. It is generally different with adults, who are usually conscious of the time and manner of such accidents, and who, there- fore, rarely fail to give a correct account of them. If the patient, supposing him to be a child, has been playing with a grain of corn, bean, pebble, or similar body, and has been suddenly seized with symptoms of suffocation, violent spasmodic cough, lividity of the face, pain in the upper part of the windpipe, and partial insensibility, the presumption will be strong that the substance, whatever it may have been, has slipped into the air-passages, and is the immediate and only cause of the suffering. The presumption will be converted almost into positive certainty if the child was just previously in the enjoyment of good health; if he was romping, jumping, or laughing at the moment of the accident, with the substance, per- haps, in his mouth, or while attempting to throw it into that cavity; and especially, if the symptoms, after having been interrupted for a few miuutes, continue to recur, with their former, or even with increased, intensity, at longer or shorter intervals. The symptoms here enumerated, however, are sometimes, it must be confessed, most painfully simulated by the cough and embarrassment of breathing occasioned by cold and other affections. The difficulty in arriving at a correct diagnosis is still further augmented, in some of these cases, by the coincidence of the respiratory trouble and the fact of the child, at the moment of the seizure, having been engaged in playing with a substance such as that above mentioned. Important information may frequently be obtained, in these accidents, by a careful exploration of the chest by means of auscultation and percussion. This is particularly the case when the foreign body is situated in the lower extremity of the trachea, or in one of the bronchial tubes, where, especially if it be bulky, or pretty firmly impacted, it must necessarily affect, more or less seriously, the respiratory functions, and thus manifest itself by the altera- tions which it induces in the sounds of the lungs and chest. These alterations FOREIGN BODIES. 451 are always less distinct, and, indeed, not unfrequently entirely absent, when the extraneous substance occupies the larynx, or the upper portion of the trachea. A stethoscopic examination, however, although generally useful, and, there- fore, never to be omitted, does not always afford satisfactory evidence of the nature of the case. Of the truth of this fact my observation has furnished me with several instances, in none of which, notwithstanding the most careful and repeated exploration, could the situation of the intruder be determined. Two circumstances may be mentioned as likely to occasion such a result. In the first place the auscultatory signs may be masked by previous disease, or by disease awakened soon after the occurrence of the accident, as inflamma- tion of the windpipe, lnngs, or pleura; and, in the second place, the patient, especially if a child, may offer such resistance, either by his movements or cries, as absolutely to prevent the possibility of a thorough exploration. In the latter case, the obstacle may always be promptly and effectually sur- mounted by the use of chloroform. Some inference, too, of a diagnostic character, may generally be drawn from the nature of the foreign substance. Ponderous bodies, such as bullets, shot, metallic buttons, pebbles, and pieces of coin, generally at once descend into the bronchial tubes, from which they will afterwards be unable to rise in the act of coughing, sneezing, or any other violent expiratory effort, as bodies are liable to do when they are of an opposite description. If the foreign body be large, and at the same time very rough, angular, or spiculated, it will probably be arrested in the larynx or the trachea. The same circumstance will be likely to occur if it be long and narrow, as in the case of a needle, pin, nail, or fish-bone, unless it should happen to enter the glottis vertically, when it may at once fall into one of the bronchial tubes. In some instances, as stated elsewhere, the foreign substance is capable of producing a peculiar noise, occasionally detectable even at a distance from the patient's body. No definite information can be derived from the state of the voice when the foreign body lies in the trachea or in one of the bronchial tubes. Under such circumstances, it may be more or less changed* or, in rare cases, perhaps, even entirely absent; but as the alterations are not peculiar, but altogether similar to those produced in ordinary affections of the air-passages, it is evident that they are of no diagnostic value. The reverse, however, is the case when the foreign substance is retained within the larynx ; for then the changes in the vocal functions, if not actually characteristic, may, in conjunction with other symptoms, afford most important, if not conclusive, information. The pain accompanying this accident cannot be regarded as diagnostic, inasmuch as it may be produced by other causes, as inflammation, neuralgia, or spasm of the air-passages. The symptoms of extraneous bodies in the respiratory organs may be imitated by different diseases, either directly affecting these organs or acting upon them sympathetically. Of these diseases the most important are croup, hooping-cough, ulceration of the larynx and trachea, aneurism of the aorta, and worms in the intestines. It is generally easy to distinguish between the symptoms of a foreign body and those of spasmodic croup, by observing that, in the latter affection, the chief difficulty of breathing exists during inspiration, while in the former it exists during expiration. Important information may also be derived from the state of the voice, which is usually characteristic in croup, and from the state of the pulse and skin, which are rarely excited until after the extraneous substance has had time to cause inflammation and sympathetic irritation, whereas they are usually more or less seriously disturbed at an early stage in 452 DISEASES AND INJURIES OF THE AIR-PASSAGES. laryngeal disease. Besides, in the latter affection, the symptoms are con- tinued, whereas in the case of a foreign body in the air-passages, there are frequent intermissions, followed by sudden aggravations of suffering. Pro- fessor J. B. S. Jackson, of Boston, has communicated to me the particulars of two cases, in which the symptoms produced by foreign bodies in the air- passages were mistaken for those of membranous croup. Alarming symptoms, simulating those of a foreign body in the air-passages, may arise during an attack of hooping-cough. Here mistake may be pre- vented, first, by a careful consideration of the history of the case; secondly, by the existence of the peculiar hoop, which is always wanting in the latter affection ; and lastly, by the fact that the embarrassment of breathing occurs in this disease, as in croup, not during expiration, but during inspiration. Spasm of the glottis, by producing suffocation, may give rise to symptoms simulating those of a foreign body in the windpipe. A common cause of this is ulceration of the larynx. Should such an occurrence take place while the patient is eating, it would be very natural to ascribe it to the presence of a foreign body in the air-passages, although these passages might be entirely free from mechanical obstruction. The diagnosis, in such an event, would, of course, be extremely difficult, if not impossible. The history of the case might furnish some clue, though hardly any of a satisfactory character. Upon whatever cause the symptoms depend, tracheotomy alone would be likely to save the patient, and it should, therefore, be performed without delay. Similar embarrassment may arise from an aneurism of the thoracic aorta. The pressure of such a tumor may produce great narrowing both of the tra- chea and of the bronchial tubes, particularly the latter, thereby seriously impeding the passage of the air to the lungs. The diagnostic signs, in cases of doubt, are the gradual approach and persistent character of the symptoms in aneurism, and their sudden, violent, and intermittent character when occa- sioned by the presence of an extraneous substance. Moreover, it is worthy of note that such accidents are most frequent in children, while aneurism of the thoracic aorta is almost exclusively confined to elderly subjects. The sympathetic irritation induced by worms in the alimentary canal, may closely simulate the phenomena produced by the presence of a foreign sub- stance in the windpipe. The most certain diagnostics, in circumstances of doubt, are the history of the case, and the prompt relief which usually follows the exhibition of anthelmintic remedies, when the affection is of a verminous character; and the failure of these means, when the symptoms depend upon the presence of a foreign body. Symptoms, closely resembling those produced by foreign bodies in the air- tubes, may be caused by the lodgment and impaction of extraneous substances in the pharynx and oesophagus. This fact shows the importance of thoroughly examining, in all cases of doubt, the latter passages with the finger and pro- bang before we attempt an operation for the relief of the patient, or before we rest satisfied that the obstruction is really in the windpipe. From the want of such precaution serious consequences might arise. Finally, it is well known that if a foreign body, such, for instance, as a piece of meat, or cartilage, is retained even for a short time in the oesophagus or fauces, the irritation occasioned by its presence will often remain for hours, if not days, after its removal. Such is the distress sometimes, under these circumstances, that it is very difficult to persuade the patient that the sub- stance is not still in its original situation. As the same thing may occur when the foreign body is in the windpipe, the practitioner, unless fully on his guard, may be led into most serious error. Indeed, there is reason to believe that bronchotomy has occasionally been performed in such cases. It is not always easy to determine, from a consideration of the history and symptoms of the accident, whether the offending substance is in the larynx, FOREIGN BODIES 453 or in some other portion of the windpipe Our knowledge upon the subject, indeed, is far from being satisfactory. From an analysis of sixteen cases of foreign bodies in the larynx, I am led to conclude, that, as a general rule, whenever there is aphonia, whether par- tial or complete, the substance is situated in this portion of the windpipe; at all events, there is a strong probability that this is the case, a probability which is converted into perfect certainty, if, conjoined with this symptom, there is pain, soreness or uneasiness in the region of the larynx, along with dyspnoea, a whistling sound in respiration, absence of serious disease in the bronchial tubes and lungs, and inability, on the part of the observer, to per- ceive the offending body moving up and down the trachea. It is important, however, in reference to this subject, to bear in mind that the voice may be seriously affected, and yet the foreign body not be lodged in the larynx, but in the trachea, or in one of the bronchial tubes. When a foreign body descends into one of the bronchial tubes, the respira- tory murmur in the corresponding lung is generally more or less affected. The wall of the chest, however, is not always, perhaps not even generally, dull or flat, as in pneumonia and phthisis, in which the parenchymatous sub- stance of the organ is condensed by abnormal deposits; on the contrary, the sound is frequently unnaturally clear and resonant, very much, indeed, as in pulmonary emphysema. This peculiarity is sometimes recognized over the entire lung; while at other times it is limited to particular portions, as one- half, a third, or one-fourth, according to the size and situation of the foreign body. When the extraneous substance is so large as to obstruct the bron- chial tube completely, there must necessarily be marked dulness on percussion, and great diminution, if not entire absence, of motion in the ribs. The respiratory murmur, under the same circumstances, may be very much diminished, or wholly absent, according to the amount of the pulmonary obstruction. In most instances it is lessened only somewhat in intensity, because a certain quantity of air still enters the lung by the side of the foreign body. It is only when the extraneous substance is very bulky, or when the tube is completely closed by it, or partly by it, and partly by abnormal de- posits, as mucus or lymph, that the respiratory murmur can be no longer recognized, or only in the most imperfect manner. It has already been seen that the extraneous substance may change its place in consequence of the impulse which it receives during coughing, during violent expulsive efforts of the lungs, or even during the various movements of the body. Thus, in one of my cases, the foreign body, a grain of corn, was impacted for upwards of a week in the right bronchial tube, when, all of a sudden, during a severe paroxysm of coughing, it passed over into the left, where it was discovered on the dissection. Its former presence on the right side was denoted not only by the alterations in the respiratory murmur and the extraordinary resonance on percussion, but by the peculiar pathological ap- pearance of the mucous membrane in the right bronchial tube. It should also be recollected that the changes in the respiration may be materially influenced, if not entirely masked, by the deposits produced by the irritation of the foreign substance; thus frequently divesting them of their diagnostic value. The foreign body occasionally plays up and down the trachea, either in consonance with the respiratory movements, or in consequence of severe fits ot coughing. During these changes, it is very apt to cause severe spasm and irritation by impinging against the mucous membrane of the larynx, sufficient, in some instances, to induce suffocation. In many of these cases the patient is rendered conscious of this occurrence, not only by the pain and spasmodic c°ugh, but by the peculiar sensation which the substance produces as it passes up and down the windpipe. Sometimes, again, the extraneous body can be 4ot DISEASES AND INJURIES OF THE AIR-PASSAGES. distinctly felt and even heard during these moveraents, as happened in an interesting case observed by Professor May. The patient was a child five years old; and the substance, a grain of corn, could be distinctly heard and felt at every expiration as it struck the upper part of the trachea. Occasionally, the noise produced by the foreign body, or, more properly speaking, by the air as it rushes past it, is so peculiar that it may be regarded as pathognomonic of the nature of the accident. Sometimes the sound is of a whistling nature; at other times, it resembles a cooing rhonchus; and now and then it is a peculiar, flapping noise. The preceding facts will, commonly, enable us to determine whether the foreign substance is firmly impacted in one of the bronchial tubes, or whether it is liable to move up and down the trachea during coughing and respira- tion. It may be assumed, as a general rule, that the substance, whatever it may be, remains loose. This is often true in cases even of long standing, but it is particularly so of recent ones, before the occurrence of much secre- tion, tending to attach the foreign body or impair its mobility, and before the development of serious structural lesion, as, for example, the formation of an abscess, in which the body may become permanently imprisoned, When we add to the above facts the absence of all laryngeal disease, and the unaffected state of the voice, the conclusion will be inevitable that the in- truder is lodged in one of the bronchial tubes, or alternately in one of these tubes and in the trachea. I do not think it is possible to determine, from anything that has yet transpired, whether a foreign body is permanently arrested in the trachea. The number of such accidents is exceedingly limited, and the phenomena attending them have been studied with too little attention to justify us in deducing from them any special conclusions. Spontaneous Expulsion.—Almost every possible variety of substance, capable of entering the windpipe, may be spontaneously expelled. In my Treatise on Foreign Bodies in the Air-Passages, I have given the particulars of numerous cases illustrative of the subject. Among the more ordinary substances may be mentioned cherry-stones, nuts and fragments of their shells, water-melon seeds, beans, grains of corn and of coffee, bits of bone, nails, and tacks; among the more uncommon, teeth, pieces of coin, bullets, cockle-burs, and ears of grass and grain. Professor Hamilton has communicated to me the particulars of an instance in which a tin whistle was spontaneously ejected. Nunn, Colles and Heustis have, respectively, reported cases in which riddance was thus effected of a puff-dart, a pop-gun, and a piece of feather nearly two inches in length. The expulsion usually occurs in a paroxysm of.coughing, and the effort is no doubt greatly facilitated by dependency of the head, as when it is hanging over the edge of the bed. In forty-nine cases, tabulated in the work above referred to, riddance was effected, in this manner, in thirty-seven; in one in sneezing; in oue in dreaming; and in one in spontaneous vomiting; the mode of expulsion in the remainder not being mentioned. Two cases have been communicated to me of the spontaneous expulsion of bullets in the act of coughing. At least two cases, in which shot were similarly disposed of, are upon record. In all these instances the patient's head was at the moment in a state of dependency. The time at which the expulsion occurs varies from a few hours to many years. In a case reported to me by Professor Flint, of New York, nearly three years elapsed ; and Dr. Wulkupf, of Kentucky, has communicated to me the particulars of one of upwards of eleven years' interval. In general, it will he found that the patient recovers after riddance has been effected; but, now and then, he perishes from the injury sustained by the sojourn of the foreign sub- stance, as inflammation of the lung, or of the lung and pleura. In the case FOREIGN BODIES. 455 mentioned by Lescure, in which the foreign body, a piece of bone, was expelled at the end of seventeen years, death occurred eighteen months after the event, in consequence of the disorganized condition of the pulmonary tissues. On the other hand, the lungs may be greatly disorganized by the foreign sub- stance, and yet not cause death after riddance has been effected. In a case which came under my observation, many years ago, in a boy upwards of eleven years of age, gangrene of this organ, eventuating in the formation of a large cavity, occurred, followed by complete recovery. The expulsion usually takes place by the glottis; but now and then through the walls of the chest. In the former case, the substance generally escapes by the mouth; sometimes with a good deal of force, in a violent expiratory effort. In children, the substance is occasionally swallowed, thus creating a painful state of uncertainty in regard to its disposition, which is, perhaps, only relieved by finding it in the alvine evacuations. Treatment.—The treatment of foreign bodies in the air-passages is medical and surgical; the former being intended to protect the patient from suffoca- tion and disease of the respiratory organs, the latter to effect riddance of the intruder. An individual who has a foreign body in his windpipe should be regarded as an invalid, unfit to leave his room, or to attend to business. The treat- ment, in the early stage of the complaint, should be limited to a general supervision of the patient's health; that is, his diet should be carefully regu- lated, the bowels should be moved from time to time with mild purgatives, and the utmost attention should be paid to the temperature of the apartment, which should be uniformly maintained at about 68° of Fahrenheit. The chest should be thoroughly examined at least once a day by auscultation and percussion, to ascertain the condition of the lungs and bronchial tubes. Cough should be subdued by mild expectorants, containing, if there be fre- quent spasms, a suitable quantity of morphia. Should symptoms of pneu- monia, bronchitis, or pleuro-pneumonia supervene, they must be promptly met by the ordinary remedies, particularly the lancet, active purgatives, and tartar-emetic, aided, if necessary, by leeches and blisters. By watching the patient in this way, the respiratory organs may be protected from mischief, and the extraneous substance be expelled spontaneously ; or, should an ope- ration become necessary, he will be in a much better condition to undergo it with impunity. The expulsion of the foreign body does not always secure immunity from danger. The air-passages, irritated by its presence, may have taken on in- flammation before its extrusion, or this action may be set up soon after, and in either case the danger to life may be very great. A knowledge of this fact is of great practical importance, and cannot be too strongly impressed upon the mind of the attendant in all cases of this character. It would seem reasonable, at first sight, to suppose that emetics would be beneficial in expelling foreign bodies from the windpipe, but experience has shown that they are not only useless, but often dangerous, by impelling the intruder into the larynx, and thus causing violent spasm of the glottis. Be- sides, their employment may occasion the loss of valuable time. In forty-six cases, analyzed in my Treatise on Foreign Bodies in the Air-Passages, in which various emetic articles were exhibited, there was not one in which they were of any material service, while in quite a number they were positively injurious. Their employment should, therefore, be discountenanced. Sternutatories of every description, mild and harsh, vegetable and mineral, have been employed, with a view of aiding the expulsion of the intruder, but, with the exception of the case related by Boyer, in which the nose was tickled with snuff, while the patient was partially asleep, no benefit has fol- lowed their use. It is possible that this class of remedies might occasionally 456 DISEASES AND INJURIES OF THE AIR-PASSAGES. be beneficial, if conjoined with the use of chloroform. The proper plan would be to make the patient inhale this fluid until he is nearly insensible, and to irritate the Schneiderian membrane with snuff or some other substance the moment he begins to regain his consciousness. Should sneezing ensue while he is in this condition, with the air-tubes in a state of perfect relaxation, it is easy to conceive that the foreign body might be ejected. Nature would be taken, as it were, by surprise, as she has sometimes been by a dream, as in the remarkable case which happened to Mr. Cock, of London. A very interesting case, in which a piece of fish-bone was expelled from the windpipe under the influence of the inhalation of iodine, occurred in 1832, in the practice of Mr. Day, of England. Inversion of the Body.—This operation, as the name implies, consists in suspending the patient by the heels, or in securing his body, with the head inclined downwards, to a chair, narrow table, or other suitable object. While in this position, the chest and back are repeatedly and smartly struck with the hands, to aid, first, in dislodging the offending substance, and, next, in pro- pelling it through the glottis, or, in case of bronchotomy, through the arti- ficial opening in the neck. With the same view, the thorax is sometimes suddenly and forcibly compressed, the patient having previously taken a full inspiration. The object of this manoeuvre is to empty the lungs as rapidly and as completely as possible, in order that the air, as it rushes through the windpipe, may carry the intruder before it. The compression is usually effected with the hands, applied at opposite points of the trunk; but, per- haps, a better method is to make it with a broad bandage, arranged so as to encircle the chest, and slit at the ends, after the fashion of the bandage used in tapping the abdomen. The patient having taken a full inspiration, the extremities of the bandage are suddenly drawn in opposite directions, thereby compressing the thoracic walls equably and forcibly at every point. The great objection to this operation is the risk which the patient incurs from suffocation, occasioned by spasm of the glottis, from the contact of the extraneous body in its attempt to pass through the larynx. The only way of preventing this is either to administer chloroform, or, what is preferable, to open the windpipe as a preliminary measure. By this procedure, all danger of producing spasm of the glottis will be removed, and the foreign body will have a chance of escaping either through the larynx, or at the wound in the neck. Without this precaution, inversion of the body, unless practised with the greatest possible care, may be attended with very serious, if not fatal, consequences. In the interesting case of Mr. Brunei, recorded by Sir B. C. Brodie, inver- sion invariably produced the most distressing coughing, with symptoms of impending suffocation, compelling the experimenter at once to desist. The object was, by permitting the patient's head and shoulders to hang over a chair, while the body was in the prone position, to afford the extraneous sub- stance, a half-sovereign, an opportunity of slipping through the rima of the glottis into the mouth. During every effort of this kind, there was a distinct perception of a loose substance passing forward along the trachea, and strik- ing against the larynx. Tracheotomy was afterwards performed, and an attempt made, but in vain, to extract the coin with the forceps. Finally, at the expiration of the sixteenth day after the operation, the patient's body and shoulders were secured to a peculiar contrivance, a sort of platform, made movable on a hinge in the centre, and so arranged as to permit the head to be brought to an angle of about 80° with the horizon. The back being now struck with the hand, severe coughing ensued, followed almost immediately by the ejection of the intruder. Operative Interference___Convinced that no person with a foreign body id the air-passages can be for a moment free from the danger of suffocation, 1 FOREIGN BODIES. 457 am very decidedly of opinion that no time should be lost in opening the wind- pipe. I am acquainted with the history of quite a number of cases in which life was destroyed by waiting in the vain hope that spontaneous expulsion might occur, and thus obviate the necessity of surgical interference. A vio- lent cough coming on, the patient may drop down in a fit of unconsciousness, from spasm of the glottis, and be instantly choked to death. Now, although the operation may not be immediately followed by the escape of the foreign body, yet it will at least effectually prevent spasm of the glottis, and thus afford the extraneous substance an opportunity of being extruded either by the natural or artificial route. The patient has thus two chances of coughing it up, whereas, before, he had hardly one, the contraction of the muscles of the larynx constantly acting as a barrier to its escape. Even when the wound finally closes, without the foreign body being expelled, the operation may have been of the greatest possible benefit in preventing suffocation. The operation which is usually performed is tracheotomy, as it affords much easier access to the foreign body than laryngotomy, as well as a much better chance for its spontaneous expulsion. The latter operation, however, should always be selected when it is certain that the substance is impacted in one of the ventricles of Morgagni, unless the patient is a child, with a very short, thick neck, rendering it difficult to obtain a sufficiency of room for the easy introduction of instruments. The incision in the trachea may occasionally be advantageously prolonged into the larynx, and conversely. In laryngo- tomy it is sometimes extended upwards through the greater portion of the thyroid cartilage. The manuer of executing these operations, for this and other purposes, will be described under a distinct head. Meanwhile, it may be observed that, when it is performed for the removal of foreign bodies, the patient should always take chloroform or ether, and that the whole procedure should be conducted in the most careful and deliberate manner. The moment the operation is completed, the patient is turned upon his abdomen, with the face towards the floor. The object of this procedure is to relax the edges of the wound, so as to afford a freer passage for the escape of the foreign body, and also for the discharge of any blood that may have accidentally entered the windpipe. If the substance is not speedily ejected, the best plan will be to invert the patient's body, and to strike the chest with the hand, or with a pillow. This procedure should be tried in all cases of balls, shot, peas, beans, water-melon seeds, plum-stones, cherry-stones, button-moulds, and other similar articles. Inversion of the body, with previous opening of the tube, is a comparatively safe operation. Succussion and percussion are important auxiliaries in such a case. If these measures fail, search should be made for the substance with the forceps, or hook, with a view to its extraction ; but all such attempts should be conducted in the most gentle manner, nor should they be prolonged be- yond a few seconds at a time; inasmuch as they almost invariably excite violent coughing and suffocative feelings. The use of chloroform and the bending of the head will greatly facilitate this step of the procedure. The foreign body, both in laryngotomy and tracheotomy, may escape either at the artificial opening or by the glottis. In either case, it may be thrown to a considerable distauce, perhaps the very moment the tube is pierced; or it may be intercepted by the edges of the wound; or it may, if it take the natural route, lodge in the mouth, or pass into the stomach. Great care is taken not to permit any blood to enter at the artificial open- ing, as the smallest quantity may not only induce violent cough and spasm, but instant suffocation. Should the accident be unavoidable, the patient must immediately be turned upon his abdomen, and, if necessary, the blood must be sucked out of the tube with the mouth. It is worthy of remark that 458 DISEASES AND INJURIES OF THE AIR-PASSAGES. the thyroid veins, which are generally so much distended in consequence of the difficulty of breathing and the struggles of the patient, often cease to bleed the moment the windpipe is opened and the air is freely admitted into the lungs. When the extraneous body refuses to escape, or resists our efforts at re- moval, the edges of the tracheal wound should be kept apart by means of blunt hooks, in order to favor extrusion. No canula should ever be inserted, as it would seriously interfere with the expulsion of the extraneous substance. The outer wound should be covered, in this case, with a piece of gauze, ar- ranged in the form of a bag, to prevent the ingress of flies and dirt. Riddance having been effected, the wound is closed with adhesive strips, aided, if necessary, by a few interrupted sutures, care being taken not to carry them through the substance of the trachea. Simple water-dressing is the best application, but even this may, in general, be omitted. The after-treatment must be strictly antiphlogistic ; the respiratory organs must be diligently watched; and the air of the patient's apartment must be maintained, throughout, at a uniform temperature of about 75° of Fahren- heit. It should be remembered that no patient is safe, or out of danger, after this accident, so long as there is inflammation of the respiratory organs, whether the intruder has been expelled or not. Bronchotomy does not always insure the speedy ejection of the offending body; on the contrary, we not unfrequently see cases where the only apparent good from the operation is relief from spasm of the glottis, the extraneous substance being, perhaps, permanently retained, or, at any rate, not ejected until some time afterwards, perhaps, indeed, not until the wound is entirely cicatrized, as happened in one of ray own patients. Hence it may become necessary to repeat the operation a second, and even a third time. Instruments.—Various instruments have been contrived for the purpose of effecting the dislodgment and removal of foreign bodies. Of these, a few of the most eligible and important require particular notice. 1. Figure 269 represents a pair of forceps, constructed for me by Mr. Kolbe, after a model of my own. They are composed of German silver, and Fig. 269. The author's trachea forceps. are a little upwards of eight inches in length. The handle is considerably curved on the flat, and has two large rings for the thumb and finger. The blades, which are rounded aud very slender, are five inches long, and terminate each in a fenestrated extremity, nine lines in length by three lines in width, the outer surface being smooth and convex, the inner flat and slightly ser- rated. The great advantages of this instrument are, first, that it may be used with equal facility as a probe and an extractor; secondly, that it may be bent at any point and in any direction, according to the pleasure of the ope- rator; and thirdly, that it cannot possibly seriously impede the passage of the air, during the attempts which are necessary to explore the windpipe for ascertaining the precise situation of the foreign substance. 2. The forceps represented in fig. 270 are intended for holding apart the edges of the wound in the trachea, while the surgeon attempts to extract the FOREIGN BODIES. 459 foreign substance with other and more suitable instruments, introduced be- tween their expanded blades. I have repeatedly found them very serviceable. 3. Figure 271 represents a long slender hook, composed of silver, and well adapted for extracting foreign bodies, as beans, grains of corn, coins, prune-stones, pebbles, and bits of bone, situated in the inferior portion of the trachea, or in one of the bronchial tubes. The curved part of the instru- ment is very short and blunt at the extremity. Fig. 270. Fig. 271. Fig. 272. Trousseau's forceps. Bluut hook. Sponge mop. i- For exploring the air-passages, or dislodging foreign bodies from the arynx, especially the ventricles of Morgagni, hardly anything better could be imagined than the probe sketched in fig. 272. It is about nine inches in length, bulbous at the extremity, and composed of silver. Being flexible, &Til CmVe !"ay be '^Parted to it that may be desirable. ' ™ne instrument delineated in fig. 273 is merely a whalebone probang, 460 DISEASES AND INJURIES OF THE AIR-PASSAC ES. bent at an angle of about forty-five degrees, and surmounted at its extremity by a small piece of very soft sponge. It is admirably adapted for removing extraneous matter from the larynx, and should find a place in every surgeon's drawer. 6. Another instrument which the operator should have at hand, especially when the extraneous body is impacted in one of the. ventricles of the larynx, is a flexible, grooved director, such as is usually found in the common pocket case. The scoop-shaped extremity may be used with great advantage under such circumstances, particularly if it be slightly bent. 7. In a case recently under the care of Dr. John L. Atlee, and of his son, Dr. Walter F. Atlee, the foreign body, consisting of a piece of clay pipe- stem, an inch and a half long, was readily seized and extracted with a pair of Toynbee's ear forceps, one of the blades of which happily slipped into the interior of the tube, and thus enabled the operator to take a firm hold of it. The patient was a child four years of age, who recovered without an untoward symptom. Difficulties.—The difficulties experienced in these operations, especially in tracheotomy, arise chiefly from the imperfect manner in which the patient's head is held, extraordinary shortness and thickness of the neck, uncommon turgescence of the cervical vessels, or irregularity in their distribution, ossi- fication of the rings of the trachea, enlargement of the thyroid gland, and, finally, the occurrence of hemorrhage. These difficulties may usually easily be avoided by proper care on the part of the operator and his assistants. The rule is never to cut anything that can possibly be spared, but to hold it out of the way. Should any vessels be accidentally opened, they must immedi- ately be seized and ligated. In laryngotomy, the only artery at all in danger of being wounded is a small branch of the superior thyroid, which traverses the crico-thyroid liga- Fig. 274. Fig. 275. Tracheal plexus of veins. Middle thyroid artery ascending along the trachea. ment, and which, in the adult, is about the size of a crow-quill. In tracheo- tomy, the bleeding may proceed from the tracheal plexus of veins, fig. -?*i FOREIGN BODIES. 461 or from the middle thyroid artery, fig. 275, given off either by the innominate or the common carotid ; in some instances it is double, one offset being de- rived from the former, and the other from the latter vessel. In a prepara- tion in the possession of Dr. S. W. Gross, the middle thyroid arises from the left subclavian, about three-quarters of an inch in front of the thyroid axis. Although the hemorrhage in tracheotomy is usually insignificant, yet it may occasionally be very profuse, if not fatal; only so, however, in the hands of an ignorant, timid, or inexperienced operator. I have heard of at least half a dozen cases in which the patient perished from this cause. Occasion- ally quite a considerable flow of blood is occasioned by the division of the mucous membrane, especially when it is in a state of congestion, or inflam- matory irritation, as it is apt to be when the foreign body has been retained for any length of time. Under such circumstances, the hemorrhage will, of course, be internal, and may proceed to such an extent as to cause the most serious impediment to the respiratory function. Whenever such an occur- rence is threatened, the proper treatment consists in turning the patient as speedily as possible upon his face, in order that the fluid may escape at the artificial opening as fast as it is effused. Finally, in opening the trachea, it should constantly be borne in mind that the innominate artery and vein may ascend unusually high up in the neck, or that they may cross this tube in such a manner as to incur the risk of being wounded by the incautious use of the knife. Contra-indications.—Under no circumstances should bronchotomy be per- formed without a thorough exploration of the chest and oesophagus. It should be remembered that mere spasm of the glottis, caused by the lodg- ment of a foreign body in the fauces or gullet, or by derangement of the digestive, respiratory, and nervous systems, may induce a train of phenomena closely resembling those occasioned by the presence of a foreign body in the air-tubes. An important question here presents itself: At what period after the occur- rence of an accident of this kind should an operation be considered as im- proper? Or, more correctly speaking, what are the circumstances which contra-indicate a resort to the knife ? It must be obvious that the mere lapse of time should not be taken into the account in the decision of such a ques- tion ; for it is well known that one individual may experience as much dam- age from the presence of a foreign body in a week as another may in a month or a year. Thus, to particularize, the lungs may become seriously diseased, if not partially disorganized, in a few days, in one case, while in another they may suffer little, if indeed at all, during any stage of the accident. Hence, it should be a rule with the practitioner, in every instance of the kind, to in- stitute, as a preliminary step, a careful and thorough examination of the chest, with a view of ascertaining the precise condition of the respiratory apparatus. If this be found to be healthy, or even comparatively healthy, an operation, all other things being equal, would not only be justifiable, but highly proper, whatever length of time might have elapsed since the inhalation of the extra- neous substance; if, on the other hand, it be seriously diseased, the knife should be studiously withheld, certainly temporarily, if not altogether, on the ground that the artificial opening would be very likely to complicate the morbid action, and thereby enhance the danger both to the part and to the system. I should certainly not consider it proper to operate upon an indi- vidual who, in consequence of having inhaled a foreign body, was laboring under violent pneumonia, a large abscess, or extensive tubercular deposits. lo employ the knife, in such an event, could hardly fail to injure the patient and to throw discredit upon surgery. Mortality from Foreign Bodies.—Some very interesting statistical facts ave been furnished upon this subject by the collection of the recorded cases 462 DISEASES AND INJURIES OF THE AIR-PASSAGES. of foreign bodies in the air-passages, illustrative both of the nature of spon- taneous expulsion, and of the effects of bronchotomy. In the work already several times alluded to, I have recorded the particulars of 159 cases, in which spontaneous ejection took place in 57, 8 terminating fatally. Inversion of the body alone was successful in 5 cases, and unsuccessful in 6. Of 68 cases of tracheotomy, 8 died, and 60 recovered. Of 17 persons upon whom laryn- gotomy was performed, 13 lived, and 4 died. Laryngo-tracheotomy was prac- tised in 13 cases; in 10 the operation was followed by recovery, and in 3 by death. Thus, of the 98 cases in which the windpipe was opened for the re- moval of foreign bodies, 83 were successful and 15 fatal, or in the ratio of about 5J to 1. Of the three operations performed upon the above cases, that of tracheotomy affords the most favorable results, the recoveries being in the proportion of 8i to 1 death; whereas, in the other two, the mortality of each was twice as great. All these operations are, other things being equal, more successful the earlier they are performed, as there is then less disturbance in the respi- ratory organs. The causes of death after bronchotomy are various. The most common, undoubtedly, is inflammation of the lungs, which, as has already been seen, is liable to arise at various periods after the accident, and which often makes great, if not destructive, progress before the operation is performed. When death results from this cause, it may take place soon after the windpipe is opened ; or, as is, perhaps, more generally the case, it may be postponed for a considerable time; until, in fact, the wound made in the operation shall have been completely cicatrized. Death is sometimes occasioned by an inordinate deposition of mucus at the former seat of the foreign body, or in its immediate vicinity; it may also be produced by apoplexy of the brain, and by hemorrhage into the air-passages. The adjoining sketch, fig. 276, for which I am indebted to Dr. Brinton, of this city, illustrates a very siugular case of foreign Fig. 276. body in the larynx, which I saw with that gentleman in October, 1856, in a boy, nine years old, who, on the evening of the 24th of September, had inhaled the shell of a chinkapin. The symptoms being urgent, tracheotomy was performed the next day, but no extraneous substance could be detected any- where by means of the probe. Nearly three weeks after the accident, Dr. Brinton, satisfied that he had discovered the situation of the shell, enlarged the wound, which had been all along kept open with hooks, by dividing the cricoid cartilage and the crico-thyroid membrane. Again, however, nothing certainly was found, notwithstanding that a large probe was repeatedly pushed up into the fauces. The boy experienced some benefit from the opera- tion, and was for awhile even under the impression that he had swallowed the intruder. He progressed favorably enough until the 5th of November, except that he had occasionally a spasmodic attack, which he was in the habit of relieving by holding the edges of the wound temporarily apart with a pair of curved forceps. At the time here alluded to, hav- ing a more violent paroxysm of dyspnoea than usual, he thrust the instrument forcibly through the poB- Perforation of the larynx. terior and lateral wall of the trachea, and, in the BRONCHOTOMY. 463 act of doing so, ruptured a small artery, the blood of which, descending into the trachea, caused instant suffocation. The shell, on dissection, was found firmly imbedded in the right ventricle of the larynx, a portion being hooked round the inferior vocal cord ; it was three-quarters of an inch in length by four lines in width, was covered over with bands of lymph, and could not be detected by the probe carried upwards through the wound in the neck. An opening, the result, doubtless, of ulcera- tion, existed in the posterior and lateral wall of the larynx, through which the boy had pushed the forceps so as to cause the fatal hemorrhage. The trachea was completely filled with blood. 15. BRONCHOTOMY. Under this denomination are included the three operations known, respect- ively, as laryngotomy, tracheotomy, and laryngo-tracheotomy. These opera- tions may be rendered necessary by the following circumstances: 1. The presence of foreign bodies in the air-passages. 2. Spasm and oedema of the glottis. 3. Ulceration, scalds, and contusions of the larynx. 4. Polypous growths. 5. Laceration of the windpipe. 6. Tonsillitis and retro-pharyn- geal abscess. 7. Impacted matter in the oesophagus. 8. Suspended anima- tion. 9. Carotid aneurism. 10. Membranous croup, diphtheria, erysipelas of the fauces, and smallpox of the larynx. Laryngotomy.—Laryngotomy is a very simple and easy operation. The only structures that are divided are the skin, the cervical fascia, and the crico- thyroid membrane. If the patient is an adult, he may sit upon a chair, or, what is preferable, especially if he take chloroform, lie upon a narrow table, the head and shoulders being properly elevated and horizontalized by pillows. If, on the.contrary, he is a child, he should be supported upon the lap of an assistant, and his body and limbs should be securely fastened with an apron, very much as in the operation for hare-lip. The head is thrown backwards and held by another assistant, in such a manner as to render the parts pro- minent and make the chin look directly forwards in the direction of the middle line. With a small, narrow scalpel, the surgeon, stationed in front of the patient, if he sits, or by his side if he is recumbent, makes an incision along the centre of the larynx, commencing at the top of the thyroid cartilage and terminating at the base of the cricoid. In the adult, the length of this inci- sion will be fully one inch and a half, and hardly any less in a thick, short- necked child. It embraces the skin and cervical fascia, and usually also the crico-thyroid artery. Should this vessel bleed, it must either be forcibly twisted or secured with the ligature, lest the blood should find its way into the windpipe, and thus occasion severe cough, if not suffocation. All that now remains to be*done is to divide the crico-thyroid membrane, in its whole extent, in the direction of the cutaneous wound. Should the opening not be sufficiently large, the incision may be prolonged into the contiguous carti- lages, or a piece of the membrane may be cut away on each side of the wound. borne surgeons prefer making a crucial incision, and such a proceeding is quite proper when it is desirable to afford free play to the instruments without interfering with the thyroid and cricoid cartilages. Tracheotomy.—If the operation of laryngotomy is simple and easy, it is far different with that of tracheotomy. This is particularly true with regard to tracheotomy in children with short, thick necks, to say nothing of the cries and struggles which they are sure to make if they are not under the influence of chloroform, or nearly choked by the foreign body. The use of anaesthetic agents, however, greatly facilitates the operation, and divests it of much of the dread which surgeons have always so justly entertained respecting it. 464 DISEASES AND INJURIES OF THE AIR-PASSAGES. In performing tracheotomy, fig. 277, the same general rules are to be observed as in laryngotomy. An incision is made through the common Fig. 277. Operation of tracheotomy. integuments, directly along the middle line, extending from the base of the cricoid cartilage to within a quarter of an inch of the top of the sternum. The sterno-hyoid and sterno-thyroid muscles of the opposite sides are next separated from each other at their raphe, by a cautious use of the handle of the knife, aided, if necessary, by the point of the instrument, when the cervical' fascia and the thyroid plexus of veins will be fully brought into view. The former is divided in the same careful manner, while the latter is pushed aside, and protected by a blunt hook. If the middle thyroid artery is cut, which, however, is a rare contingency, it must instantly be secured. The isthmus of the thyroid gland, even when it descends considerably lower than usual, will seldom embarrass our progress ; should it do so it must be held out of the way, although it has sometimes been divided with impunity. Generally, however, it will be well to avoid it; should this be impracticable, any bleed- ing that may be apprehended can be effectually avoided by embracing the part in two ligatures, the knife being afterwards carried between them. Satisfied that there is no blood at the bottom of the wound, the surgeon steadies the trachea with the left index finger, or, what is better, with a tena- culum, and divides at least three of its rings. In executing this step of the operation, the knife is entered at a right angle to the surface of the tube, with its back towards the sternum, care being taken to cut from below up- wards, lest injury be inflicted upon the great vessels at the root of the neck. The incision in the trachea must strictly correspond with the centre of the external wound, and should be at least an inch in length. If shorter than this, it will scarcely suffice for the spontaneous ejection of the foreign body, or, when this does not happen, for the proper play of the forceps. BRONCHOTOMY. 465 Laryngo-tracheotomy___In performing laryngotomy, it not unfrequently happens that the opening afforded by the division of the crico-thyroid mem- brane is inadequate for the purpose for which it was made. In this event it may very readily be enlarged to the requisite extent, by dividing the cricoid cartilage and one or two of the upper rings of the trachea. The operation, thus performed, has been denominated laryngo-tracheotomy, as denotive of the parts concerned in it. The chief objection to it is the danger of wound- ing the isthmus of the thyroid gland, and the branch of the superior thyroid artery, which so frequently courses along its upper border. When the foreign body is so firmly impacted in the larynx as to render it impossible to remove it by the ordinary operation, we may divide the thyroid cartilage in its whole length along the middle line. vol. n___30 466 INJURIES AND DISEASES OF THE NECK. CHAPTER X. INJURIES AND DISEASES OF THE NECK. SECT. I.—WOUNDS. Although wounds of the neck are treated upon the same general prin- ciples as wounds in the other parts of the body, yet they possess certain peculiarities which render it necessary that they should be noticed separately. Of these peculiarities the most important are hemorrhage, inflammation of the air-passages, emphysema, inanition, and the occurrence of fistule. In regard to their character, wounds of the neck may be incised, contused, lacerated, punctured, and gunshot, precisely as in other regions of the body. In their extent, they vary from the merest scratch to almost complete sever- ance of the neck, involving, of course, in the latter case, muscles, fasciae, nerves, and vessels, along with the windpipe and oesophagus. The most frightful injuries of this description are generally inflicted in attempts at suicide, and yet, strange to say, these attempts are often entirely abortive, depending upon the fact that most persons, intent upon self-destruction, select the upper part of the neck, in the belief that suffocation will speedily ensue simply by opening the larynx. The consequence is that, although the gash may be a most horrible one, yet, the large vessels and nerves escaping, the patient not unfrequently makes a good recovery. The sources of the hemorrhage in wounds of the neck vary according to the situation of the injury. Wrhen the knife is drawn deeply across the lower cervical region, the bleeding usually proceeds from the carotid artery and jugular vein ; when the larynx is involved, the thyroid vessels generally furnish the blood, while high up, as when the lesion occupies the interval between the hyoid bone and the chin, the hemorrhage is derived from the lingual artery. It has been doubted whether the windpipe and oesophagus could be completely severed without injury of the carotid artery and jugular vein ; but the possibility of the occurrence has been attested by several well authenticated cases. The hemorrhage attending wounds of the neck may be almost instantane- ously fatal, especially when it proceeds from the large vessels; or, the patient fainting, a temporary stop may be put to it until the surgeon has time to apply the ligature. Not unfrequently death is occasioned by the blood flow- ing into the air-passages, and so causing suffocation, even, perhaps, when no important artery has been laid open, or, if laid open, after it has been tied. Sometimes, again, the event is brought about by secondary hemorrhage, at the distance of a number of days or several weeks from the receipt of the injury. The proper treatment of the bleeding is by ligation of the affected vessels. The jugular vein has been tied in numerous instances of cervical wounds, and I should certainly not hesitate to resort to this expedient if I found that the hemorrhage could not be effectually stopped by compression and other means. In most of the reported cases of the operation the result was most satisfactory. Wounds of the windpipe are, in themselves, not particularly dangerous, but they nearly always become so, in consequence, as already stated, of the .j WOUNDS. 467 intromission of blood, thereby threatening suffocation, and of the remarkable susceptibility of the lungs, after such lesions, to inflammation. These, then, are the great sources of peril in cases of this description, and too much vigi- lance cannot be exercised to guard against their occurrence. When the tube is completely severed, the danger is, of course, imminent, death usually follow- ing in a short time from suffocation from the ingress of blood. In a case recently communicated to me by Dr. James D. Maxwell, of Indiana, a child, twelve years of age, lived fifteen days in this condition. The windpipe had been completely severed between the cricoid and thyroid cartilages. The oesophagus had also been freely divided. The immediate cause of death was broncho-pneumonic inflammation. Separation of the epiglottis is also generally fatal; if the detachment is partial, the flap may become entangled in the glottis; if complete, death will be likely to happen from inanition or inflammation. Larrey and others have mentioned cases in which the epi- glottis was shot completely away, and yet the patients made a good recovery. Gunshot wounds of the windpipe are generally mortal, although occasionally recovery takes place under circumstances apparently of the most desperate character. There is reason to believe that this tube possesses the faculty of deflecting bullets. Thus, in a case which I attended in 1858, with Dr. Hooper, of this city, a man was struck by a pistol ball directly over the middle line of the neck, about two inches above the sternum, and yet there was no symptom whatever denotive of perforation of the trachea, or of serious lesion of any kind. The treatment of wounds of the windpipe should be conducted by suture, and position, aided by a strict surveillance over the lungs. I am aware that surgeons generally are averse to the use of the suture in lesions of this tube, but I cannot myself see any reason for sharing their fears in regard to its alleged injurious effects. It is the abuse, and not the proper use, of the remedy that produces harm. In regard to injuries of the larynx and trachea, the operation is always perfectly safe, provided the surgeon does not effect approximation until all danger of internal bleeding has ceased. For this purpose he should wait from three to six hours, by which time all oozing will generally have stopped. Then with a fine needle and thread the edges of the wound should be carefully tacked together, by passing the instrument simply through the fibrous covering of the trachea, without, of course, in- cluding any portion of its rings. The stitches should be about three lines apart, and one end of the ligature should be cut off close to the knot. The external wound should afterwards be closed by sutures and adhesive strips. If any muscles are divided, their ends should be tacked together with the needle and thread. If the larynx be the part involved, the sutures are carried through the perichondrium, or even through the edges of the cartilages themselves. When the epiglottis is nearly severed, the best plan will be to cut off the flap, lest, falling into the glottis, it should cause suffocation. The dressing is completed by placing the head in an easy, comfortable position, with a slight inclination forwards, and confining it there by means of a tightly-fitting head-bandage, the extremities of which are secured to a broad roller encircling the upper part of the chest. Great care must be taken that the head is not drawn too far forwards, otherwise there will be danger of overlapping of the edges of the wound, both in the windpipe and in the soft parts. The advantages of the suture in wounds of the windpipe are, first, a more rapid cure, and, consequently, less danger of hemorrhage and inflammation; secondly, greater facility of administering food and drink; and, lastly, much less risk of stricture and fistule of the tube. Should emphysema or internal bleeding occur after the parts have been approximated, it would be easy to open the wound, to a small extent in front, both in the integuments and in 468 INJURIES AND DISEASES OF THE NECK. the windpipe, and even to introduce a canula, until all danger from these causes has subsided. The after-treatment is strictly antiphlogistic. The tongue is frequently moistened with iced water; food and drink are, if necessary, conveyed into the stomach by means of a suitable tube, passed through the mouth; and the bowels are moved by enemata. Cough is allayed, and sleep induced, by morphia. The head and shoulders are elevated, and the dressings are dis- turbed as little as possible, the sutures being retained as long as they may seem to do good. Pulmonic and bronchial involvement are met by the usual means. Particular attention must be paid to the temperature of the patients apartment; it should be regulated by the thermometer, and be constantly kept at 80° of Fahrenheit. The admission of cold air, especially through the wound, cannot fail to be pernicious, from its tendency to awaken cough and inflammation of the respiratory organs. The patient must be watched with the greatest possible care. If he be suicidally inclined, he must be put in the strait jacket, otherwise he will be sure to tear away the dressings, and open the wound, if he do not inflict other mischief. Laceration of the windpipe is occasionally met with, generally as a result of a blow, kick, or fall upon the neck, without any external wound, and is always a dangerous accident, imperilling life by paralysis of the air-passages, spasm of the glottis, or suffocation from emphysema. In a case reported by Dr. John L. Atlee, the patient, a boy, aged four years, perished from the latter cause in less than fifteen minutes after the receipt of the injury, produced by striking his neck forcibly against a door-scraper. The air, under such cir- cumstances, escapes from the wounded parts into the cellular tissue of the cervical region, and thence spreads more or less rapidly over the head, trunk, and even the upper extremities, followed by frightful dyspnoea, and, if succor be not promptly afforded, by death. These injaries may affect both the larynx and the trachea, the former appa- rently more frequently than the latter. Laceration of the trachea alone may be caused by a sudden and violent effort at inspiration after the integrity of the tube has been impaired by atrophy and ulceration, as in an instance reported to me by Dr. Thomas Marshall, of Kentucky. The proper remedy in these injuries is obviously tracheotomy, performed without a moment's delay, especially if there be a rapid escape of air into the surrounding structures. The wound should be kept open with a suitable tube, the head maintained in a fixed position, and every effort made to allay spasm and prevent the occurrence of severe inflammation. The skin must be freely punctured, if there be extensive emphysema. In case of extreme urgency, tracheotomy should, it seems to me, be performed even if the patient be in the act of dying, or has actually ceased to breathe. Wounds of the oesophagus and fauces should always be treated upon the same principles as wounds of the intestines ; that is, by sutures, placed from two to three lines apart, the needle being carried close down to the mucous membrane, and the ends of the ligature, drawn very tightly, cut off close to the knot, the thread eventually finding its way into the interior of the tube. The patient is supported by the stomach tube, introduced several times a day, and also, if necessary, by nutritive enemata. Wounds of the cervical nerves are always objects of deep interest. Division of the phrenic nerves is necessarily instantaneously mortal, and the same is true of division of the pneumogastric nerves, although this has occasionally been denied. If only one of the pneumogastric nerves be severed, the patient may survive for some time, but will finally perish from the effects of congestion and inflammation of the lungs. Wounds of the neck are sometimes followed by paralysis of the superior ex- tremity, in consequence of violence inflicted upon the axillary plexus of nerves. WRYNECK OR TORTICOLLIS. 469 In 1858, a young man was at the Jefferson College Clinic, who had been struck in the neck with a long, narrow knife, the blade entering a little to the left of the median line, and passing behind the trachea and oesophagus, both of which, as well as the large cervical vessels, escaped injury. The right superior ex- tremity became immediately palsied, succeeded by a sense of numbness in the thumb and first two fingers, rendering it thus highly probable that the weapon had wounded the median nerve, either close to its origiu, or at the axillary plexus. The muscles soon began to waste, and when I saw the case, about six weeks after the accident, the whole limb was excessively atrophied and withered, purple, and icy cold. The deltoid was very tender on pressure, and severe pain extended along the arm as far as the ends of the fingers, which hardly admitted of the slightest motion. The general health had suffered a great deal, the countenance was very pallid, and there was great disorder of the digestive organs, with loss of sleep. Such lesions, unfortunately, are generally hopelessly irremediable. In the case here described, I was induced, as the man was poor, and endured great pain, to advise amputation at the shoulder-joint, if, in the course of a few months, there should not be marked evidence of returning power in the limb and subsidence of pain. SECT. II.—WRYNECK OR TORTICOLLIS. Wryneck, the torticollis of the old surgeons, consists in a permanent structural shortening of some of the cervical muscles, especially the sterno- cleido-mastoid, twisting the head over to the corresponding side, while the Fig. 278. chin projects proportionately in the opposite direction, as seen in fig. 278, from one of my clinical cases. The distortion thus produced is character- istic, causing a disagreeable, sinister, and constrained appearance, which nothing else can imitate. When ex- isting in a high degree, the ear is approximated to the upper extremity of the sternum, the clavicle is elevated and deformed in consequence of the excessive tension of the sterno-cleido- mastoid muscle, and the chin is thrown far beyond the middle line, almost into a horizontal position. The expres- sion of the features is remarkably altered; the face on the affected side ''avmg a withered, atrophied appear- ance, the corner of the mouth being depressed, and the eye being much lower nan the opposite one. The head is nearly immovably fixed, so that if the patient wishes to look at any object, he is obliged, unless it is directly in front nun, to turn his whole body ; and there is generally, in the more aggravated cases, a peculiar lateral curvature of the neck, the concavity of which pre- sents towards the side of the contracted muscles. niimK n6? °CCUrs in both sexes' but my experience has afforded a larger umoer of cases in females than in males, and there is no doubt that the affec- on is generally considerably more frequent in the former than in the latter. som 5SIOn.ls most common in children from three to ten years of age, and treniM GS begl"S S00n after birth- Tt has been said to be occasionally con- fc i»J, and cases of this description are no doubt now and then met with, Wryneck. 470 INJURIES AND DISEASES OF THE NECK. but they must be extremely rare, none having ever fallen under my observa- tion. The affection recognizes several distinct causes, of which the principal are inflammation, disease of the cervical vertebrae, and paralysis of the mus- cles. It may also be induced simply by a vicious position of the head, in consequence of the existence of an enlarged and painful condition of the lym- phatic ganglions of the neck, compelling the patient to keep the cervical mus- cles in a constrained and rigid state. Any circumstance, in fact, that has a tendency to destroy the equilibrium of these muscles, and place them in an antagonistic state towards each other, may produce the distortion at any period of life, particularly in children during the rapid development of the body. However induced, the affected muscles soon become permanently contracted and greatly indurated, as is rendered evident both to the touch and the knife. They feel like dense, rigid cords, which hold the head firmly in its unnatural position, and whose outline is easily traced along the neck. They are dimi- nished not only in length, but also in breadth and thickness; their fibres, in cases of long standing, are converted into pale, fibrous filaments, united by unyielding cellular tissue, and hence, when an attempt is made to divide them, they offer an extraordinary degree of resistance, almost creaking under the knife. These circumstances, taken in connection, afford indisputable evi- dence that, whatever the exciting cause of wryneck may be, the muscles con- cerned in its production become the seat of inflammation and plastic effusion, probably at an early period after they have lost their equilibrium, unfitting them for the resumption of their functions without the division of their fibres. The number of muscles affected in wryneck varies in different cases. Al- though the sterno-cleido-mastoid always suffers more than any other, yet it is by no means the only one which is concerned in producing and maintaining the distortion. The platysma, trapezius, scalene, splenitis, and even the ele- vator of the scapula, not unfrequently participate in the disorder. It has been found that the sternal portion of the mastoid always suffers first, but I have never seen a case of confirmed wryneck where the clavicular division was not also implicated, and generally in a very marked degree. The prognosis of wryneck depends upon circumstances. In the more simple forms of the affection, caused solely by muscular contraction, a cure may gene- rally be certainly calculated upon, especially when the case is comparatively recent. When, on the other hand, the deformity is of a complicated cha- racter, as when it is associated with organic disease of the spine, serious lesion of the nervous system, or a crippled state of a large number of muscles, the patient may consider himself fortunate if he obtain any relief at all. In the treatment of this affection, the first indication is to ascertain, if pos- sible, the nature of the exciting cause, and then to regulate ourselves accord- ingly. If it depend upon rheumatism, the diagnosis may usually be easily determined by observing that this disease exists at the same time in other parts of the body, and that the muscles of the neck are extremely painful and intolerant of motion and manipulation ; more or less fever will probably be present, and the features will exhibit a wan and contracted appearance, ex- pressive of the local and constitutional distress. If the case be seen early in the attack, bleeding by leeches will prove beneficial; the bowels should be well moved ; and the system should be promptly brought under the influence of calomel and opium, followed by colchicum. Anodyne embrocations, and the application of steam, directed to the part by means of a tube, will be the most suitable local remedies. . A careful examination will generally be sufficient to detect the presence of organic disease of the cervical vertebrae. The most important signs are, the existence of the strumous diathesis, unnatural projection of the spine, and the impossibility experienced by the patient in performing the most simple move- WRYNECK OR TORTICOLLIS. 471 ments of the neck. The proper treatment will be the prone position, main- tained for months together, and a course of alterants and tonics, with a caustic issue at the seat of the disease. Paralysis of the sterno-cleido-mastoid muscle has been more frequently accused as a source of wryneck than it probably deserves. Yery few of the cases that have fallen under my observation could be traced to such an origin. The affection usually begins insidiously, and may depend upon various causes, especially disorder of the digestive organs and of the cerebro-spinal axis. It may affect both muscles, but, in general, it is limited to one, and then the other, continuing its function, contracts upon itself, and is eventually con- verted into a dense, rigid cord, in obedience to a law that a muscle, deprived of antagonism, is gradually reduced to a kind of fibrous mass, much below the volume of the original. The diagnosis is easily established by a careful examination, which will disclose the great differences in the state of the two muscles, the excessive distortion of the features, and the atrophied condition of the face on the side corresponding with the contraction. The treatment must be directed to the removal of the exciting cause; where this cannot be detected, the case must be managed upon general prin- ciples. Gentle purgation, a judicious regulation of the diet, and strict atten- tion to the secretions, will always be beneficial, and must, therefore, not be neglected. Chalybeate tonics, the cold shower bath, followed by dry friction with the flesh brush, and exercise in the open air, will be required for the weak and anemic. Shampooing and electricity have been highly lauded in this form of wryneck, but their value has been greatly overrated. When the affection has reached its confirmed stage, the only remedy is the division of the contracted muscle, and it is well to know that nothing is to be gained in such a case by delay or by a resort to extending apparatus, however ingeniously constructed, or diligently and perseveringly applied. Such a hope is perfectly futile. The subcutaneous operation possesses great advantages over the direct section practised in former times, which always exposed the patient to severe suffering and to protracted suppuration, besides generally eventuating in an imperfect cure. The modern procedure is en- tirely free from all such contingencies. The only objection that can be at all alleged against it is the difficulty of its execution, but this, I am satisfied, has been greatly exaggerated, for there is no educated surgeon who need be afraid of undertaking it, provided he will recall to mind, at the time, his knowledge of the anatomy of the parts. None but the merest bungler could possibly injure the carotid artery or the internal jugular vein; and as to the external jugular, which lies just behind the sterno-cleido-mastoid muscle, no serious harm could result from its subcutaneous division, as the bleeding could easily be controlled by pressure. In performing the operation, which should be done while the patient is under the effects of chloroform, the head, inclined slightly forwards, should be held as firmly as possible by an assistant, while another has charge of the extremities. The left finger is then insinuated behind the sternal portion of the muscle, just above its origin, when a delicate tenotome, fig. 279, such as that used in the operation for club-foot, is inserted flatwise be- Fig. 279. hind the muscle at its outer edge, -c-rr— and thence carried on in close *—________*- ---"^^--f^^SJJ contact with its posterior surface, —Ma^^^^ until its point meets the finger on Tenotome. the opposite side. The cutting edge being now turned forwards, the muscle is carefully divided from behind forwards by a sort of sawing motion, from nine to twelve lines above the sternum. The sudden retraction of the belly of the muscle, sometimes with 472 INJURIES AND DISEASES OF THE NECK. a distinct noise, will denote the completion of the operation. If the clavicular portion be now found to be tense and resisting, the knife should next be passed beneath it, and its division effected in the same cautious manner. Bands of the cervical aponeurosis occasionally project, and may be severed with a narrow, blunt-pointed bistoury, having only about a line of cutting edge near its extremity. If the border of the trapezius be at fault, it may now be divided, and so of any other muscle, provided its proximity to the great cervical vessels and nerves does not absolutely forbid interference. The above procedure is the one which I have always adopted, and in no instance has it been attended by any casualty. The fact is, it is a very simple operation, and one entirely free from danger. The puncture made with the tenotome is closed with a bit of adhesive plaster, and the patient is placed in bed with his head in a relaxed and easy position. Light diet is en- joined, and a mild purgative may be given the morning after the operation. As soon as he is able to get up, which will usually be in four or five days, the head should be supported with a suitable apparatus, so constructed as to produce gra- dual extension of the affected side of the neck. Yarious con- trivances of this kind may be obtained of any of the more re- spectable cutlers, all of them possessing more or less merit, and well calculated, if judi- ciously applied, to effect a cure, though not without protracted perseverance. The annexed drawing, fig. 280, exhibits the apparatus of Professor Jbrg, one of the best of the kind hitherto in use. It consists of a leather corset for the chest, and a firm band for the head, connected by a steel rod, which is moved by a ratchet-wheel, turned by a key, the whole arrangement being such as to per- mit the head to be moved to one side or the other at pleasure. The cure is promoted by daily frictions with stimulating liniments. Jorg's apparatus for torticollis. SECT. III.—DISEASES OF THE THYROID GLAND. The thyroid gland is subject to various diseases, of which abscess, serous cysts, and hypertrophy are the most frequent and important. The heterolo- gous formations rarely affect this organ. 1. Abscess.—Abscess of the thyroid gland is very rare ; it is attended by the usual symptoms, and may, when neglected, acquire a large bulk, hanging down the neck like a big pouch. In its earlier stages, it is not always easy, or even possible, to form a correct idea of the nature of the disease; but when the quantity of matter is considerable, its presence will be indicated by a sense of fluctuation, by pain and difficulty of breathing, and by a swollen, DISEASES OF THE THYROID GLAND. 473 discolored, and cedematous state of the integuments. These symptoms, joined with the history of the case, and the concomitant febrile excitement, are quite sufficient, in every instance, to establish the diagnosis. The matter, bound down by the cervical fascia and muscles, is often long in reaching the surface, to say nothing of its tendency to extend down the neck, and its escape should, therefore, always be eucouraged by an early incision in the lower part of the swelling. Such an abscess is sometimes of a latent character. Many years ago, I attended, along with Dr. Woodward, of Cincinnati, a man aged forty-four, who died of pneumonia, after an illness of three weeks. On inspection, I found the whole of the thyroid gland, with the exception of a small portion of its inferior extremity, converted into a thin, delicate sac, containing nearly ten ounces of thick, yellowish pus, free from odor. The thyroid cartilage was completely denuded, and the matter had burrowed upwards, underneath the hyoid bone, on the left side, as far as the root of the tongue. No symp- toms,' whatever, indicative of disease of the thyroid gland, had existed dur- ing life. The abscess was evidently of a strumous character. 2. Cystic Tumors.—This organ is, at times, the seat of serous cysts, simi- lar to those of the liver, brain, ovaries, and other structures. Yarying in number, in different cases, from one to several dozens, they are situated either directly in front of the neck, or at one side of the middle line, and are found of all sizes, from that of a cherry-stone to that of an egg. They are composed of thin, elastic coats, and are occupied by a watery, yellowish, or oily-looking fluid, coagulable by heat, alcohol, and acids, thus showing its albuminous constitution. The development of these tumors is, in general, very tardy; they are free from pain and discoloration of the integuments, and they communicate to the finger a soft, elastic sensation, which readily distin- guishes them from solid tumors in the same situation. The disease is rarely met with under the age of twenty-five or thirty. The treatment of the cystic tumor of the thyroid gland is similar to that of hydrocele, and may be conducted by incision, injection, or seton, the lat- ter of which is usually the most certain and efficient. When there are seve- ral such tumors, the best plan is to treat them with the tent, retained until there is a sufficient amount of inflammation to protect the cavity against re- accumulation. Excision may be necessary when the coats of the cyst have undergone the fibrous, cartilaginous, or osseous degeneration. 3. Goitre or Bronchocele.—Goitre, technically termed bronchocele, is a chronic enlargement of the thyroid gland. The affection, which is much more common in women than in men, and in children than in adults, not un- frequently exists as an endemic, especially in the valleys of the Alps, Apen- nines, and Pyrenees. In this country, it is often observed in the mountain- ous regions of Vermont, New Hampshire, Connecticut, New York, Virginia, and Pennsylvania. In our southern States it is uncommon. It has occa- sionally been noticed among our aborigines, but not to any extent. I have never seen an instance of it in the negro. In England, it is very common in Derbyshire, Norfolk, and Surrey. In the valleys and gorges of the Alps, it is frequently associated with cretinism. The afflicted being has a short, stunted body, shrivelled limbs, a large, unseemly head, a vacant countenance, and a depraved intellect. In fact, in many cases, he is idiotic. The cause of bronchocele is evidently closely connected with the locality in which the disease occurs. Low and moist situations are most obnoxious to rt. while high and airy regions are comparatively exempt. Confined, ill-ven- tilated places, affected with frequent inundations, are remarkably favorable to its production. It is probable that the habitual use of water, strongly im- pregnated with calcareous matter, is a powerful predisposing cause. Goitre seldom makes its appearance, even in countries where it is indigenous, before 474 INJURIES AND DISEASES OF THE NECK. the tenth or twelfth year. Occasionally it is hereditary, and it not unfre- quently occurs in several members of the same family. It has been observed in the horse, cow, sheep, dog, and other inferior animals. The tumor varies in size, from the slightest increase of the natural volume of the gland, to that of a fist, a cocoa-nut, or an adult head. When of the latter dimensions, it may reach as high up as the ears, backwards as far as the trapezius muscle, and downwards over the sternum, forming a most dis- gusting and shocking mass. Both lobes are usually affected, though seldom in an equal degree. Sometimes the disease is confined exclusively to the isthmus, or to this part and to one of the lateral lobes. The swelling in- creases very slowly, and often remains stationary for years together. Its surface may be smooth and uniform, or rough and lobulated. A very common accompaniment is an en- Fig. 281. largementof the subcutaneous veins. No pain attends goitre, except what results from its pressure on the neighboring structures; the skin is free from discoloration, and the general health is unimpaired. When the tumor is of unusual bulk, there may be difficulty of breathing, head- ache, vertigo, noise in the ears, and an altered state of the voice, which often becomes hoarse and croaking. In such cases the trachea is more or less flattened, elliptical, or even tri- angular, from the pressure of the superincumbent mass. The exter- nal characters of goitre are well exhibited in fig. 281, from a prepa- ration in the Mutter collection. The internal structure of the tu- mor is liable to considerable variety, depending upon its age and progress. When of moderate standing, it is generally of a soft, gelatinous consistence, emitting, on pressure, a ropy, glutinous fluid. In more ancient cases it is of a pale cinnamon tint, hard to the feel, and interspersed with numerous cysts, generally not larger than a pea, containing a serous, glairy, or melicerous substance, and occasionally pus, fibrin, or even pure blood. These cysts are Goitre or bronchocele. Fig. 282. Fig. 283. Cystic degeneration of the thyroid gland. Ossified thyroid gland. merely enlarged cells, which are dispersed through the organ in the natural Btate. Fig. 282, taken from one of my specimens, exhibits these cavities DISEASES OF THE THYROID GLAND. 475 hvpertrophied from disease, and occupied by a white, semi-concrete sub- stance, similar to coagulated lymph. Calcareous concretions are sometimes found, either alone or in union with cartilaginous and osseous productions. In a small goitrous tumor now in my private collection, obtained from a man fifty years of age, there are several small steatomatous masses, with a circular nodule of bone, about six lines in diameter. It is of a yellowish color, very compact in texture, and surrounded by a thin, imperfect capsule. Occasionally the whole organ is transformed into an osseous cyst, filled with various kinds of matter, especially the jelly-like, the suety, and the meliceric. I have a specimen of this kind in my cabinet; one of the lobes has almost entirely disappeared, whilst the other, fig. 283, is converted into a firm, solid capsule, as hard as bone, though scarcely a line in thickness. On sawing through this osseous tumor, which does not exceed the volume of a hen's egg, I found it filled with a white, curdy, friable substance, not unlike semi- concrete cheese. The diagnosis of goitre is usually sufficiently easy. Its early appearance, its tardy progress, its situation in front of the neck, its indolent character, and its ascent with the larynx and trachea in deglutition, leave little room for doubt in any case. The diseases with which it may be confounded are aneurism of the carotid artery, varix of the internal jugular vein, encysted tumors, and swelling of the lymphatic ganglions. When goitre is extensive, and occupies the side of the neck, a part of it will necessarily project over the carotid artery, and thus receive its pulsation. In this manner the disease might easily enough be mistaken for aneurism. The signs of distinction are, the slow and indolent nature of the swelling, the absence of bellows-sound, and the facility with which the morbid mass may, in most instances, be pressed away from the cervical vessels, when the head is bent forwards so as to relax the muscles of the neck. An instance now and then occurs in which the whole tumor is the seat of a violent pulsation imparted to it by the action of the carotid and enlarged thyroid arteries, in consequence of an anemic state of the system. The nature of the lesion is readily detected by the appearance of the patient and by the history of the case. Varix of the internal jugular vein is uncommon. The enlargement is seated low down in the neck, just above the sternum, and forms a tumor of an oblong shape, about the size of an egg, soft, elastic, and compressible. It is of a bluish color, has a tremulous, pulsatory motion, and is diminished, or tem- porarily effaced, by pressure upon the distal portion of the vessel. An encysted tumor, situated directly over the thyroid gland, may simulate goitre. Seldom exceeding the volume of a wralnut, it is free from pain, par- tially translucent, soft, elastic, and obedient to the motions of the windpipe. W hen the diagnosis is at all equivocal, recourse is had to the exploring needle. A scrofulous lymphatic ganglion, occupying the site of the thyroid gland, may prove a source of error. The history, however, of its origin and progress, the hardness of the swelling and its tendency to suppurate, the presence of the strumous diathesis, and the existence of similar enlargements in the neigh- boring parts, will always be sufficient to enable the surgeon to distinguish between the two affections. The treatment of goitre is generally conducted too much upon empirical principles. Hence, failure is too commonly the rule ; success the exception. At the present day, reliance is mainly placed upon iodine and its various combinations, aided by the use of leeches, blisters, and purgatives. It must be obvious that no remedies, however valuable in themselves, or however judiciously and faithfully employed, can avail in every instance. When the tumor is of long standing, when it has attained a large bulk, and, above all, 476 INJURIES AND DISEASES OF THE NECK. when it has undergone some of the transformations previously adverted to, no mode of treatment whatever will be likely to make the slightest impression upon it. Such cases are literally hopeless. It is only in the milder forms of the disease, and in its earlier stages, that any decided benefit is to be looked for. My own plan has been, for many years, to subject the patient to a sort of preliminary treatment, consisting of light diet, and gentle, but steady, pur- gation. When plethora is present, a full bleeding may be advantageously premised. After the lapse of ten or twelve days, the use of iodine may be commenced, either in substance, or in the form of Lugol's solution. The tincture I rarely employ, as it is apt to prove irritating. In whatever form iodine is administered, it is best always to combine with it a small quantity of opium or hyoscyamus ; the dose should be graduated according to the age and susceptibility of the patient, and the effects of the remedy should be care- fully watched. After it has been taken for a fortnight or three weeks, its use should be suspended for several days, when it may be resumed and continued as before. In some instances, the protiodide of mercury will exercise a bene- ficial influence, especially if carried to slight ptyalism. This article is parti- cularly serviceable in recent cases, in which the swelling mainly depends upon interstitial deposits. The bowels are in no instance to be neglected. Much purging, however, is neither necessary nor proper. The diet should be vegetable and farinaceous. Change of residence is frequently indispensable, especially when the individual lives in a country where the disease is endemic. The topical treatment consists of the inunction of iodine, aided by leeching and blistering. The detraction of blood from the affected part is almost always beneficial, from the tendency which it has to unload the capillary ves- sels, and to rouse the absorbents. From ten to a dozen leeches may be applied every six or eight days, directly over the swelling, and the bleeding be en- couraged by fomentations. In some instances a rapid reduction of the tumor is effected under the use of blisters, reapplied once a week. But I have found no local remedies so efficacious as a combination of equal parts of iodine and camphorated mercurial ointments, rubbed thoroughly upon the tumor twice a day. A piece of oil silk is worn next the skin, and over this, in cold wea- ther, a piece of flannel, for the double purpose of preventing the unguent from soiling the dress and keeping the neck sufficiently warm. In whatever form iodine be applied, care should be taken that it is not so strong as to fret and irritate the skin, otherwise inflammation, and not absorption, will be the result. The seton, first recommended by Celsus, and again, in 1824, by Dr. Quadri, of Naples, has been frequently used in the treatment of goitre, and occasion- ally patients have been thus cured. The only case, however, to which it is at all applicable, is where the tumor contains one or more large cysts, which, being traversed by the foreign substance, may be thereby obliterated. The insertion of the seton has sometimes been followed by copious hemorrhage; and in several instances the patient has perished from the violence of the resulting inflammation. At present the practice is nearly obsolete. Starvation of the tumor, by tying the thyroid arteries, has been practised, but without any encouraging results. The operation was first executed by Mr. Blizzard, of London, and since then by Walther, of Germany, Dr. Jameson, of Baltimore, and several other surgeons. In some of these cases no incon- venience ensued, and the bronchocele, in a short time, became considerably reduced in size ; in others, no visible effect of any kind was produced; while in a third class the patient either died of hemorrhage or of inflammation. WThether the diminution of volume was permanent, in any instance, we have no means of determining. The probability, however, is that it was not; for such is the amount of blood which the tumor receives, and so great the num- DISEASES OF THE THYROID GLAND. 477 ber of anastomosing vessels, that its proper circulation would, no doubt, be speedily re-established. For the pulsating form of bronchocele, depending upon an anemic condi- tion of the system, the most appropriate remedies are quinine and iodide of iron, aided by a tonic regimen, and the ordinary external applications. When the tumor resists our curative efforts, and endangers suffocation, it has been proposed to afford relief by extirpation. But the question arises, is such a procedure proper or justifiable ? In a word, can the thyroid gland, when in a state of enlargement, be removed with a reasonable hope of saving the patient? Experience emphatically answers no. This conclusion is not at all invalidated by the fact that the operation has, in a few instances, been performed successfully. It only proves that an undertaking may occa- sionally be accomplished under circumstances apparently the most despe- rate. What has once been effected may be effected again. But no sensible man will, on slight considerations, attempt to extirpate a goitrous thyroid gland. If a surgeon should be so adventurous, or fool-hardy, as to undertake the enterprise, I shall not envy him his feelings, while engaged in the per- formance of it, or after he has completed it, should he be so fortunate as to do this. Every step he. takes will be environed with difficulty, every stroke of his knife will be followed by a torrent of blood, and lucky will it be for him if his victim live long enough to enable him to finish his horrid butchery. Should the patient survive the immediate effects of the operation, if thus it may be called, death will almost be certain to overtake him from secondary hemorrhage, or from inflammation of the cervical vessels, oesophagus, and respiratory organs. When the tumor is large, the wound is of frightful ex- tent, involving all the most important and delicate structures of the neck, and rendering it altogether improbable, from the constant motion of the windpipe and oesophagus, that much of it will unite by the first intention. Thus, whether we view this operation in relation to the difficulties which must necessarily attend its execution, or with reference to the severity of the subse- quent inflammation, it is equally deserving of rebuke and condemnation. No honest and sensible surgeon, it seems to me, would ever engage in it. Finally, when the case is utterly hopeless, and life is threatened by suffo- cation, temporary relief may occasionally be afforded by the subcutaneous division of the cervical aponeurosis and muscles, at the seat of the greatest constriction, thereby removing tension and pressure from the respiratory passages. 4. Malignant Disease.—I am not aware that colloid has ever been noticed in this gland; but we find it occasionally the seat of scirrhus, encephaloid, and melanosis. The deposits sometimes exist as a primary affection, but more generally they show themselves in connection with carcinoma in other parts of the body, as the liver, mamma, testis, alimentary canal, uterus, and lymphatic ganglions. In the former case, the malady is most common after the age of forty, and usually exhibits itself in the form of small nodules, dis- persed through the substance of the gland, which often retains its integrity m the midst of the heterologous matter. At other times, it is seriously changed in its character, the organ itself being enlarged and deformed. The diagnosis of these affections is generally obscure, and hence they often prove fatal before an opportunity is afforded for ascertaining their real nature. Their presence may usually be suspected when the thyroid gland, in advanced life, is the seat of sharp, lancinating pains, when the affected part steadily augments in size and consistence, when the skin becomes adherent and dis- colored, and when there is great and progressive emaciation, with hectic irritation, a sallow, sickly expression of the countenance, and the existence of malignant deposits in other organs. Encephaloid here, as elsewhere, always proceeds more rapidly than scirrhus; the tumor also acquires a much 478 INJURIES AND DISEASES OF THE NECK. larger bulk, there is commonly great enlargement of the subcutaneous veins, and the general health is earlier and more severely affected. In melanosis, which is still more rare than scirrhus and encephaloid, the tumor is seated just beneath the skin, and occasionally imparts its peculiar color to it. .No- thing is to be expected from medicinal means in these diseases, any more than in similar affections in other parts; and, as to extirpation, I know of no cir- cumstances that would render it advisable. SECT. IV.—ENCYSTED AND OTHER TUMORS. Yarious tumors, mostly of an innocent character, are liable to form in front of the neck, often very embarrassing in their diagnosis and treatment. A very brief account of some of the more important of these growths is all that will be necessary. 1. Synovial Burse.—An encysted tumor sometimes forms in the upper and forepart of the neck, taking its rise in the synovial sac, situated between the hyoid bone and the notch of the thyroid cartilage. This sac, which, in its natural state, is hardly a few lines in diameter, may, in consequence of inflam- mation, acquire the volume of an egg, if not of a small orange. It is of an oblong shape, elastic, slightly translucent, and filled with a thin, serous, oily, or viscid fluid. The superincumbent skin is healthy, and the swelling is en- tirely free from pain. The treatment is by seton, injection, or incision, as in encysted tumors in other parts of the body. 2. Sebaceous Tumors.—Occasionally a solid tumor forms in the thyro-hyoid region, and produces considerable disfigurement. In 1841, I removed a swelling of this kind from the neck of a young Jfidy, at that time a resident of Louisville. It made its appearance at an early age, and had attained the bulk of a large orange. The tumor was free from pain or discoloration, and was slightly movable from side to side. It extended upwards nearly as far as the chin, while below it overlapped the thyroid and cricoid cartilages. The operation was not difficult, and the patient made a speedy recovery. No vessels required to be tied. The Fig. 284. Fibrous tumor of the neck. tumor was occupied by a tough, putty-like substance, and had evi- dently originally been of a seba- ceous character. 3. Fibrous Tumors.—A fibrous tumor now and then forms in front of the neck, and may, in time, acquire an enormous bulk, seri- ously interfering with the pa- tient's looks and comfort. The annexed drawing, fig. 284, exhi- bits a growth of this description, removed by me from a youth of seventeen. It had been in pro- gress for several years, and, although free from pain, was productive of great inconveni- ence. After removal, it was found to weigh upwards of five pounds, and to present a beauti- ful specimen of the fibrous struc- ture. The tumor was situated superficially, but much care was, ENCYSTED AND OTHER TUMORS. 479 nevertheless, required in its removal on account of the great enlargement of the subcutaneous and other veins. 4. Serous and Bloody Tumors.—An encysted tumor, occupied by serum, blood, or sanguinolent matter, occasionally forms in front of the neck, between the sternum and the thyroid gland, taking its rise apparently in the cellular substance between the sterno-hyoid and sterno-thyroid muscles. Its progress is chronic, and it seldom acquires a volume larger than that of a small orange, which it also generally resembles in shape. It fluctuates distinctly under pressure, is free from pain, and readily obeys the movements of the larynx during efforts at deglutition, rising as the tube ascends, and falling as it de- scends; circumstances which, together with its tardy development, the absence of enlargement of the subcutaneous veins, and the impaired condition of the general health, are always diagnostic of the nature of the affection. The en- cysted tumor, according to my observation, is almost exclusively met with in young and middle-aged females. Cases occur in which it is congenital. The proper remedy for this morbid growth is excision, which, with proper care, may always be performed with perfect safety. The knife should be used in such a manner as not to penetrate the cyst, since, if this happen, the ope- ration will be one of great difficulty, whereas, under opposite circumstances, removal may generally be effected by enucleation. Yery little hemorrhage attends the procedure, and the recovery is usually rapid. I have seen a num- ber of cases where this tumor was greatly diminished by the long-continued application of iodine, but I have never known the treatment to be followed by a permanent cure. A very interesting case of encysted tumor of the neck and chest, of enor- mous size, was published in the North American Medico-Chirurgical Review, for March, 1860, by Dr. 0. B. Knode, of St. Joseph's, Missouri. Occupying the anterior cervical region, it extended outward on each side nearly to the shoulder, and down some distance below the ensiform cartilage, being eighteen inches in length, and more than two feet in circumference. It fluctuated dis- tinctly on pressure, and contained a gallon and three pints of inodorous and insipid fluid, of the color and consistence of weak coffee. When the fluid had been withdrawn, a hard, nodulated mass, as large as a double fist, was found, with strong attachments to the hyoid bone, thyroid cartilage, and sterno-cleido-mastoid muscle. Immediately after the operation, the parts were firmly strapped with adhesive plaster, and the patient put under the use of iodide of potassium, in doses of five grains thrice a day. At the end of a fortnight the fluid had reaccnmulated to the extent of two quarts. It was now again evacuated, and the part strapped as before. In less than a week all discharge had ceased, the solid mass gradually diminished in size, and the man eventually completely recovered. 5. Abscess.—The synovial pouch in front of the neck, or the parts immedi- ately over it, may become the seat of an abscess. It may have an independent origin, or it may be caused by reflected irritation from the throat, windpipe, or lungs. The symptoms may be so obscure that the disease may elude de- tection during life. In general, however, there is more or less tumefaction of the affected part, difficulty of swallowing, spasmodic cough, and a sense of strangulation. An early incision is required, to prevent the abscess from •mrsting into the windpipe. 6. Malignant Tumors. — Malignant tumors of the neck, encephaloid in character, occasionally occur, generally commencing in the lymphatic gan- glions, and capable of attaining an enormous bulk, as seen in fig. 285. They are nodulated in appearance, rather diffused than circumscribed in shape, soft at some points and hard at others, and accompanied by marked enlargement °f the subcutaneous veins. Their growth is usually rapid, and this fact, together with the history of the case, is always sufficient to distinguish them 480 INJURIES AND DISEASES OF THE NECK. from benign formations. In the latter stages of the disease, the countenance assumes the yellowish, sallow aspect, so common in carcinoma elsewhere, and Fig. 285. Encephaloid tumor of the neck. the general health rapidly declines, life being worn out by the excessive pain, and constitutional irritation. SECT. V__BLEEDING AT THE JUGULAR VEIN. This operation, fig. 286, may become necessary in cases of great urgency, as in sudden and severe apoplectic Fig. 286. seizures, and in violent inflamma- tion of the brain, eye, and ear. In general, however, it may be dis- pensed with even here, the requisite quantity of blood being more easily obtainable at the bend of the arm. The patient's head being firmly supported upon a pillow, and in- clined a little upwards and towards the opposite side, the vein is made to rise by pressure with the finger or thumb, applied just above the clavicle. The lancet is then intro- duced about midway between this point and the jaw, being carried obliquely upwards and outwards,so as to divide the fibres of the pia- tysma myoid muscle crosswise in- stead of vertically, as this affords the edges of the wound a much better chance of retracting. A kind of pasteboard trough or glass tube maybe used to guide the blood into the receiver. The pressure below the orifice should not be removed until the operation is completed, lest air should pass into the vein, and thus destroy life. The requisite quantity of blood having been drawn, the wound is covered with a strip of adhesive plaster, supported by a compress and bandage carried round the neck and shoulders. WOUNDS OF THE CHEST AND LUNGS. 481 CHAPTER XI. INJUKIES AND DISEASES OF THE CHEST. SECT. I.—WOUNDS OF THE CHEST AND LUNGS. Wounds of the chest, like those of the abdomen, necessarily divide them- selves into external and internal, or those which affect the wall of the chest, and those which implicate its contents. They may, as in other parts of the body, be of various kinds, as incised, lacerated, punctured, or gunshot, and they may be either simple or complicated, according to the nature and amount of tissue involved in the injury. External wounds of the chest, unless accompanied by severe concussion, profuse hemorrhage, or fracture of the ribs, are rarely attended with any particular danger, and require no other treatment than that which regulates the conduct of the practitioner in the management of wounds in general. When the lesion is considerable, it may be necessary, especially if the patient is harassed with cough, to adopt means for securing the quietude of the chest by the application of a broad bandage and the occasional exhibition of an anodyne draught; but under ordinary circumstances both these expedients may be dispensed with. Any foreign substance, as a splinter of wood, a ball, or a loose piece of bone, must, of course, be removed, either on the instant, or as soon as its situation is rendered obvious. The direction which a ball sometimes pursues upon striking the chest, especially if it come in contact with the sternum, spine, or ribs, is very remarkable, and is well worthy of remembrance in a practical point of view. Thus, instead of lodging at or near the point of entrance, it has been known to make almost the entire cir- cuit of the thorax, passing underneath the integuments, and becoming arrested a short distance from the point of ingress, or, perhaps, issuing even at the same orifice, as has occasionally happened in military engagements. When this is the case, the course of the projectile is generally indicated by a reddish or purplish line, which will be more distinct in proportion to the size of the ball; and, in addition to this, there is not unfrequently a crackling sensation imparted to the finger as it sweeps over the chest in pursuit of the intruder, caused by the presence of air. In some instances the ball lodges between two ribs, perhaps splintering them, and finally effecting an entrance into their substance. t External wounds of the chest are seldom attended with much hemorrhage; it is only when one of the intercostal arteries is laid open that there will be likely to be much bleeding, and in that event the proper procedure will, of course, be the ligation of the vessel. The operation, however, is generally difficult, if not impossible, owing to the deep situation of the vessel. When this is the case, I should not hesitate to drill a small aperture into the rib, just above the artery, and to pass a silver wire round its bleeding orifice. Such ? Pr°cedure, although apparently harsh and unscientific, would not, I suppose, involve any special risk from inflammation of the pleura. Lesion of the internal mammary artery is occasionally followed by hemorrhage into the anterior mediastinum. If so copious as to compress the heart and lungs, or vol. ii._31 482 INJURIES AND DISEASES OF THE CHEST. cause great exhaustion, the proper plan will be to expose and ligate the ves- sel at all hazards. Wrounds involving fracture of the ribs or sternum must be treated upon the same general principles as fractures of these bones without such lesion of the soft parts, that is, the movements of the thorax must be controlled with the bandage, and cough and pain allayed by anodynes and appropriate anti- phlogistic measures. Internal wounds of the chest are much more serious accidents than external; they are generally made by balls and sharp-pointed instruments, as knives, dirks, lances, sabres and bayonets, and are often attended with severe lesion of the contents of the thoracic cavity, terminating life either on the spot, or at a period more or less remote from the occurrence of the injury. Hence their effects may be conveniently arranged under two heads, the primary and secondary; the former including shock, collapse of the lung, hemorrhage, and pneumothorax; the latter, inflammation and its consequences, as accumu- lations of serum, lymph, and pus in the pleural cavity. Internal wounds of the thorax may be further divided into those which merely pierce its walls, without inflicting any injury upon its contents, and those in which the contents participate in the mischief. Death from mere shock is by no means uncommon in wounds and injuries of the chest; cases of the kind are frequently met with both in civil and military practice, and their occurrence has occasionally been noticed where, upon dissection, no serious lesion has been detected to account for so unto- ward a result. The treatment of such cases does not involve anything pecu- liar, as it does not differ from that of shock from other causes. Our principal reliance must necessarily be upon sinapisms and stimulants, especially in the form of enemas, with opium, to calm the nervous system and sustain the heart's action ; but great caution should be observed in their use, particularly if there be reason to believe that the depression is dependent, in part, upon intra-thoracic hemorrhage, lest, by the induction of early reaction, the bleed- ing should be encouraged instead of being repressed. Collapse of the lung is much less frequent than was formerly supposed, and is not, by any means, a necessary effect of a penetrating wound of the chest. The occurrence will be most likely to happen when the wound is direct and of large size; under opposite circumstances, and especially when the open- ing presents a valvular arrangement, or when the passage leading from it is long and devious, the air will find it difficult, if not impossible, to enter the chest to such an extent as to counterbalance that in the lung, which will thus, consequently, retain its natural position. Even when the wound is of con- siderable size the organ is sometimes found to resist collapse, as is proved by the fact both that the respiration is unembarrassed and that the lung is seen moving to and fro beneath the aperture in the thoracic wall. Still more satisfactory proof is occasionally furnished by the protrusion of a portion of the lung across the wound in the chest, thus constituting what has been, curi- ously enough, called pulmonary hernia, or pneumonocele. Collapse of the lung is always a serious occurrence, as the patient is thus generally instantly deprived of one-half the quantity of air which he was accustomed to breathe before he was injured ; if both organs be similarly affected, the difficulty will, of course, be proportionately increased, although even then the case is not necessarily fatal, for both clinical observation and experiments on the inferior animals have shown that the lungs, under these circumstances, so far from collapsing, may become so completely distencle with air as to project from the thoracic cavity on each side, and yet the su • ject make a very rapid and satisfactory recovery. It is not improbable tba the state of the patient's strength exerts a considerable influence upon the production of collapse ; the accident being more likely to take place when lie WOUNDS OF THE CHEST AND LUNGS. 483 is exhausted by shock and loss of blood than when he is able to command the free use of his respiratory muscles. In the former case, he is very much in the condition of a person who is partially asphyxiated, and, consequently, incapable of distending his lungs, which are thus easily collapsed by the accidental ingress of the smallest quantity of air; in the latter, on the con- trary, his efforts, which are often very violent, enable him effectually to resist the encroachment, and even to force the lungs somewhat out of the chest. Collapse of the lung is characterized by excessive dyspnoea, the patient struggling violently for breath, and throwing himself about in the greatest distress and anguish ; the ribs on the affected side are immovable, the respi- ratory murmur is completely absent, the voice is weak and indistinct, and percussion elicits an unusually clear resonance. With these symptoms are conjoined those of sudden and severe prostration, as excessive pallor of the countenance, a feeble, almost imperceptible, pulse, and clammy sweats, fol- lowed by coldness of the extremities. When the chest is pierced without collapse of the lung, the air generally makes a peculiar noise as it rushes into the pleuritic sac ; and, if the opening of communication is sufficiently large, the lung may be seen to move up and down in consonance with the egress and ingress of the atmosphere, filling, perhaps, the whole, or, at any rate, the greater portion, of the thoracic cavity. The voice is not materially changed, if at all, and the vesicular murmur is nearly natural, although the respiration is performed with great labor and difficulty. Soon after the accident there will be an escape of blood at the wound at each effort at inspiration, and, if the pulmonary tissue has been injured, the patient will cough up blood, or, perhaps, have actual hemoptysis, especially if some of the larger vessels have been divided. A discharge of blood by the mouth is not, however, a positive evidence of penetration of the lung, experience having shown that the mere concussion of the chest by a ball or shot is capable of producing it. The prognosis of penetrating wounds of the chest is exceedingly unfavor- able. In many of the cases life, as above stated, is destroyed on the instant, or, at all events, in a short time after the infliction of the injury, either by shock or hemorrhage, or the two together. When both sides are pierced death may take place from collapse of the lungs, although such an event is much more infrequent than is commonly supposed. Should the patient be so fortunate as to escape from the immediate effects of the lesion, he will stand a fair chance of perishing from inflammation of the lungs and pleura; or, surmounting this, from pyemia or hectic irritation. Gunshot wounds of the chest are generally much more dangerous than wounds inflicted with the lance, sabre, or bayonet, owing to the fact that they are attended with more laceration, and frequently also with the lodgment of the bullet and other foreign matter. A penetrating wound of the apex of the lung is not so dangerous as one of the base of this organ, as it is less "able to be followed by copious hemorrhage and by severe inflammation. In the old mode of warfare more than half of those who were shot through the chest died, but this ratio has been immensely increased since the introduction of the conical ball. The mortality from this cause in the Russian army at the siege of Sebastopol seems to have been most appalling, only 3 out of 200 • having recovered. In the British army, on the contrary, during the same campaign, the surgeons saved 27 out of 147. The fatality in this class of injuries is, doubtless, much influenced by the mode of treatment and other attentions received by the wounded. The Russian surgeons in the Crimean war relied, it would seem, chiefly upon the use of digitalis, whereas the British depended mainly upon copious venesection. J be treatment of penetrating wounds of. the chest requires, in the first place, accurate closure of the orifice of communication, provided there are no contra- 484 INJURIES AND DISEASES OF THE CHEST. indications ; and, in the second, the employment of such measures as tend to prevent the occurrence of severe inflammation of the pleura and lung, which is so liable to happen after all injuries of this kind, even when the latter organ is not directly implicated. The treatment of hemorrhage will be considered under the head of hemothorax. If any foreign substance is present, it should promptly be removed, pro- vided it is easily accessible, for the rule here, as in all other visceral cavities, is to refrain from all officious interference. Nothing, under such circum- stances, can more clearly betray the ignorance of the surgeon than the intro- duction of the probe into the chest; a careful exploration of the outer wound is always admissible, especially when suspicion exists that a rib has been fractured, or that a ball has lodged in one of the intercostal spaces. If a probe be required, the finger, if not too large, will always answer that object better than anything else. I have met with cases of shot wounds of the chest where the ribs were so much splintered as to require removal with the cutting-pliers; but the in-i stances demanding such a procedure must necessarily be uncommon, and, in general, the duty of the surgeon is limited to the extraction of the loose, or partially detached, fragments. Such cases, it need hardly be added, arei extremely apt to prove fatal. If the lung is collapsed, an attempt may be made to draw the air out of the thoracic cavity with a large syringe, but such a procedure will generally be unnecessary, as the organ will of its own accord soon regain its natural! position. If a portion of lung protrude, or puff out through the wound, it, should immediately be returned, and proper means taken to prevent a recur- rence of the accident. On no account should it be excised, not even if it be1 gangrenous, as might happen if a number of days have elapsed since the' receipt of the injury, or if the case has been injudiciously treated. Under' such circumstances, the separation of the slough should be promoted by mild' applications, and when this has been effected any outward tendency on the[ part of the lung may easily be counteracted by graduated compression during, the granulating and cicatrizing processes. I am aware that a number of, cases have been reported of excision of portions of the lung thus protruded, but such cases should certainly not be taken as guides of practice, or as examples for our imitation. When the wound is very large, it should be closed with a suitable compress, but, in general, this object may be attained by adhesive strips, or collodion plaster. Cases occur in which, when the orifice is very capacious, occlusion may be effected by sliding the integuments down over it from the parts in its immediate vicinity. Such a procedure would, of course, be objectionable in the event of there being extensive injury of the bony case of the chest. Collapse of the lung, partial or complete, is sometimes produced by an accumulation of blood within the chest, occurring immediately after the receipt of the injury. Should this be found to have proceeded from one of the intercostal arteries, the proper remedy will be the ligature, after which the blood may either be removed mechanically, or be permitted to drain off spontaneously, by making the patient lie upon the affected side, so as to render the wound, if possible, the most dependent part of the body. If, on the other hand, it is evident that it has been derived from the lung itself, the best thing that can be done is to let it remain, in the hope that, by compress- ing the wounded structures, it will serve as a hemostatic. When the lung retains its natural position within the chest, the inflamma- tion consequent upon the injury soon causes it to adhere to the edges of the wound, and, in this manner, all communication between the exterior and the pleuritic cavity is generally speedily cut off; an occurrence which is one of the greatest safeguards that can possibly happen in such a case, and which WOUNDS OF THE CHEST AND LUNGS. 485 should always, if possible, be promoted by making the patient lie upon the affected side. If, on the other hand, the lung is collapsed, it may be so tied down by effused blood and inflammatory deposits as never to regain its ori- ginal situation. To avert and moderate inflammation of the lungs and pleurae in wounds of the chest is one of the great desiderata of our treatment, as this constitutes the chief source of danger in the event of the patient surviving the immediate effects of the injury. The principal agents for accomplishing this are the lancet, tartar-emetic and opium, purgatives, cupping, and counter-irritants, especially epispastics. If the system has not been too much drained of blood by the accident, the bleeding should be both early and free, and be repeated at short intervals until a decided impression has been made upon the disease; otherwise our chief reliance should be upon the use of tartrate of antimony and potassa, in union with anodynes, to allay pain and cough, and promote sleep. For controlling the circulation, free use should also be made of veratrum viride, its effects being carefully watched, lest too much cardiac depression should arise. The bowels should be thoroughly moved by senna and sulphate of magnesia, or calomel and jalap; blood should be taken by cups or leeches from the chest, over the seat of the morbid action; and, if these remedies do not prove speedily successful, a large blister should be applied, care being taken to let it remain upon the skin until complete vesi- cation has been produced. Many of these cases, however, either do not bear these depletory measures at all, or only to a very limited extent, and not a little judgment is often required to determine when to employ or to reject them. Perhaps our best guide, under such circumstances, is the state of the pulse and of the countenance; when the former is hard, full, and frequent, and the latter hot and flushed, lowering agents are plainly indicated, whereas, if the reverse be true, they should be refrained from, tonics and stimulants being, perhaps, used in their stead. Penetrating wounds of the chest are extremely liable to be followed by serons, sero-sanguinolent, and purulent effusions, no matter what means may be adopted for their prevention. If the accumulation be trifling, it will gene- rally disappear spontaneously, or under the influence of suitable local and constitutional remedies, as in ordinary pleurisy, or pleuro-pneumonia; but when it is abundant, means must be adopted for its removal, otherwise the patient will be extremely apt to perish. I have seen several cases of death simply from neglect of this precaution. The presence of fluid is denoted by the ordinary symptoms of thoracic effusion, of which absence of the respi- ratory murmur, dulness on percussion, excessive dyspnoea, harassing cough, and inability to lie on the sound side, are the most prominent and charac- teristic. If the accumulation is very great, there will be, in addition, partial effacement, aud, perhaps, even bulging of the intercostal spaces, thus im- parting greater certainty to the diagnosis. All doubt, of course, vanishes 'f the fluid escapes at the external wound. The formation of pus is generally preceded and accompanied by rigors and hectic irritation. The proper treatment of this accident is sufficiently obvious. If the ex- ternal wound has not yet closed, the body is placed in such a position as to render that the most dependent part, and it is seldom that any other proce- dure will be necessary. In a case which was under my charge in 1848, in a patient, aged twenty, whose chest had been penetrated by a pistol ball, eva- cuation of the cavity could only be effected by placing him on his knees and elbows at the same time raising the hips and lowering the head, thus making ie orifice as dependent as possible, an operation which was repeated, for several weeks, at least three times in the twenty-four hours ; the young man ultimately making an excellent recovery, with a collapsed lung. Before this spedient was resorted to, the fluid was occasionally drawn off with a syringe. / 486 INJURIES AND DISEASES OF THE CHEST. Where no opening exists, or where it cannot be made available for the pur- pose in question, a new one should be made, care being taken to select the most suitable part of the chest for furnishing a ready outlet to the pent-up fluid, and to avoid injury to the intercostal arteries. Patency of the orifice is maintained by a proper tent, or canula, well secured to the side of the chest, lest it should slip into its cavity. Injuries of the lungs not unfrequently exert a very prejudicial secondary effect upon these organs, eventuating in the production of abscess, or the development of phthisis, the latter being more likely to take place when there is an hereditary tendency to this disease. Such occurrences cannot always be avoided, but the fact that they may happen should be borne in mind by the surgical attendant, as this will be one of the surest means of preventing them. Although balls and other foreign bodies, lodged in the lungs, occasionally become encysted, yet in the great majority of cases they ultimately produce extensive and fatal disorganization of the pulmonary structures. The time at which this result occurs is very variable. A man, aged thirty-five, shot at the battle of Novi, died at the end of seven years, the bullet being found near the base of the left lung, in a distinct membrane, surrounded by indu- rated tissue. His health, after he had recovered from the more immediate effects of his wound, remained tolerably good for four years, when he was seized with an increase of dyspnoea, nocturnal cough, and hectic irritation, with pain in the chest, and inability to lie on the right side. He had no other sign of pulmonary disease, but finally died completely exhausted. In a case related by Dr. M. H. Houston, of Wheeling, a piece of coarse domestic linen, evidently the patch of a bullet, about two inches and a half in length by two in width, when unrolled, was found in the left lung, twenty-five years after its introduction. The cavity in which it lay was opposite the fifth intercostal space, near the spinal column; it was lined by a smooth, tough membrane, and communicated with several of the bronchial tubes, into one of which the foreign substance projected, thus keeping up the cough and irritation which had so long annoyed the patient. The ball, along with a piece of rib, had been extracted immediately after the receipt of the injury. In the chapter on gunshot wounds, allusion is made to a case where an ounce bullet was found in the right lung, in a distinct cyst, forty-five years after its introduction. In a few fortunate instances, the foreign body has been ejected during a violent paroxysm of coughing, excited by its presence. In a case which I attended in 1848, with Dr. T. L. Caldwell, of Louisville, the ball, on dissection, was found lying loose upon the surface of the diaphragm, on the right side, the patient having survived the effects of his wound nearly one month. It had entered the chest between the tenth aud eleventh ribs, two inches from the spine, and had perforated the base of the lung, which was completely collapsed. Penetrating wounds of the thorax occasionally remain fistulous for an almost indefinite period. Such an event will almost certainly arise when the pulmonary and costal pleurae fail to adhere for some distance around the more dependent parts of the external orifice, thereby forming a kind of pouch, in which the matter, furnished by the sac, is allowed to accumulate, instead of passing off as fast as it is poured out. The manner in which the pouch is usually emptied is by the patient placing himself in a particular atti- tude favorable to the escape of its contents; but as this is often irksome aud inadequate, it is seldom that the case receives the requisite attention, and hence many years often elapse before a cure is finally effected. The proper remedy is a counter-opening, made at the most dependent portion of the sac, so as to admit of a ready drain, both during recumbency and in the erect posture, the puncture being prevented from closing by a tent or canula. I" HEMOTHORAX. 487 a case which was under my care, some years ago, I pierced the chest through the fifth intercostal space, directly over the pericardium, and soon succeeded in effecting obliteration of the adventitious cavity. The patient was a young man who had inflicted a penetrating wound between the second and third ribs, in front of the chest, with a hatchet, which flew off its handle, while he was engaged in nailing laths. The cure of these affections, which is gene- rally followed by a remarkable retrocession of the wall of the chest, is some- times promoted by weak astringent and detergent injections, or by injections of a very dilute solution of iodine. Another uupleasant secondary effect of wounds of the chest is necrosis of the ribs and sternum, the exfoliation of which is generally a work of time and suffering, months not unfrequently elapsing before complete riddance can be effected of the disease. The existence of the lesion is usually indicated by a puffy and painful swelling of the part, by a foul discharge, and by the appear- ance of one or more cloacae, leading from the surface to the dead bone below. As soon as the bone is found to be loose, no time should be lost in removing it, the same procedure being employed as in necrosis in other pieces of the skeleton. SECT. II.—HEMOTHORAX. The hemorrhage which succeeds wounds of the chest, constituting what is called hemothorax, may proceed either from the lung, or from some artery in the wall of the thorax, as one of the intercostal, or a branch of the internal mammary; not unfrequently it is derived from both sources. The quantity of blood poured out varies from a few ounces to several quarts, and hence its effects upon the lung and system may either be very slight or exceedingly severe; perhaps, in the latter case, causing death by exhaustion within a few minutes after the accident, or putting life in jeopardy at a more remote period by inflammation and various deposits. The symptoms which characterize intra-thoracic hemorrhage are such as denote loss of blood in other parts of the body, with the suoeraddition of respiratory embarrassment occasioned by the mechanical compression of the lung. The countenance is deadly pale, the pulse small, quick, and tremulous, the surface cold and clammy, the breathing oppressed, the head giddy, and the mind anxious. Thirst and restlessness generally exist in a high degree ; the patient experiences a sense of weight in the chest, and is unable to lie on the sound side ; the thoracic walls emit a dull sound on percussion; and, if the effusion be large, there will be entire absence of vesicular murmur, with a tendency to flattening of the intercostal spaces. Blood usually escapes at the external wound, and, in the event of injury of the pulmonary tissue, is also discharged by the mouth, either in a pure state, or mixed with frothy mucus. Hemoptysis, however, is not always present in penetrating wounds of the lung. When blood escapes from the chest into the subcutaneous cellular tissue along the spine, it is apt to gravitate towards the loins, giving rise to an ecchymosic appearance of that region, which some, as Valentin, Larrey, Louis, and others, have been led to regard as pathognomonic of hemothorax, or effusion of blood into the pleural sac. This statement, however, must be received with some allowance; for it has been shown, on the one hand, that this phenomenon is often entirely wanting in hemorrhage of the chest, and, on theother, that it may be present simply as a consequence of a bruise or contusion, when there has been no injury of this cavity. the manner in which the blood in hemothorax is disposed of is subject to some diversity; when the quantity is small, it is generally absorbed, followed, probably, by some adhesive action of the pleura; if, however, the quantity 488 INJURIES AND DISEASES OF THE CHEST. be large, it will not only seriously compress the lung, but, assuming the solid form, it will be sure to excite severe inflammation, eventuating in serous and other effusions, which thus greatly complicate and aggravate the original difficulty. Instances occur in which, along with the extravasated blood, there is a considerable accumulation of air, thus combining hemothorax with pneu- mothorax, and, of course, increasing the urgency of the symptoms and the dangers of the case. It will thus be perceived that the prognosis of intra-thoracic hemorrhage is always serious, except in the minor and more unimportant cases. Death may occur within a few minutes after the accident, or the patient may recover from the primary effects, and perish from the secondary, particularly from the mechanical compression of the lung and the irritation which the blood excites by acting as a foreign body. The treatment of this form of hemorrhage is by no means satisfactory, since it is based rather upon speculation than upon any well-defined princi- ples. The patient should lie on the affected side, and the wound be kept open, unless it be found that the escape of blood is so excessive as to threaten serious, if not fatal, exhaustion, in which event it must be promptly closed. The head and shoulders should be elevated, iced water applied to the chest, acetate of lead and opium freely given internally, and, if the strength be not too much impaired, blood taken from the arm, to the extent of slight syncope, the operation being repeated as often as there is a decided tendency to overaction and to recurrence of hemorrhage. When the blood proceeds from the lung, a circumstance, however, which cannot always, or, perhaps, even generally, be ascertained, the most judicious plan, probably, will be to let it remain in the hope that it may exert a favor- able hemostatic action upon the wounded part; but as soon as all apprehen- sion is over in regard to a recurrence of the bleeding, as it generally will be in five or six days, the effused fluid should be evacuated by operation, either by enlarging the original wound, or, if this be situated unfavorably, by mak- ing a free opening through one of the intercostal spaces at the most depend- ent portion of the chest, or wherever the results of percussion and ausculta- tion may unite in locating the extravasated substance. The respiratory organs must be incessantly watched, to guard them from harm, the slightest tendency to inflammation being promptly averted with the lancet, tartar- emetic, calomel, and opium, aided by thorough and early vesication of the chest. SECT. III.—PNEUMOTHORAX. Pneumothorax is caused by injury of the substance of the lung, admitting of an escape of air into the pleural cavity, and, in some cases, also into the posterior mediastinum, and thence by the cervical vessels and nerves into the subcutaneous cellular tissue of the neck, trunk, and extremities. But in order that the latter occurrence may happen, it is necessary that there should not only be a wound of the lung, but likewise of the costal pleura. When these two conditions co-exist, it is easy to perceive how the air in the pul- monary vesicles may, during the expansion of the lung, be forced into the areolar structure beneath the lining membrane of the thoracic cavity, and thus constitute what is denominated emphysema. Collections of air in these situations may be caused by injury inflicted upon the lung through the walls of the chest, especially if the wound be very small, oblique, or valvular, thereby interfering with the outward escape of the fluid; or they may form independently of any external wound, in consequence of the laceration of the pulmonary tissues by a piece of broken rib, or the sudden and violent com- HYDROTHORAX AND PYOTHORAX. 489 Fig. 287. pression of the lung during a fall of the body from a considerable height, although such an event must be extremely rare. Emphysema of the cellular tissue of the trunk occasionally occurs without pneumothorax, as when a portion of lung that has become firmly adherent to the wall of the chest has been injured by the end of a broken rib being driven into its substance. In such a case, which is also one of extreme in- frequency, the air may readily escape from the wounded organ into the areo- lar structure beneath the costal pleura, and from thence into that of the trunk and extremities, but cannot obtain access to the thoracic cavity. The symptoms denotive of pneumothorax are generally of a very decisive nature. Percussion of the chest affords a remarkably resonant, or hollow, drum-like sound, wholly dissimilar from what is elicited in any other disease, and, therefore, of itself characteristic of the presence of air; the vesicular murmur is either much diminished, or entirely absent; the breathing is con- siderably embarrassed; the voice is feeble ; difficulty is experienced in lying on the affected side; and the respiration in the sound lung is puerile. The symptoms of emphysema are also distinctly marked. The puffy, colorless, and elastic swelling, crackling under pressure, and commencing at a particular part of the chest, either at the wound, or, if there be none, op- posite a broken rib, and gradually spread- ing in different directions, is an unmistak- able sign of the existence of air beneath the integuments. The air, in consequence of the permeable nature of the structure in which it is lodged, may readily be pushed from one place to another, especially soon after it begins to make its appearance ; and occasionally travels with astonishing rapi- dity over the greater portion of the body, destroying all distinction of the chest, neck, and face, and thus inducing the most un- Beemly and frightful deformity, as seen in fig. 287. The treatment of pneumothorax and em- physema is very simple. In general, the air in the pleural cavity will be rapidly de- composed and absorbed; should it prove troublesome, by causing serious respiratory difficulty, it may be let out slowly by means of a delicate trocar, introduced so as to make a valve-like aperture, which should be closed immediately after with ad- hesive strips, aided by a compress and bandage. Emphysema is usually easily controlled by compression ; but if it should threaten to become very extensive and in- convenient, or if it actually be so when advice is demanded, the most prompt and effectual remedy will be a moderately free incision at the seat of injury, or a number of little punctures in different parts of the body. General emphysema of the whole sur- face, after wound of the right side of the chest. SECT. IV.—HYDROTHORAX AND PYOTHORAX. Under these names may be described those collections of serum and of pus Jhicb supervene upon acute and chronic pleurisy, whether the result of acci- Qent or of disease. Collections of this kind are extremely common, and are 490 INJURIES AND DISEASES OF THE CHEST. of great surgical interest, from the fact that they may generally be removed by a very simple and safe operation. " In acute pleurisy, large quantities of serum are frequently poured out in an astonishingly short time, especially when the disease is of great extent and of unusual violence. The fluid is generally thin, colorless, and intermixed with lymph ; sometimes it is of a reddish hue, from the presence of hematin, and occasionally it is found to be remarkably yellowish, and of a thick, viscid consistence, not unlike copal varnish or fresh olive oil. It is very seldom that genuine pus is poured out in acute pleuritis, yet such cases are sometimes met with, and that, too, at an early period of the disease. I have seen several instances, chiefly in young, plethoric children, in which one of the thoracic cavities was literally filled with purulent fluid in less than a fortnight from the commencement of the disease. The water in chronic pleuritis is generally much more abundant than in the acute disease, often amounting to a number of quarts, if not to several gallons. It is also more thick and turbid than in acute attacks, being usually of a light lemon color, and of a somewhat oleaginous consistence. Sometimes it is of a greenish or reddish hue, and cases occur in which it contains blood and pus. The fluid, when drawn off, and allowed to stand for some time, gene- rally separates into two parts; one, thin and viscid, like serum, occupying the top; the other, which consists of fragments of lymph and albumen, resting at the bottom. This disunion not uufrequently takes place during the sojourn of the fluid in the cavity of the chest. Large quantities of lymph are often intermixed with this fluid; and in- stances are met with in which it consists almost entirely of pure pus, or, at all events, of a preponderance of purulent matter. When this is the case, the fluid is generally more or less fetid ; sometimes, indeed, almost insupport- ably so. The quantity of pus is occasionally enormous, amounting, perhaps, to several gallons. When the disease is of long standing, the matter may be partly contained in separate cavities among the layers of adventitious membranes which are so liable to form under such circumstances. I have repeatedly met with cases of chronic pleurisy in which three or four such cavities existed; some being filled with pus, some with serum, and some with a mixture of these fluids, or of these fluids and of blood. Finally, it is proper to add, that old thoracic accumulations occasionally contain gas, and various kinds of concretions, especially the fibrous and fibro-cartilaginous. The effects which these various effusions exert upon the lung, are generally very distressing, if not most disastrous, compressing and condensing its sub- stance, so as to render it unfit for the purposes of respiration., When the quantity of fluid is very great, the organ is sometimes reduced to a mere cake- like mass, hardly as large as the hand, lying in the back part of the chest, by the side of the spinal column. In this condition, it is occasionally bound firmly down by bands of lymph, so that, even if the fluid be ultimately gotten rid of, it remains afterwards incapable of expansion. Very frequently, also, especially in protracted cases, the pulmonary tissues become thoroughly solidified, in consequence of the mechanical compression to which they are subjected, thus rendering them hopelessly impervious to the air. The pleura, in chronic inflammation, is usually very much thickened from interstitial and surfacial deposits, and closely adherent to the surrounding parts. The diagnosis of these collections is a subject of the deepest interest, and, therefore, deserving of special consideration. It is founded mainly upon three circumstances: first, the history of the case; secondly, the changes in the configuration of the thorax; aud thirdly, the alterations in the respiratory functions. 1st. The history of the case will show whether the effusion is the result of traumatic or constitutional causes; if the latter, whether the consequence of HYDROTHORAX AND PYOTHORAX. 491 ordinary pleurisy, pleuro-pneumonia, or of tubercular disease; finally, whether the affection is acute or chronic, open or latent. 2d. Whenever the pleuritic effusion is unusually copious, it sensibly en- croaches upon the chest, so as to cause a very manifest enlargement of the corresponding side ; the intercostal spaces being not only abnormally widened, but perhaps thrust considerably beyond the level of the ribs. The diaphragm is also more or less depressed, and the heart is thrown out of its natural posi- tion, either to one side or down towards the stomach. The extent of the dilatation of the chest varies in different cases, but rarely exceeds two inches. The best way of determining it is to measure both sides with a graduated tape, carried from a central point of the sternum, under the mamma, to the Bpinous process of the corresponding vertebra. The eye alone, however, is often quite sufficient to detect the difference, even though it be comparatively slight. When the intercostal spaces are much distended, and there is at the same time great wasting of the tissues, fluctuation may occasionally be detected; but such an occurrence is very uncommon. 3d. The effects exerted by these effusions upon the respiratory sounds and movements are generally of an unmistakable character. The alteration of the vesicular murmur is always in direct ratio to the quantity of fluid, being deep and feeble when it is moderate, but entirely wanting when it is very abundant, except, perhaps, along the spinal column, where it may still be somewhat audible over a space a few inches in extent. When old adhesions exist between the pulmonary and costal pleura?, as often happens in the upper part of the chest in tubercular disease, the fluid, unable to compress this por- tion of the lung, may allow it to receive a certain quantity of air after respi- ration has ceased everywhere else. No friction sound is ever present when there is much fluid in the chest. To produce such an effect, it is necessary that the two pleura? should not only be roughened with lymph, but that they should be able to rub more or less against each other. JEgophony exists only when the effusion is moderate, or only a few lines in depth; hence, it is not present either in the very early or in the more advanced stages of the disease. Finally, during certain movements of the body, especially if sud- denly made, a splashing noise may occasionally be heard within the chest, resembling that produced by agitating a cask partly filled with water. Dnlness on percussion is always present when there is much effusion; com- mencing at the lower part of the chest, from which it gradually ascends as the fluid mounts upwards, and changing with the position of the patient. This symptom, however, considered by itself, is of no diagnostic value, inas- much as it always attends solidification of the lungs, in whatever manner in- duced. When the pleuritic effusion is blended with the extrication of gas, percussion elicits a remarkably clear tympanitic sound. The most important functional symptoms, especially in chronic pleuritic effusions, are hectic fever, rapid emaciation, pain in the chest, troublesome cough, a sense of tightness and oppression, great dyspnoea in ascending a flight of stairs, and inability to observe recumbency. If the patient lies down at all, he lies on the affected side, on his back, or in an intermediate posture. Collections of water, or of water and pus, in the pleuritic sac, occasionally find their way out to the external surface ; generally through one of the in- tercostal spaces, as in two cases which have been kindly shown to me by Dr. Da Costa. Sometimes the discharge takes place through the bronchial tubes. Le Dran, Andral, and others have recorded instances in which it was evacuated ^through the diaphragm. When the patient survives such an event, the track is lined by false membrane, and often remains fistulous for a long time. 492 INJURIES AND DISEASES OF THE CHEST. But a spontaneous opening is a rare occurrence, and as the fluid, when existing in large quantity, cannot be brought successfully under the influence of the absorbents, the question naturally arises, How shall it be gotten rid of? for, if it be allowed to remain in the thorax, it must inevitably destroy the patient, and that in a short time. But one rational answer can be given to this question, namely, removal by operation. The operation called tap- ping of the chest, although occasionally performed by some of the older sur- geons, was not placed in its true light until within the last ten years. In this country, attention was first prominently directed to the subject by Dr. Bowditch, of Boston, in a series of papers which have honorably associated his name with this department of pathology and practice. From the results of his cases, as well as from the results of the cases of other observers, it is evident that the operation, when properly performed, is not only perfectly safe, but generally eminently successful, the issue being always more favor- able, other things being equal, in proportion to the shortness of the time that has elapsed since the commencement of the disease, the excellence of the general health, and the absence of purulent matter. When the patient is much exhausted from protracted suffering and serious organic disease, the chances of recovery will, of course, be much lessened. The operation of tapping the chest is very simple. The instruments which are required are a scalpel and a long, slender trocar, furnished with a stop- cock, fig. 288, to prevent the entrance of the air into the serous sac. The Fig. 288. Instrument for tapping the chest. patient being comfortably propped up in bed, a small incision is made through the integuments, previously rendered tense, just above the upper margin of one of the ribs, generally the sixth, about midway between the sternum and spine, or just posterior to the digitations of the great serrated muscle. When the fluid points externally, the puncture is made at the most prominent and dependent portion of the swelling. The trocar is then thrust boldly through the intercostal space, penetrating the muscles and pleura, as well as any false membranes that may be adherent to its surface. The trocar being now with- drawn, the fluid will come away in a full stream, a suitable vessel having been provided for its reception. A large gum-elastic bag or beef's bladder, secured by a nozzle to the extremity of the canula, will be found to be the most eligible article for the purpose. When it is filled, the stopcock is shut until the bag can be re-attached, and thus the operation is continued until the cavity is completely emptied. Upon withdrawing the canula, the integu- ments immediately resume their natural position, and thus effectually occlude the puncture. The edges of the outer wound are approximated by an ad- hesive strip, which is the only dressing required, the bandage being objec- tionable on account of its constricting effects. The site of the operation and mode of performing it are well illustrated in fig. 289, from Erichsen. The operation is generally well borne, especially if the patient is slightly under the influence of chloroform, which also, in great measure, prevents the cough that is otherwise so apt to attend it. If the patient becomes faint, his HYDROTHORAX AND PYOTHORAX. 493 head should be gradually lowered, and free use be made of brandy. The former of these precautions will usually be required anyhow, with a view to Fig. 280. Tapping of the chest. complete clearance of the chest. As the fluid flows off, the lung, if not ad- herent or solidified, steadily expands, and at length regains its natural volume. If the accumulation has been very great, the operation will probably be obliged to be repeated several times before a final cure can be effected. The after-treatment is very simple; opium is given to allay cough and pain, and the system is supported by good diet and milk punch. When the case is very tedious, the fluids manifesting a strong tendency to re-accumulate rapidly after each operation, the cure may be expedited by the cautious injection of some slightly stimulating lotion, or simple tepid water, and the daily applica- tion of the dilute tincture of iodine to the walls of the chest. When a spontaneous opening arises in the chest in empyema, it will gene- rally be found to be altogether inadequate for effectual drainage, both on account of its small size and its vicious site. When this is the case a counter- opening, or a puncture in some more eligible situation, should be made ; for it is exceedingly desirable, in every instance of the kind, that the matter should have an opportunity of escaping as fast as it is formed. A similar procedure may occasionally be required after the operation of tapping. The use of the drainage-tube has lately been recommended under such circum- stances, but such treatment, it seems to me, should not be encouraged, as it is both harsh and dangerous. Paracentesis of the chest is sometimes attended with injury to the lung, the point of the instrument being thrust into its substance. Such an acci- dent, which, however, is seldom followed by serious consequences, will be most liable to happen when the organ has contracted firm adhesicfns. The intercostal artery is easily avoided by making the puncture in the lower part oi the intercostal space, at a considerable distance from the inferior margin of the upper rib. Much outcry has been made about the risk of the entrance of air during the operation, but I am not aware of any case that has proved ml 0r ^at ^as ^ to any seri°us detriment from this cause. the most valuable statistical facts relative to thoracic paracentesis are those 'urnished by Dr. John A. Brady, of Brooklyn, New York, consisting of an analysis of 132 cases. Of these, the operation eventuated in complete re- covery in 19; 14 were relieved ; and 37 ended fatally ; in 1 the result was not known; and in 1 no benefit followed. In quite a number of the patients 494 INJURIES AND DISEASES OF THE CHEST. that died, the disease had committed irremediable ravages before recourse was had to the operation. Of the 37 fatal cases, 11 were carried off by phthisis. Dr. Bowditch, in a communication which he kindly addressed to me in May, 1858, stated that he had tapped 72 persons, making in all 125 punctures, during the last six years ; but he made no mention of the relative number of recoveries and deaths. He added that in every case marked relief had fol- lowed. The ages of his cases ranged from four years to seventy-six. Finally, the reraoval of the fluid from the pleuritic cavity, whether by medi- cine or operation, is always followed, especially in cases of empyema, by a remarkable contraction of the corresponding side of the chest, which gene- rally remains during the rest of life, except when the patient is very young, and the lung regains its full expansion, when it sometimes nearly entirely dis- appears. SECT. V.—WOUNDS OF THE HEART. Wounds of the heart may be of an incised, punctured, or gunshot nature, according to the character of the vulnerating body ; and their gravity is gene- rally such as to lead very speedily to fatal results. Severe lesions are some- times inflicted upon this organ without any serious injury of the integuments, or any solution whatever of their continuity, as in fracture of the ribs and sternum, in which some of the fragments are driven into its substance, or so rudely pressed against its surface as to cause more or less contusion. Wounds of the heart may be limited to the walls of the organ, penetrate its cavities, or affect its pax-titions. In the first case, they may be said to be superficial; in the other two, deep, and, consequently, of a more serious cha- racter. Experience has shown that those parts of the organ which are least protected by the sternum and ribs are those which are most liable to be in- jured. In 121 cases, analyzed by Dr. A. M. Jamain, the right ventricle suffered in 43, the left in 28 ; the right auricle in 8, the left auricle in 2; the apex and base of the heart in 7 ; the inter-ventricular septum in 2; both ventricles in 9, and both auricles in 1. In 61 cases, analyzed by Dr. Ollivier, of Angers, 29 affected the right ventricle, 12 the left, 9 both ventricles, 3 the right auricle, 1 the left auricle, and 7 the apex or base of the heart. In gunshot wounds of the heart, the ball may lodge in the walls of the organ, or in the inter-ventricular septum, as in the interesting case related by Professor Carnochan. At other times, but this, also, is extremely rare, it may penetrate one of the cavities of the heart, and then fall into the inferior cava, descending, perhaps, nearly as far as the bifurcation of that vessel. Of this occurrence, a remarkable example is afforded by the unique case reported by Dr. Simmons, of a young man who received a pistol-shot in his chest, during my residence at Cincinnati, in 1835. He died at the end of ninety- seven hours, without having given any evidence whatever of being wounded in i he heart, Upon dissection, however, an opening, pretty firmly closed by blood and plasma, was discovered in the upper part of the right ventricle, the inner surface of which exhibited a lacerated appearance, but no appreciable lesion existed in any other portion of the organ, aud it was only by accident that the ball was detected in the inferior cava. Of 22 cases of accidental rupture of the heart, analyzed by Mr. Gamgee, U occurred on the right side and 10 on the left; 8 of the former affecting the ventricle, and 4 the auricle, while of the latter 3 involved the ventricle, and 7 the auricle. The pericardium in half of the cases was intact. Such an occur- rence can only be explained on the assumption that the ventricle was dilate at the moment of the percussion. Wounds of the heart are often complicated with other injuries, as fractures WOUNDS OF THE HEART. 495 of the ribs and sternum, and wounds of the lungs, the diaphragm, and large vessels. The symptoms of wounds of the heart are not always well marked, but often quite the reverse, thus occasioning great doubt as to their diagnostic value. In general, they are such as are indicative of severe shock, whether from mere nervous depression or from loss of blood, which is often exceedingly profuse. The patient is faint, anxious, and deadly pale ; the pulse is small, frequent, and irregular; the surface is cold and clammy; the pupils are dilated ; the voice is feeble and indistinct; and the respiration is laborious, and often inter- rupted by sighs. The pain is usually very severe, especially in the region of the sternum; and, upon applying the ear to the heart, a peculiar noise is perceived, similar to that which is heard in aneurismal varix, or during the passage of blood from an artery to a vein. Although the patient is usually very much exhausted by the shock consequent upon a wound of this organ, cases not unfrequently occur in which he is able to walk or run a considerable distance before he falls down or expires. These symptoms are, obviously, not pathognomonic; for they may be caused by various other lesions, as a wound of the lungs or large vessels. Import- ant information may often be derived from a consideration of the situation and direction of the wound. Thus, if a knife, sabre, or ball has entered the chest on the left side, between the fourth and fifth ribs, about two inches from the sternum, and the patient is in the condition above described, there will be strong reason for concluding that the heart has been laid open, especially if the external wound has pierced the pleura. Probing, in such cases, can be of no use in any respect, and should, therefore, be avoided. The prognosis of wounds of the heart is generally, though not invariably, unfavorable. Much will depend, in every case, upon the nature of the injury, especially its extent and direction. Sometimes a single shot is sufficient to cause death almost instantaneously, as happened in the case of a boy, aged seventeen, from which the accompanying sketch, fig. 290, was taken. He was out gunning with his brother, who, in shooting at a rabbit, about twenty yards off, accidentally hit him in the chest, a stray shot passing through the left ventricle, near its middle. When a ball or knife takes an oblique, tortuous course among the muscular fibres of the heart, their contraction may be such as to close the track made by the vulner- iiting body until a clot is formed, and so oppose, in great measure, the effu- sion of blood, thereby affording the wound an opportunity of undergoing reparation. However this may be, there are numerous instances upon re- cord which serve to prove that recovery is by no means impossible. Thus, Dr. Randall, of Tennessee, has reported the case of a negro boy, who died sixty- seven days after having been wounded in the chest with a load of shot. 1 he lesion_ was followed by severe inflammation of the lungs, but there was no indication that the heart had been injured, and the lad was thought to be convalescent, when he suddenly died from over-indulgence in eating. Upon ci.issection, five sn°ts were found in the heart, three in the base of the ventri- cle, and two in the bottom of the auricle ; the wounds in the walls of the urgan being all firmly healed, and the surfaces of its cavities exhibiting no Fis often tender on percussion, and the integuments sometimes pit on pressure. An increased discharge, of a thin, watery, and fetid nature, from the corre- sponding nostril, is occasionally present. The pain generally extends to the surrounding structures, as the teeth, nose, orbit, and forehead. The above 500 DISEASES OF THE JAWS, TEETH, AND GUMS. symptoms, which are always less marked in the chronic than in the acute form of the malady, are not diagnostic, and the practitioner should, therefore always institute the most thorough examination before he finally decides on their value. It is of great importance that this disease should be early recognized and properly treated, as its tendency, when neglected or mismanaged, is to run into suppuration and other mischief. Diseased teeth, or stumps of teeth, are of course, removed, even when it is not very apparent that they are the cause of the inflammation. If the symptoms are severe, blood is taken from the arm, and by leeches from the cheek or the alveolar process ; the bowels are freely evacuated with senna and salts; and the action of the heart is still further depressed, if necessary, by the exhibition of antimony and diaphore- tics, the latter of which are particularly indicated when the inflammation has been induced by cold. Fomentations and the application of steam are often beneficial in assuaging pain and relieving morbid action. 3. Abscess.—The formation of abscess in the antrum is denoted by an increase of the local and constitutional suffering, described as attending inflammation. The pain becomes more violent, and assumes a throbbing, pul- satory character, darting about in different directions, and being accompauied, in most cases, by a feding of weight and tightness at the focus of the mor- bid action. Aching sensations are perceived in the teeth, the nose, and frontal sinuses; and there are often severe rigors alternating with flushes of heat. By and by, an erysipelatous blush appears on the cheek ; the surface pits on pressure, and is exquisitely painful on the slightest touch. On raising the lip, the gum over the large grinders is found to be abnormally red and tumid, evincing the same increase of disease here as in the other situations. When the natural outlet of the sinus is not obstructed, there is often an escape of pus from the corresponding nostril, which, together with the symptoms just narrated, leaves no doubt respecting the true nature of the complaint. The matter in this disease is rarely abundant, except in the chronic form, when it may amount to several Fig. 291. ounces. It is generally of a thick, cream-like consistence, of a yellow- ish-green color, and highly fetid, apparently from its long retention. In the more violent grades of the disorder it is often intermixed with flakes of fibrin. In chronic ab- scess, the lining membrane usu- ally undergoes serious structural changes, becoming thickened, floc- culent, and even ulcerated, at the same time that the walls of the antrum are expanded in every di- rection. The treatment of abscess of the antrum is conducted on the same principles as that of abscess of the soft parts. The rule is to af- ford a free outlet to the pent-up fluid; if possible, before the oc- currence of serious structural change. Such a step is not neg- lected even when there is no ma- terial obstruction in the natural Perforation of the antrum. Orifice of the SJnUS, the inSUffl- UPPER JAW—ACCUMULATIONS OF FLUID. 501 ciency of this, from its elevated, and, consequently, unfavorable position, being well known. As the abscess is frequently directly dependent upon the irri- tation of a decayed tooth, or as some of the teeth are apt to become involved in the disorder, the safest and most expeditious way of affording relief is to extract the affected tooth, the fang of which often projects into the sac of the abscess and only requires removal in order to let out its contents. Should the opening thus made be inadequate, it may be easily enlarged by means of a trocar, fig. 291, or a very narrow trephine. Patency is carefully main- tained until the mucous membrane has regained its normal functions; an occurrence which may often be greatly expedited by the use of mildly astrin- gent injections, and suitable constitutional measures. The tooth usually selected is the middle grinder, especially if it be diseased. When the abscess points at the alveolar process, the puncture may be made there, but with a result much less promising of ultimate success. 4. Accumulations of Fluid.—The maxillary chamber is sometimes the seat of a species of dropsy, produced by the occlusion of its natural outlet, and the consequent retention of its natural secretion. The cavity, in fact, is placed in the same condition as a mucous crypt laboring under obstruction of its orifice ; the result in either case being an encysted tumor, as in fig. 292. The retained substance may be simply of a thin, watery character, or it may be thick and ropy like mucus, glairy and albu- minous like the white of an egg, yellowish and oily like the contents of a joint, or pale and tremulous like jelly. Its quantity varies from a few drachms to a number of ounces, accord- ing to the duration and activity of the disease. When very abundant, as it sometimes, though rarely, is, it expands the walls of the antrum in every direction, and thus causes the most hideous deformity of the corresponding side of the face. The cheek bulges out like an im- mense protuberance, the nose is thrown out of shape, the eye protrudes from its socket, the anterior naris is completely occluded, and there is great depression of the palate. The tumor fluctuates faintly under pressure, the teeth become loose, and the skin has a livid attenuated appearance. The disease is slow in its progress, and attended with hardly any pain ; the general health remaining good. In the worst cases, mastication, deglutition, speech, and respiration are interfered with. The affection is occasionally witnessed in young subjects, but is most frequent in middle age. It is difficult to distinguish this disease from carcinomatous and other formations of the antrum. Its best diagnostic characters, perhaps, are the tardiness of its progress, the absence of pain, the want of enlargement of the neighboring lymphatic ganglions, and the preservation of the general health. In case of doubt, the exploring needle is employed, the swelling being care- fully punctured at different points of its extent. The treatment is based upon the same principles as that of abscess, evacu- ation of the contents of the chamber being effected at the most dependent portion of the tumor. The palate bulging, the opening is made there ; or a decayed tooth is extracted, and the fluid is allowed to drain off along the resulting channel, widened, if necessary, by artificial means. Gradually the osseous cyst contracts, and re-accumulation being prevented, it is eventually oo iterated, the process being often advantageously expedited by the use of v astringent injections. When the cure is very tardy, in consequence Dropsy of the antrum. 502 DISEASES OF THE JAWS, TEETH, AND GUMS. of the great bulk of the tumor, it may be well to cut away a portion of its outer wall, care being taken not to injure the integuments of the face. 5. Polyps___It is rare to meet with polyps of the maxillary sinus. A great variety of morbid growths, having scarcely any common points of resemblance, have been described under this name, much to the detriment of sound patho- logy and practice. Perhaps the best specimen of a polyp of the antrum, and one which I have certainly more than once seen in ray operations on the upper jaw, is the sarcomatons, as it is vaguely termed. It is not easy, how- ever, to describe this variety of tumor, so diversified and multiform are its component elements. Its most ordinary character is the fibrous, in which, as the name implies, there is a predominance of the fibrous structure, although there is often, if, indeed, not constantly, an intermixture of other elements, especially the cartilaginous ; small cysts, cells, or cavities, containing various kinds of fluids, as serous, glairy, and sanguineous, are sometimes interspersed through their substance, and serve to give them a compound character. Few vessels are apparent in their structure, aud hence they seldom attain any great bulk, or advance with much rapidity. For the same reason they do not bleed much when ulceration takes place, or when we attempt their re- moval. The color of these tumors varies; some are pink, some livid, some white and opaque, like an oyster. Most of these tumors spring originally from the mucous membrane of the sinus ; but occasionally their development begins in the proper substance of the bone, which, in this case, is gradually broken down and disintegrated, and ultimately lost in the new product. Their volume, though generally small, sometimes equals that of a fist; they manifest no malignant tendency, and rarely return after extirpation. Middle-aged persons are their most fre- quent subjects. Polyps of the antrum are distinguished from encephaloid and other carci- nomatous formations of the upper jaw, first, by the tardiness of their growth; secondly, by their globular, ovoidal, or pyramidal shape; thirdly, by their circumscribed character, or indisposition to ramify through the surrounding parts; fourthly, by their firm, unyielding consistence; fifthly, by their pain- lessness; and, lastly, by the absence of contamination of the neighboring lymphatic ganglions. There is, moreover, little tendency in such tumors to ulceration; the mucous membrane of the mouth retains its fluid appearance; and there is much less sanguinolent discharge from the nose than in ence- phaloid. The general health is not deteriorated, and the countenance is free from that sallow and dejected expression which forms so striking and charac- teristic a feature in malignant disease. A polyp of the antrum may occasionally be approached by the mouth, the outer wall of the cavity being opened just above the roots of the teeth. When the wall is very thin and soft, the operation may be performed with the knife, but when the reverse is the case it may be necessary, in addition, to use a gouge and mallet. The cheek is, of course, detached from the bone for some distance as a preliminary measure. I have, on several occasions, removed polypoid tumors from the antrum in this way with very satisfactory results, and the plan should always, if possible, be adopted in preference to any other, as it is unattended with disfigurement of the face. When the morbid growth is uncommonly large, it will be necessary, as a general rule, to approach it through the cheek, as in the extirpation of malignant tumors, presently to be mentioned. Little hemorrhage usually accompanies such operations. 6. Vascular Tumors.—A tumor, having all the properties of an anasto- motic aneurism, has occasionally been seen in the maxillary sinus. It ,8 difficult to determine whether it takes its rise in the mucous membrane of the sinus, or in its bony walls. However this may be, it appears to consist essen- tially in an enlargement of the branches of the internal maxillary artery, which UPPER JAW—VASCULAR TUMORS—ENCEPHALOID. 503 interlace with each other in every conceivable manner, and thus form a tumor of an erectile character, similar to a nevus of the face. As the affection pro- gresses, the walls of the antrum are absorbed, and the morbid growth becomes subcutaneous, feeling like a soft, spongy mass, and exhibiting a bluish, pur- ple, or modena color. Its pulsation, which is synchronous with the contrac- tion of the left ventricle, is very distinct under the finger, and can generally be seen at some distance. W7hen the tumor is very large, it encroaches upon the eye, nose, and mouth, and is productive of great deformity. The prominent symptoms of the disease are, its steady increase, its tendency to encroach upon the surrounding parts, its soft, spongy consistence, its pul- satory movements, and the livid discoloration of its surface, both external and internal. The attendant pain is usually slight, and the general health is seldom impaired, until after the establishment of nasal hemorrhage, which is sure to set in sooner or later, and which is often profuse and draining in its effects. If the tumor be seen early, or, rather, if it be recognized before it has attained any considerable bulk, the proper procedure would be to expose it by a careful dissection, and effect its destruction with the actual cautery, the Vienna paste, or acid nitrate of mercury. Perhaps a portion of the growth might be constricted with the ligature, as in the operation for the radical cure of hemorrhoids. Wrhen it has attained a large size, ligation of the com- mon carotid artery, as proposed and practised by the late Professor Pattison, may be tried, although, it must be confessed, with but a faint prospect of success. 1. Encephaloid.—By far the most frequent, as well as the most formidable disease of the chamber of Highmore, is encephaloid, osteocephaloma, or soft cancer, which occurs here, as elsewhere, in both sexes, in all classes of indi- viduals, and at all periods of life. I have witnessed it in children under five years, in young adults, at middle life, in old age, and in decrepitude. It is, however, undoubtedly most common between the twentieth and fortieth years. It is not known what influence, if any, occupation, temperament, climate, and other circumstances exert upon the development of this disease. In every instance of it that has fallen under my observation, it arose without any ob- vious cause. The malady usually begins in the cavity of the antrum, in connection with the mucous membrane. Occasionally it takes its rise in the cancellated struc- ture of the bone, in the socket of one of the molar teeth, in the gum, or in the periosteum. In the first case, it generally progresses until it fills up the whole siuus, after which it encroaches upon the bony parietes of the cavity, pushing them out in every direction, and thereby pressing them against the surrounding structures. As the external wall is extremely thin, in fact a mere shell, in the natural state, the morbid growth commonly advances more rapidly in this direction than in any other, forming thus, frequently at an early stage, quite a large tumor on the cheek. By and by, as it proceeds in its development, it extends towards the nostril, partially, and sometimes completely, occluding the corresponding cavity ; upwards towards the floor of the orbit, compressing and ultimately protruding the ball of the eye; down- wards towards the palate, displacing the tongue, and diminishing the mouth ; and backwards towards the fauces, impeding mastication, deglutition, speech, and respiration. At this stage of the disease, the countenance is most hideously disfigured, and the patient is an object well calculated to excite commiseration. The appearances here described are well seen in figs. 293 and 294. the integuments and mucous membrane are generally sound in the earlier stages of the complaint; but after a certain period, varying from several months to a year, they begin to assume a livid and congested appearance, 504 DISEASES OF THE JAWS, TEETH, AND GUMS. and at length yield to ulcerative action. The consequence is a fungatingand rapidly spreading sore, the seat of a thin, sanious, muco-purulent, or sanguino- Fig. 293. Fig. 294. Encephaloid of the antrum, encroaching upon the face. ing upon the mouth. lent discharge, very abundant, excessively fetid, and highly irritating. Pure blood often proceeds from it; sometimes very small in quantity, at other times so copious as rapidly to undermine the strength, and bring on hectic fever, with exhausting night-sweats. In the latter stages of the disease, sometimes before, but generally not until after ulceration has set in, the lymphatic ganglions of the temple, behind the ear, and under the jaw, become enlarged and contaminated, and finally give way from over-distension. The countenance assumes a peculiar cadav- erous expression ; the patient rapidly loses flesh and strength ; colliquative diarrhoea supervenes; the pain is excessive; and death finally occurs from exhaustion. The progress of the malady is variable ; sometimes very rapid, at other times quite tardy. I have seen death produced by it in less than six months from its commencement; and, on the other hand, I have met with cases in which the fatal event did not take place under several years. My experience is that the affection is usually more rapid here, as elsewhere, in children and youths than in the middle aged and old. When such a tumor is inspected after death, or removal, it is found to exhibit all the characteristics of encephaloid formations generally. That portion which occupies the antrum is commonly quite soft and pulpy, resem- bling, at least faintly, both in color and consistence, a section of the brain. The osseous structure is broken down and disorganized, quite vascular, ana so soft as to be easily cut. In some places, and in some specimens, it is entirely, or nearly entirely, absorbed; while in others it is replaced by fibro- cartilage, or cartilage, intermixed with spicules and scales, remnants of the original tissues. In the majority of cases, the morbid growth is remarkably vascular, being pervaded in every direction by large vessels, the walls of which are exceedingly brittle, and, therefore, liable to yield under the slightest impulse. It is owing to this circumstance that these tumors frequently attain UPPER JAW—SCIRRHUS—EXOSTOSIS. 505 such an enormous bulk, and that, when ulceration sets in, they are so liable to fungate and bleed. The diagnosis of encephaloid disease of the superior jaw, however com- mencing, is usually not difficult. The rapid growth of the tumor, its steady encroachment upon the adjacent parts, its soft and elastic feel, the livid aspect of its buccal portion, and its sharp, darting pains, readily distinguish it from all other formations of this division of the skeleton. In the latter stages of the affection, the fungous character of the ulcer, and the sanious, sanguino- lent, and bloody discharges, together with the sallow and cadaverous state of the countenance, and the enlargement of the neighboring lymphatic gan- glions, leave no doubt about its real nature. Important information will also be furnished by the history of the case, and by the fact that encephaloid occurs at all periods of life, while some of the other morbid growths of this region are seen only at certain ages. When any doubt exists respecting the character of the tumor, no objection lies against the use of the exploring needle, which will at once inform us as to the consistence of the morbid product, and the nature of its contents. If it be encysted, an escape of serum, or muco-sanguineous fluid, will afford the necessary intelligence, and enable us to shape our course accordingly. Should encephaloid matter be present, the smallest particle will, if subjected to the microscope, reveal the characteristic cancer-cell. Encephaloid disease of the jaw seldom co-exists with malignant disease in other parts of the body. The affection, in fact, in the great majority of in- stances, is more local in its character than when it invades the cellular tissue, eye, and glandular organs. It is, doubtless, owing to this circumstance that excision of the disease, especially in its early stage, is occasionally successful, though, in general, the prognosis is most unfavorable; and yet this is the only resource the surgeon has at his command. 8. Scirrhus.—Scirrhus of the upper jaw is extremely rare ; I have never seen an instance of it, and what is usually described as such is probably no- thing but encephaloid disease. If it should ever occur here, it would be likely to show itself in advanced life, as a hard, firm, solid tumor, slow in its pro- gress, and characterized by sharp, lancinating pain. It would not be likely to attain as great a bulk as soft cancer; nor would it be so liable to fungate and bleed. Of colloid and melanosis of the upper jaw, we are entirely ignorant. 9. Exostosis.—The superior maxilla is one of those pieces of the skeleton which are liable to exostosis, that is, a genuine osseous tumor. The morbid growth, varying infinitely in regard to its size and form, is most common in old and middle-aged subjects; it may appear upon any part of the bone, and, gradually augmenting in volume, may at length involve it in its entire extent. It is strictly a local affection, the result generally of external violence, or of a syphilitic taint of the system ; and rarely, if ever, degenerates into malig- nant disease. An exostosis is easily recognized. Its chief peculiarities are, its excessive hardness, its slow growth, its freedom from pain, the absence of disease in the surrounding structures, and the unimpaired state of the general health. Ihere is no discharge of blood, or muco-purulent matter, no tendency to ulceration, no alteration, at least not for a long time, in the skin of the face, or in the mucous membrane of the mouth; the principal inconvenience is Irom the size of the morbid growth, which is occasionally enormous, and from its consequent interference with the functions of the adjacent parts. When doubt exists, a small exploring needle, introduced at various points of the tumor, will at once decide the question. Little is to be accomplished in this disease by medical treatment. When the tumor is young and small, the external and internal use of iodine may be 506 DISEASES OF THE JAWS, TEETH, AND GUMS. serviceable in diminishing, and even in eradicating it. A mild mercurial course, conjoined with the internal exhibition of iodide of potassium, is indi- cated when it is dependent upon a syphilitic taint of the system. A growth of this kind has been known to drop off spontaneously. But such an event is not to be looked for, nor, as before stated, is much to be expected from therapeutic agents. In general, nothing short of extirpation will answer, and this, fortunately, is usually readily accomplished by the ordinary means. 10. Hypertrophy.—A very singular enlargement of the superior jaw, con- stituting a species of partial hypertrophy, and depending upon the irritation of an inverted tooth, is occasionally met with. An instance of the kind, the only one I have seen, fell under my observation in 1843, in a young lady, aged twenty-one. The enlargement, which had been first noticed two years and a half previously, and which was about the volume of a large hickory- nut, occupied the alveolar process of the left jaw, and was of a hard, firm consistence, free from pain and soreness, unaccompanied by disease of the gum, or derangement of the general health, and formed at the expense mainly of the outer plate of the bone. Upon sawing into the tumor, it was found to be occupied by a cuspid tooth, a little smaller than natural, but well grown, with the crown reversed, or directed upwards towards the antrum of Highmore. The parts soon healed, and with hardly any defect, save what resulted from the extraction of the canine tooth, which was deemed necessary as a preliminary step. 11. Encysted Tumors.—"Very recently, I had, at the Jefferson College Clinic, an old man, brought there by Dr. Piper, of this city, on account of an encysted tumor of the upper jaw, evidently formed in the areolar structure, just above the lateral incisor and cuspid teeth. It was about the volume of a lime, and distinctly fluctuated under pressure, its anterior wall cracking like parchment. Its contents were of a serous character. The tumor being opened with a stout knife, its secreting surface was freely touched with chro- mic acid, a tent being afterwards introduced to keep up the irritation. Healthy granulations soon sprung up, and in less than two months the cavity was completely obliterated. EXCISION OF THE UPPER JAW. Excision of the upper jaw is required chiefly in malignant disease, and under such circumstauces it may be necessary to remove, at the same time, portions of the malar, turbinated, ethmoid, and sphenoid bones, which are often involved in the morbid action. A part of this bone, it would seem, was removed by Acoluthus as early as 1693; but the honor of first extirpating the whole of it is due to the late Dr. Jameson, of Baltimore, who achieved the enterprise successfully in 1820. An account of the case is contained in the fourth volume of the American Medical Recorder, and is well worthy of an attentive perusal. Since then the operation has been repeatedly executed by American surgeons, among whom Stevens, Mott, McClellan, Mussey, Pancoast, Mutter, and the two Warrens, deserve special mention. I have performed it a number of times. In performing the operation, the patient should always be placed recum- bent, especially if the tumor is of considerable bulk, and a good deal of time is required to effect its removal. A broad and rather thin pillow should be put under the head and shoulders, and the face should be inclined towards the opposite side. Very few persons, whatever may be their courage and fortitude, can bear the shock and fatigue of an undertaking of such magnitude in the sitting posture. This precaution is the more necessary if chloroform be given, as I always do in such cases. I am aware that objections have been urged against the administration of this remedy in operations on the mouth, EXCISION OF THE UPPER JAW. 507 but without, I believe, any just reason. Be this as it may, I have employed this agent, ever since its introduction into practice, in all the amputations, both of the upper and lower jaw, that have fallen under my observation, and I have certainly, thus far, had no cause to regret it. The mouth can always be easily cleared of blood, even if the patient is unconscious, with the finger, or a sponge-mop. I have never found it necessary, in any of my operations on the upper jaw, to secure the carotid artery, as a means of preventing hemorrhage. Indeed, it is surprising that such a procedure should ever have been recommended, much less practised, by any one. My experience is that there are no organs in the body, of the same extent, in their natural and diseased condition, the removal of which is attended with so little hemorrhage. No skilful surgeon now even employs compression of the carotid artery in these operations, and, as to tying that vessel as a means of security against the loss of blood, I should as leave think of ligating the femoral artery for the same purpose. Nothing, it seems to me, could be more absurd and unnecessary. The chief danger from hemorrhage is in the subcutaneous arteries, especially the facial and its branches, and these are always readily controlled by the ligature. The deep-seated arteries, involved in tumors of the upper jaw, seldom bleed much, if care be taken to keep beyond the limits of the diseased structures. If this precaution be neglected, the hemorrhage may be copious, if not ex- hausting. The oozing which takes place from the osseous surface, after the exsection is completed, in general speedily ceases of its own accord from the contact merely of the air; when it does not, it is usually easily arrested by compresses wet with a saturated solution of alum. The actual cautery can be required only when the vessel is entirely beyond the reach of the ligature, or when a portion of the disease has been left behind ; a circumstance which should never happen in the hands of any one, as it must necessarily lead to a speedy reproduction of the tumor. The direction, extent, and number of the incisions through the soft parts must necessarily vary with the situation and volume of the tumor. In all these respects, much must be left, in every case, to the judgment and experi- ence of the operator. When the morbid growth is comparatively limited, and seated upon the anterior, or antero-lateral, aspect of the jaw, we shall generally be able to dispense with external incisions altogether, as our object may be readily accomplished simply by dissecting off the lip from its attach- ments to the bone, and holding it out of the way with a finger or blunt hook. The surface of the tumor having thus been thoroughly denuded, the bone is attacked with the pliers, and severed fairly beyond the line of the disease. By this procedure, which is admirably adapted to the more simple forms of morbid growths, the operation is divested of much of its severity, and not followed by any deformity of the features, save what results from the caving in of the integuments. V\ hen the tumor involves the body of the jaw, and is of considerable bulk, the plan which I usually adopt, and which has always answered my purpose most fully, is to make one long, curvilinear incision, extending across the niost prominent part of the tumor, from the commissure of the lips towards the zygomatic process of the malar bone, terminating within a few lines, half an inch, or an inch, of the external angle of the eye, according to the exigen- cies of the case. In this manner are formed two flaps, the upper of which is convex, and the lower concave, which are then carefully dissected up by bold and rapid strokes of the knife, and held out of the way by trustworthy assist- ants, who, at the same time, take care to compress the bleeding vessels. The space which this procedure affords is, in general, quite sufficient for the easy emoval of the entire tumor, however large or extensive its connections. In uy own cases, it has always answered the purpose most thoroughly. Should 508 DISEASES OF THE JAWS, TEETH, AND GUMS. Lines indicating the course of the knife in excision of the upper jaw. it, however, be inadequate, it can readily be increased to the requisite extent by carrying the knife horizontally along the inferior border of the orbit, as far over as the nose, as exhibited in Fig. 295. fig. 295, from a patient, affected with encephaloid disease of the antrum, whom I recently attended with Pro- fessor Pancoast. In making the first of these incisions, the facial artery is necessarily divided, and, in the second, the superior maxillary nerve, together with many of the branches of the por- tio dura of the seventh pair. In con- sequence of the injury thus sustained, the parts supplied by these nerves re- main a long time paralyzed, though ultimately the face regains, in great degree, its accustomed power and ex- pression. When the tumor, or enlargement, occupies the anterior and upper por- tion of the jaw, the external incision may extend vertically upwards by the side of the nose, from the free border of the lip to a level with the orbit of the eye. This will enable the operator to detach the wing of the nose, and to remove, if necessary, the ascending process of the jaw-bone, the lachrymal bone, the inferior turbinated bone, and even the vomer, as I have been compelled to do in two instances. When the antrum is mainly implicated in the disease, two incisions, repre- senting the form of an inverted L, are necessary, the vertical limb correspond- ing with the ascending process of the maxillary bone, and the horizontal one with the inferior border of the orbit of the eye. Whatever may be the form and direction of the incisions, care should always be taken that they are sufficiently extensive to afford ready access to the diseased mass. Nothing can be more embarrassing, or display a greater want of judgment in the operator, than a want of room in a case of this kind. The necessary incisions having been made, and the flaps dissected up, the next step is to remove the tumor. As a preliminary measure, two teeth, one in front and the other behind, must be extracted, to make room for the play of the saw and other instruments. As a general rule, this part of the ope- ration should always be performed as soon as the patient is fairly under the influence of chloroform, and, consequently, prior to the division of the soft structures. If done after that, it is liable to occasion delay and annoyance. The separation of the jaw is generally the work of a few minutes. The limits of the disease being usually well defined, care must be taken to keep on the outside of them, for the twofold purpose of avoiding hemorrhage, and removing the whole of the morbid structures. The best contrivance for ex- ecuting this part of the operation is a pair of pliers. The surgeon should supply himself with at least three of such instruments, of different shapes and sizes, figs. 296, 297, 298, as one is rarely sufficient for the purpose. He should also have several chisels, small saws, a lenticular, and a stout scalpel, the handle of which should terminate in a steel point, that it may be used a« a scraper and a cutter, as may be found expedient. When it is designed to remove the entire jaw, the saw or pliers should successively be carried through the alveolar process in front, and the hori- EXCISION OF THE UPPER JAW. 509 zontal plate behind, close to the middle line, as far back as the corresponding portion of the palate bone; the mucous membrane of the roof of the mouth 296. Fig. 297. Fig. 298. Different forms of bone forceps. having been previously divided with the scalpel, to prevent it from being bruised and lacerated. Next, the instrument is to be applied to the malar bone, at or near its junction with the maxillary, and finally, to the nasal pro- cess, which is generally divided on a level with the lower margin of the orbit. The orbital plate of the jaw bone is commonly left intact, at least in part, as it rarely participates in the morbid action. Should it do so, however, it should be cautiously removed with the chisel and knife, lest the eye and its appendages be injured. All that now remains to be done is to sever the tumor at its junction with the pterygoid process and palate bone ; and here, again, the chisel and knife will come into excellent play. Occasionally the bones, after having been pretty well severed, may be forcibly wrenched from their bed by grasping them firmly with the lion forceps, devised by Fergus- son, and represented in fig. 299. The main tumor having been removed, Fig. 299. Clawed forceps. the parts are carefully sponged, and any remnants of diseased substance that may appear are cleared away with the" lenticular, gouge, and other suitable instruments. 510 DISEASES OF THE JAWS, TEETH, AND GUMS. The cavity made by the operation being carefully sponged, any vessels that may seem inclined to bleed are at once secured. It is seldom, in any case, that more than three or four ligatures will be required. To arrest the oozing of blood from the deep portion of the wound, and give support to the cheek, the osseous gap should be stuffed with patent lint, wet with a saturated solu- tion of alum. The edges of the cutaneous wound are then approximated by the twisted suture, and a compress being applied upon the cheek, the part's are supported by a roller, passed round the head and chin in the form of a figure 8. The after-treatment is strictly antiphlogistic ; and, as the great danger to be apprehended is erysipelas, every means should be used to prevent its occur- rence. The needles are removed at the end of the third day, when the edges of the incision will generally be found perfectly united. I have repeatedly seen wounds, eight and nine inches in length, close by the first intention after these operations. The patient soon becomes accustomed to his loss; and the function of deglutition, at first so difficult and annoying, is gradually performed with its original facility. Even the faculty of mastication is regained much more rapidly than one, unacquainted with the compensating powers of nature, might be led to suppose. The deformity of the face is often comparatively trifling; and the defect in the mouth may usually be remedied, in the more favorable cases, by artificial means. It is surprising how much, even in a short time, the cavern contracts, and how all the surrounding and associated parts accommodate themselves to their new situation. It would be interesting to give an account of the results of the different operations that have been performed for the reraoval of the upper jaw for malignant and other diseases ; but for such an undertaking we have, unfor- tunately, no precise data. When the tumor is of the encephaloid character. it may safely be assumed that it will return, sooner or later, in almost every instance, however thoroughly the abnormal structure may have been extir- pated. In the non-malignant varieties, on the contrary, there is no reason to apprehend a relapse, any more than in the same class of affections in other parts of the body. SECT. II.—AFFECTIONS OF THE INFERIOR MAXILLARY BONE. The lower jaw-bone is subject to various affections, of which the principal are abscess, caries, necrosis, and different kinds of tumors. 1. Chronic Abscess.—The lower jaw, like other bones, is liable to the for- mation of a circumscribed abscess, small in size, slow in its progress, lined by a distinct membrane, and filled with strumous matter, the affected tissue being much increased in bulk and density. The disease, which has hitherto been observed chiefly in young subjects, may be caused by external injury, by cold, by the action of phosphorus, or by the irritation of decayed teeth. The symptoms are generally obscure, the most prominent being a gradual enlarge- ment of a particular portion of the bone, with a sense of excessive hardness, more or less tenderness on pressure, and fits of acute pain, recurring at van- able intervals, with difficulty of separating the jaw and of masticating, and gradual failure of the health. The treatment consists in exposing the abscess with the trephine and evacuating its contents. If the textural lesions are very great, complete excision of the affected parts may be necessary. 2. Caries___Caries of this bone does not require any particular notice, M it is neither frequent in its occurrence, nor peculiar in its character. Varioas causes may induce it, as external injury, the irritation of a decayed tootb, mercurialization, or a scorbutic, strumous, or syphilitic taint of the system. LOWER JAW — NECROSIS. 511 Whenever it takes place, the nature of the exciting cause should, if possible, be traced out, and the case treated accordingly. 3. Necrosis.—Necrosis is also uncommon, being witnessed principally as a result of profuse ptyalism, especially in young and weakly persons, of a strumous temperament. Large portions of the bone, along with the corre- sponding teeth, are often destroyed by this cause in this country, where mer- cury is given with such a profuse and daring hand. I have known cases where more than one-half of the bone perished and sloughed away from the effects of salivation. The inflammation which precedes and accompanies the necro- sis frequently involves the soft parts, producing extensive mortification, and the most horrible deformity of the features. Fortunately, such cases are becoming every year less common among us, for the vile and unmeaning practice upon which they generally depend is fast falling into desuetude. One of the worst things connected with these occurrences is the permanent closure of the jaw by the inodular tissues, which are generally extremely firm, and exhibit the same tendency to contraction as the inodular tissues of a burn. As a consequence, the poor sufferer is often unable to move the bone in the slightest degree, except, perhaps, a little laterally, and he has the greatest difficulty in feeding himself. I have seen many cases in which the power of mastication was utterly destroyed, and where the food was always obliged to be chopped as finely as possible before it could be introduced into the mouth. Articulation, of course, is impeded, and the patient, if young, must necessarily suffer in his education. In a word, I know of no class of human beings who are more deserving of our commiseration and skill than this, or who have more reason to complain of the carelessness and incompetency of medical practitioners. Xecrosis is always easily distinguished by the denuded state and whitish appearance of the affected bone, by the existence of purulent discharge, and by the excessively fetid state of the breath. The part, when struck with the * probe, emits a peculiar ringing sound, very different from that of a healthy bone. The treatment consists in attention to cleanliness and the removal of seques- ters. To fulfil the first intention, free use is made of the solutions of soda and lime, along with such remedies as shall have a tendency to improve the general health. The dead bone may be withdrawn with the fingers, or, with the fingers and forceps, the latter being always handled with the greatest care and gen- tleness. When the sequester is very large, the operator may be compelled, as a preliminary step, to cnt the gum, or even to divide the dead bone itself with the saw or pliers, but an external incision will seldom be required in any case, however extensive. When the whole of the lower jaw is necrosed, the proper procedure is to divide it at the chin, and to draw out each half separately ; the knife being employed wherever it may be necessary on account of the resistance of the soft structures. Where these precautions are used, and the operation is postponed until the sequestration is entirely, or at least measurably, completed, I feel satisfied that there will seldom be any need of interfering with the skin. The entire lower jaw, affected with necrosis, was thus removed by Dr. George McClellan in 1823. ^ ithin the last few years, the attention of the profession has been called to a singular species of necrosis of the lower jaw dependent upon the inju- rious effects of the fumes of phosphorus in the manufacture of lucifer matches. In this country, it was first noticed by Dr. James R. Wood, who gave an account of it in the Xew York Journal of Medicine for May, 1856, accom- panied by the history of a case in which he removed the entire lower maxil- jary bone for the cure of this disease. In order to produce its specific impression, it is necessary, it would seem, that the vapor should come in im- mediate contact with the periosteum, or the alveolar process of the bone; 512 DISEASES OF THE JAWS, TEETH, AND GUMS. hence it is alleged that those only who have carious teeth are liable to suffer from it. There are, however, some pathologists who assert that the phos- phorus is absorbed into the system, and that its effect upon the jaw is alto- gether secondary, acting very much in the same manner as mercury. How- ever this may be, the disease is essentially inflammatory, and gradually terminates in a loss of vitality, sometimes so extensive as to involve the entire bone. Its approaches are usually slow and insidious, the parts feeling merely somewhat tender and painful, as so often happens in slight toothache. The disease, in fact, is at first quite chronic. By and by, however, it acquires new activity, and then rapidly accomplishes its work, the local and constitu- tional disturbance being excessive, especially if abscesses form, and the mor- tification extends to the soft parts. Under such circumstances, it is not uncommon for the patient to die. The treatment of the disease, in its earlier stages, is the same as in perios- titis from any other cause; by leeches, incisions, astringent and detergent lotions, and general antiphlogistic means. Tonics will be demanded when there is profuse suppuration, or when the mortification extends to the soft parts. In the latter case, the best topical remedy will be dilute nitric acid, acid nitrate of mercury, or nitrate of silver, with chlorinated washes. Surgical interference is required when the dead bone has become measura- bly detached ; it may be removed entire, or piecemeal, according to circum- • stances. In general, the operation may be satisfactorily performed without any external incision, even when the whole bone is involved. 4. Exostosis.—Exostosis of the lower jaw is very rare. It is generally situated between the angle and symphysis of the bone, and is capable of ac- quiring an enormous bulk. Its cause may sometimes be traced to external injury, or to the irritation of a decayed tooth, which has occasionally been found completely encapsuled by the morbid growth. The disease is slow in * its progress, and seldom productive of any other inconvenience than what results from its mechanical obstruction. The treatment is similar to that of exostosis in other parts of the body. The lower jaw is sometimes expanded, at one particular point, into a hard, firm, solid tumor, constituting a species of local hypertrophy. The density of the affected part is occasionally equal to that of ivory. A few years ago, Dr. Pinkney, of the United States Navy, showed me a piece of the body of the inferior maxillary bone, which he had removed for a disease of this kind from a man at Lima, and which was so hard that he found it almost impossi- ble to divide it with the saw. An account of the cure has been published in the twelfth volume of the American Journal of the Medical Sciences. 5. Epulis.—One of the most common affections of this bone is epulis, of which the annexed drawing, fig. 300, from one of my patients, affords a good illustration in its earlier stages. It con- Fig. 300. sists, originally, of a small, fleshy-looking tubercle which, as its name implies, projects from the gums, though it is doubtful whe- ther it ever originates there. From what I have seen of it, I am inclined to believe that it generally, if not always, begins in the socket of one of the teeth, usually one of the molar, from which it gradually ex- tends upwards until, in many cases, it forms Epulis, in its earlier stages. a growth of considerable volume. It is0l a dense, firm consistence, of a florid color, and of a peculiar fibrous structure. Its shape is irregularly rounded, some- what like a mushroom, its point of attachment being usually much smaller than its free extremity. When first noticed, it has generally the appearance LOWER JAW—EPULIS — CYSTIC DISEASE. 513 of a little excrescence, situated at the side of one of the teeth, which, in time, becomes loose, and ultimately drops out. During its progress, which is commonly rapid and painful, it extends in different directions, forming a mass which fills up a considerable portion of the mouth, and which inter- feres essentially with mastication, articulation, and even deglutition and re- spiration. Fig. 301, from Druitt, exhibits this disease in its advanced stages, encroach- ing seriously upon the mouth, and impeding the movements of Fig- 301. the tongue and jaws. It is difficult, in the present state of the science, to classify this morbid growth. Most writ- ers seem to regard it as belonging to the cancroid varieties of dis- ease, and it certainly approaches these affections more nearly, in its progress, symptoms, and repro- ductive tendencies, than any other with which we are acquainted. In all the cases that have fallen under ray observation, and their number has been considerable, the repullulating disposition has been most remarkable. As to its exciting causes, absolutely nothing is known. It occurs in both sexes, and at all periods of life, though young persons ap- pear to be most subject to it. In cases of long-standing, the surface of the tumor ulcerates, and becomes the seat of severe pain, and of a fetid, sanguinolent discharge. The neigh- boring lymphatic ganglions enlarge, and the constitution evinces signs of contamination. The time at which the disease destroys life varies from twelve months to three years. The only remedy for this affection is early and effectual excision, not of the tumor, or of the parts from which it grows, but of the portion of the bone in which it has its origin. I am satisfied that it is worse than useless to temporize with such a malady; the only way is to deal it at once an effec- tual blow by sawing out a piece of the jaw, embracing its entire thickness, and reaching some distance beyond the limits of the morbid mass. I have never known a case in which any other procedure did the least good. In treating epulis, we should not lose sight of the fact that it is an affection, not so much of the gums as of the jaw-bone; and, therefore, anything short of the removal of this, at the site of the disease, is an absurdity. 6. Cystic Disease.—The cystic tumor of the lower jaw is uncommon, and altogether devoid of malignancy. . Its ordinary site is the alveolar process, where it may attain the volume of a hen's egg, or even of a large orange. It is composed of a distinct cyst, of a fibrous texture, thin, and transparent, or slightly opaque, and is occupied by a serous, sanguinolent, or glairy, mu- cilaginous fluid. Sometimes, though rarely, there are several such sacs, either closely connected together, or separated by an osseous septum. The bone around the tumor is expanded into a thin, elastic, crackling, parchment-like shell, and is easily penetrated by a sharp instrument, the puncture giving vent to the characteristic contents of the cyst. This, in fact, is the best diagnostic S1gn of the morbid growth. The disease is always tardy in its progress, and vol. ii.—33 Epulis, which, having existed many years, interfered with the movements of the tongue and jaw, and so pro- duced great emaciation. 514 DISEASES OF THE JAWS, TEETH, AND GUMS. manifests no disposition to extend among the adjacent structures. The gene- ral health remains unaffected. When any doubt exists as to the real nature of the case, recourse should be had to the exploring needle, which will usually at once dispel it. It is seldom that this tumor requires removal of the affected bone. In general, it will suffice to puncture it occasionally with a small trocar, to evacuate its contents, the escape of which is often followed by the rapid con- traction and ultimate obliteration of the sac. Something, too, may be done, in such cases, by graduated compression. When there is a strong tendency to reaccumulation, a large opening may be made, and a tent inserted ; or the necessary inflammation may be provoked by injections of weak solutions of iodine. It is only in old and intractable cases that excision of the bone, at the site of the disease, will be likely to be required. The disease to which writers have usually applied the vague and unmean- ing terms osteo-sarcoma and spina ventosa, is, in general, merely an exagge- rated form of the cystic tumor just described- It is by far the most common of the benign formations of the lower jaw. Appearing at all periods of life, it is most frequent in young adults, and is capable of acquiring an immense magnitude. Several instances have fallen under my observation in which its volume was so great as to cause the most hideous and disgusting deformity. Always slow in its growth, the tumor is free from pain, never affects the con- • stitution, and does not return after extirpation. The most common site of it is the body of the bone, but cases occur in which nearly the whole jaw is involved. The surface of the tumor is generally lobulated, and of unequal consistence, some parts being very hard and firm, others soft and fluctuating. The subcutaneous veins are rarely much enlarged, and there is no contami- nation of the neighboring lymphatic ganglions. When the tumor is very voluminous, it may encroach seriously upon the mouth and throat, interrupt- ing speech, mastication, and deglutition; but, commonly, it enlarges mostly at the expense of the cheek, which is often frightfully distorted in conse- quence. The external appearances of this form of tumor are well shown in fig. 302, from a private patient, a young man of nineteen. Fig. 302. Fig. 303. Cystic tumor of the lower jaw. The structure of this growth is composed essentially of cells, filled w various kinds of fluid, as serous, glairy, sanguineous, and purulent, surround LOWER JAW—HEMATOID TUMORS —ENCEPHALOID. 515 and traversed by osseous spicules, and fibrous, fibro-cartilaginous, and carti- laginous septa. The cavities vary very much in size and figure, and it often happens that several communicate with each other. The compact structure of the bone is generally absorbed, or softened, and broken up; and, occa- sionally, the greater p6rtion of it is converted into a hollow shell, separated into different compartments, and occupied by different kinds of fluids. The adjoining cut, fig. 303, exhibits an enormous cystic tumor of the lower jaw, which I removed, some years ago, from a man upwards of forty years of age. It had been growing for sixteen years. The operation was completely suc- cessful. The diagnosis of this disease cannot be mistaken. The tardiness of its development, its unequal consistence, its fluctuating feel, and its outward growth, together with the absence of local and general contamination, are sufficient to distinguish it from all other affections of the jaw. In cases of uncertainty, the exploring needle is employed. Sometimes the tumor, espe- cially when composed of large cavities, sounds, on percussion, like a dice- box; a noise which is never heard in carcinoma. Relief is afforded by excision of the diseased mass; and it is here, more particularly, that modern surgery has achieved some of its proudest triumphs. Tumors of enormous volume, and involving nearly the whole of the jaw, have been removed, again and again, successfully; and such undertakings may always be attempted the more cheerfully because of our positive conviction that there will be no repullulation. 1. Hematoid Tumors.—There is a peculiar tumor of the lower jaw, which, from the nature of its structure, deserves to be designated by the term hema- toid, as most expressive of its true character. I have seen only one case of it, a brief history of which will afford a sufficiently accurate idea of its anatomy, symptoms, and progress. The patient was a man, aged thirty-five, and the affection had been first noticed about three years before I saw him, in Octo- ber, 1844. It made its appearance in the form of a hard, solid tubercle, not larger than a hazelnut, on the left side of the jaw, just behind the cuspid tooth. Its progress was very slow for a long time, but at length it began to increase with considerable rapidity, and became the seat of a constant, dull, aching pain. At the time of my examination, the tumor extended from the middle of the large grinder on the left side to the lateral incisor on the right, bulging forwards in such a manner as to cause considerable deformity of the chin. The corresponding teeth inclined backwards and inwards, and were so loose as to be unfit for mastication. The gum was abnormally red, and somewhat hypertrophied, but otherwise perfectly sound. There was no enlargement of the neighboring lymphatic ganglions, and the general health was good. The tumor was found, after removal, to be about the volume of a medium- sized orange, and to consist of a mere osseous shell, without any vestige of 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 sur- face of the bony wall, and exhibited distinct traces of organization. The man promptly recovered after the operation, and has ever since remained well. 8. Encephaloid.—The only form of carcinoma of the lower jaw worthy of notice is encephaloid. The malady may occur here, as elsewhere, at all periods of life, but it is much more frequent in childhood and adolescence than in middle age and decrepitude. Indeed, the very worst cases of it that 1 have ever witnessed took place before the tenth year, and ran their course with a rapidity truly frightful. Most of the subjects of the disease perish within the first twelve months from the commencement of the attack; and, if an attempt be made to relieve them by operation, however early performed, the disease is sure to return in a very short time, either at the cicatrice or in 516 DISEASES OF THE JAWS, TEETH, AND GUMS. the adjacent structures, especially the lymphatic ganglions. As the symp- toms, diagnosis, and prognosis of encephaloid of the lower jaw do not differ, in any respect, from those of encephaloid of the upper jaw, any further ac- count of it here would be useless. 9. Deformity.—A very unseemly deformity of the lower jaw is occasionally produced by an elongated condition of it; it is generally caused by the drag- ging exerted upon the bone by the vicious cicatrice of a burn, or by the pressure of some tumor, but instances occur in which it is congenital. The elongation is generally, if not always, associated with a peculiar oblique or horizontal direction of the bone. Besides the disfigurement which it occa- sions, such a defect is necessarily attended with more or less inconvenience in mastication, and in the retention of the saliva. For the cure of this de- formity, an ingenious operation was devised by the late Dr. Hullihen, of Virginia, consisting in the excision of a Y-shaped portion of the bone on each side; and in one case in which he performed the operation, the result was most gratifying, although the distortion had been unusually great. 10. Anchylosis or Immobility of the Jaw.—This distressing affection, which may be produced in a variety of ways, may exist in such a degree as to ren- der the patient entirely unable to open his mouth or to masticate his food. The most common cause, according to my observation, is profuse ptyalism, followed by gangrene of the cheeks, lips, and jaw, and the formation of a firm, dense, unyielding inodular tissue, by which the lower jaw is closely and tightly pressed against the upper. Such an occurrence used to be extremely frequent in our Southwestern States, during the prevalence of the calomel practice, as it was termed, but is now, fortunately, rapidly diminishing. Chil- dren, of a delicate, strumous constitution, worn out by the conjoint influence of mercury and scarlatina, measles, or typhoid fever, are its most common victims; but I have also seen many cases of it in adults and elderly subjects. In the worst cases, there is always extensive perforation of the cheeks, per- mitting a constant escape of the saliva, and inducing the most disgusting disfigurement. Secondly, the affection may depend upon anchylosis of the temporo- maxillary joints, in consequence of injury, as a severe sprain or concussion, or arthritic inflammation, leading to a deposition of plastic matter, and the conversion of this substance into cellulo-fibrous, cartilaginous, or osseous tissue. I have met with quite a number of such cases: several in very young subjects. Thirdly, the immobility is occasionally produced by a kind of osseous bridge, extending from the lower to the upper jaw, or from the lower jaw to the tem- poral bone. Such an occurrence, however, is uncommon, and is chiefly met with in persons who have suffered from chronic articular arthritis. Finally, immobility of the jaw may be caused by the pressure of a neigh- boring tumor, especially if it occupy the parotid region, so as to make a direct impression upon the temporo-maxillary joint. However induced, the effect is not only inconvenient, seriously interfering with mastication and articulation, but it is often followed, especially if it occur early in life, by a stunted development of the jaw, exhibiting itself in marked shortening of the chin, and an oblique direction of the front teeth. When complicated with perforation of the cheek and destruction of the lips, the patient has little or no control over his saliva, and is so horribly deformed as to render him an object at once of the deepest disgust and the warmest sympathy. The treatment of this affection must depend upon the nature and situation of the exciting cause. When the difficulty is in the joint, occasioned by the formation of cellulo-fibrous adhesions, the only thing that can be done is to break up the adhesions, upon the same principle as in anchylosis of any other LOWER JAW—ANCHYLOSIS OR IMMOBILITY. 517 joint. For this purpose, the patient being thoroughly influenced by chloro- form, the jaw is forcibly depressed, either by a wedge made of cedar wood, Fig. 304. or by the instrument sketched in fig. 304, and depicted by Scultetus, in his well known work, the Armamentarium Chirurgicum, but reintroduced to the notice of the profession by Dr. Mott. It is constructed, as will be perceived, on the lever and screw principle, and may be employed with great advantage ia all cases of anchylosis of the jaw, not only for breaking up the adhesions within the joint, but also for main- taining the separation afterwards. Owing to the remarkable tendency which the parts have to reunite, the instrument must be daily used, for a number of hours, for many months, if not for several years. Meanwhile, sorbefacient lotions should frequently be rubbed over the joints, and every precaution taken to keep down inflammation. The annexed sketch, fig. 305, exhibits an instrument, which, as a mere lever for separating the jaw, and breaking up morbid adhesions, is superior Fig. 305. Scultetus's lever for separating the jaw. Lever for separating the jaw. to that of Scultetus, which it closely resembles in its mode of action. It diffuses its pressure more widely and equably over the teeth, and is therefore less liable to fracture aud dislocate them. When the immobility depends upon the presence of inodular tissue, the proper remedy is excision of the offending substance, an operation which is both tedious, painful, and bloody, and, unfortunately, not often followed by any but the most transient relief, owing to the tendency in the parts to re- produce the adhesions, however carefully and thoroughly they may have been removed. There is the same remarkable disposition in these cases to the contraction and regeneration of the inodular tissue as in burns and scalds. Daring my residence in Kentucky, I had a large share of such cases, and although I never failed to make the most thorough work, not unfrequently repeating the operation several times at intervals of a few months, it is my duty to state that but few of them were permanently relieved. After the exci- Bion is effected, the patient must make constant use of the wedge, wearing it for months and years, so as to counteract the tendency to reclosure. Any pieces of dead bone, and loose or ill-placed teeth that may be present, should always be removed prior to the operation upon the soft parts. Immobility of the lower jaw, caused by the formation of an osseous bridge, connecting this piece with the upper jaw, may be remedied by the removal j>' the adventitious substance, by means of the saw and pliers. Sometimes, oweyer, such a procedure is rendered inexpedient, on account of the long Duration and excessive firmness of the anchylosis, and the large quantity of the new osseous tissue. hen the closure is of long standing, it occasionally becomes necessary to 51S DISEASES OF THE JAWS, TEETH, AND GUMS. divide the masseter muscles, as they are often found, when this is the case, to be permanently contracted. The operation, performed, of course, subcuta- neously, requires some care, lest important vessels should be divided. The gap in the cheek, left by salivation, and so often accompanying closure of the jaw, may be filled up by a flap borrowed from the neighboring integu- Fig. 306. Fig. 307. Plastic operation on the cheek. ments, and carefully stitched in place. The adjoining sketches, figs. 306, 307, exhibit the manner of performing the operation. EXCISION OF THE LOWER JAW. Excision of the lower jaw has, of late, become rather a frequent operation, and it is, therefore, very important that surgeons should have accurate ideas respecting the best mode of executing it. The bone may be removed entire, or it may be divided at its middle, and disarticulated at one joint, or, lastly, a considerable portion may be cut away at its centre, body, or ramus. The first attempt at amputation of the lower jaw was made by Dr. W. H. Dead- rick, of Tennessee, in 1810, upon a lad fourteen years of age. The tumor was of a cartilaginous structure, and occupied the left side of the bone, filling nearly the whole of the mouth, and causing great difficulty in swallowing, and even, at times, in breathing. An incision was commenced under the zygo- matic process, and carried across the tumor, in the direction of the jaw, to nearly an inch beyond the middle of the chin. From the centre of this, and, consequently, at a right angle with it, another incision was extended a short distance down the neck. The flaps thus marked off being separated from the morbid growth, the bone was sawed off just in front of the ramus and at the centre of the chin. The wound was united in the usual manner, and the boy had a speedy recovery; being found perfectly well thirteen years after the operation. In 1823, Dr. Mott excised nearly the whole of the inferior jaw on one side; and eighteen months after he removed all that portion of the bone which is included between the right temporo-maxillary joint and the bicuspid tooth on the left side. This, so far as I am aware, was the first case in which exarticulation of this bone was effected in the United States. The operation is conducted upon the same general principles as excision of the upper jaw ; the patient is placed in a similar position, and is brougb EXCISION OF THE LOWER JAW. 519 folly under the influence of chloroform. The external incisions are made in such a manner as to avoid the unsightly appearance resulting from a large and exposed scar. For this purpose, when it is designed to remove one-half of the bone at its articulation, the knife should, as a general rule, be carried alon» its base, from the zygomatic process, about three-quarters of an inch in front of the ear, to the chin, and thence some distance up the median line, or even as high up as the red margin of the lip. When the tumor is of immense size, two incisions are sometimes required, so as to include an elliptical por- tion of the soft parts; but, unless this is the case, or the skin is seriously involved in the disease, not a particle of integument should be sacrificed; for during the healing process there is usually inordinate contraction, and hence, if this precaution be neglected, great deformity may be the conse- quence. By making the perpendicular incision in front of the ear, there will be little danger of wounding the temporal or external carotid artery, and the trunk of the portio dura. Sometimes, as when the disarticulation is effected with difficulty, a short horizontal incision, just below the zygomatic process, will be advantageous ; but, in general, this is unnecessary. #The duct of Steno should always be avoided, as it readily may be by being careful not to carry the knife too high up, or too far forwards. When the alveolar process alone is involved, it has been recommended that the base of the bone should be left intact, on the ground that it would serve to give support to the soft parts, and become the nucleus of a new deposit. It has even been insisted upon that, in such a case, extirpation could he easily and safely effected without any external incision, simply by detaching the lip or cheek from the jaw, and holding it out of the way dur- ing the division of the bone. Such a procedure cannot be too pointedly condemned; it does the work only half, and is sure to be speedily followed by a recurrence of the disease. When the operation involves the removal of the jaw at the joint, the best plan is to expose the tumor as rapidly and carefully as possible, and then saw the bone at the anterior limits of the morbid mass. This greatly expedites not only the process of disarticulation, but the separation of the jaw from its muscular and mucous connections, as it enables the operator, by seizing its anterior extremity, to move the bone in any direction he pleases. Conve- nient saws for dividing the bone are represented in the annexed sketches, figs. 308 and 309. Fig. 308. Fig. 309. Saws for dividing the jaws. One of the most important circumstances to be observed in exsection of tQ6 lower jaw, is to keep in close contact with the morbid structure, and yet sufficiently away from it to prevent any portion of it from being left behind. t>y attention to this rule, which I regard as one of paramount importance, two great ends are attained, namely, the easy removal of the tumor by a neat and rapid dissection, and the avoidance of hemorrhage. Cutting into the tumor is almost sure to be followed by the division of large vessels, which do 520 DISEASES OF THE JAWS, TEETH, AND GUMS. not fail to bleed profusely, unless checked by compression, until the operation is completed. Besides, chipping off a piece here and another there generally necessitates a tedious after-section, alike painful to the patient, and annoying to the operator. Another important rule, in these operations, is to work as much as possible with the handle instead of the edge and point of the knife, especially in de- taching the bone from the soft structures. Whenever it can be done a por- tion of the periosteum should be saved, and there are few cases, except in the malignant forms of tumor, in which this membrane is so thoroughly involved in the disease as to render this impracticable. The part thus rescued is of great importance afterwards in filling up the void produced by the removal of the bone, at the same time that it prevents undue injury to the other soft structures. One of the great difficulties connected with the excision of the lower jaw is the liberation of the coronoid and condyloid processes. The instrument which has always, heretofore, been employed for this purpose is the knife, or the knife and saw. The fibres of the temporal muscle, embracing the coro- noid process *>n every side, are directed to be cut close to their attachments, or, instead of this, the process is sawn through at its base; the structures of the temporo-maxillary articulation are always divided with the extremity of the knife, entered at any point that may be most convenient. Now, it has always appeared to me that this mode of procedure should, if possible, be avoided, as it is apt to be followed by serious hemorrhage, and by injury of important nerves. This is especially the case with regard to the separation of the condyle, lying, as it does, in close and intimate relation with the in- ternal maxillary artery, which must necessarily be endangered by the knife in this stage of the operation. A wound of this vessel, just as the operation is about to be finished, is an embarrassing circumstance, from the difficulty of applying a ligature, and is liable to be accompanied by copious hemorrhage. The coronoid process, although it projects up some distance into the zygo- matic fossa, is separated with less difficulty, and, as it lies anterior to the maxillary artery, there is little danger of interfering with this vessel. Still, a pretty smart hemorrhage occasionally results from the division, simply, of the little arteries of the temporal muscle. To obviate this danger, as well as to expedite the process of disarticulation, usually, and, in truth, very justly regarded, in the ordinary mode, as no very easy part of the operation, I have used with great advantage an instrument combining the principles of a lever and a knife. The accompanying sketch, fig. 310, will convey a much better idea of it than the most elaborate descrip- tion. The blade is slightly curved upon the flat, and is Fig. 310. Fig. 311. three inches and a quarter in length, by three-eighths of an inch in width ; its thickness is about one line and a third. Its free extremity terminates in a convex edge, beveled off in front and behind, so as to admit of being used for dividing the periosteum, or scraping the bone, as may be deemed necessary. The other extremity is set in a stout, rough handle, nearly four inches long. A perfectly straight instrument of this kind, as seen in fig 311, may be used with much advantage. The body aud ramus of the jaw being detached from its connections, the semi-blunt edge of the elevator is insinuated beneath |i| the fibrous covering of the coronoid process, and, after separating it for some distance, the bone is prized out. In the same manner the soft structures may be peeled from the condyle of the jaw, and the latter lifted from the glenoid cavity. The whole procedure is the work of Elevators. a few seconds, and its great beauty, as was before stated, AFFECTIONS OF THE TEETH. 521 is its entire freedom from danger to the maxillary and other arteries, as well as the trunk and deep-seated branches of the portip dura. When these processes with their investing structures are perfectly sound, the separation must be effected, at least in part, with the knife, but even here the instru- ment above described will afford valuable aid. The gap left by this operation is often filled up, especially in young sub- jects, by a cartilaginous formation, of an irregularly cylindrical shape, which, while it serves to support the jaw in mastication, assists materially in re- establishing the symmetry of the features. The time required for the pro- duction of this substitute varies, it may be supposed, in different cases, from a few months to several years. Even when one-half of the bone has been removed, nature sometimes succeeds most admirably in her object. In 1832, I had an opportunity of seeing an Irish lad, aged seventeen years, from whom Dr. Cusack, of Dublin, had extirpated, four years previously, the left half of the inferior maxilla, on account of a fibro-cartilaginous affection. In this instance, nature had made an attempt at reproduction, by means of a thick, rounded piece of cartilage, sufficiently strong to subserve the ordinary pur- poses of mastication, which was performed with the greatest facility. SECT. III.—AFFECTIONS OF THE TEETH. The diseases of the teeth are of too frequent occurrence, and too severe in their character, to justify their exclusion altogether from a work on surgery; it is true there are numerous monographs on dental science, but so there are on every other subject, and if we adopt the principle of omitting everything thus published, there will really be very little left for the formation of a sys- tematic treatise on any branch of the healing art. A knowledge of the affections of the teeth is of great importance to every physician, but it is particularly so to the country practitioner, who, in consequence of his remote- uess from the regular dentist, is often obliged to extract teeth, and to give advice in regard to their diseases. 1. Sympathies.—The sympathetic relations of the teeth are adverted to in the first volume, in the chapter on Irritation. Their influence in inducing and maintaining ill health in the jaws, gums, eyes, ears, head, and lymphatic ganglions, as well as in other parts of the body, is displayed in a great variety of ways, and deserves the most careful consideration of the general practi- tioner. Without an intimate knowledge of their relations, he must remain ignorant of the pathology of some of the most common affections about the head and face, and be, consequently, unable to treat them upon correct scientific principles. 2. Dentition.—In children, during the progress of the first dentition, the surgeon is often called upon to relieve suffering on account of the pressure upon the gum by an advancing tooth, or, perhaps, more correctly speaking, the gum and the membranous cyst by which the tooth is surrounded. A great deal of irritation may thus be induced, which causes not only much local dis- tress, but occasionally, also, much disturbance in the other organs, especially the brain, stomach, and bowels. In the more severe cases, the gum is red, tumid, and tender, the mouth is hot and dry, and the child is thirsty, feverish, and restless. NoJ unfrequently convulsions, coma, and death follow, from arachnitis, gastritis, or enteritis, or from a combination of these diseases. I he proper remedy for difficult dentition is free division of the gums and the inclosing membrane of the advancing tooth. The operation is usually performed with what is called the gum-lancet, but a far better instrument for ls PDrpose is the blade of an ordinary pen-knife, the point of which, being \ery narrow and sharp, is thrust down in contact with the offending tooth, 522 DISEASES OF THE JAWS, TEETH, AND GUMS. which is thus at once liberated from its confined position, much to the com- fort both of the parts and of the system. The head of the little patient, during the operation, is held between the surgeon's knees, an assistant having charge of the rest of the body. In dividing the gum over the large grinders, a crucial incision is usually made, whereas a single one will always answer for the incisors. Very little bleeding follows the operation, generally just enough to relieve the engorged vessels ; but now and then, as happened to me in one case, many years ago, it is so copious as to prove fatal, although such an event is not to be looked for unless there is a hemorrhagic diathesis. It has been objected to this operation that, when it is not followed by the immediate ex- trusion of the tooth, the cicatrice that will form over it by the healing of the gum will afterwards render its eruption more difficult; but such a conclusion is altogether erroneous, it being well known that all new tissues are much more easily destroyed than old or pre-existing ones. Excessive suffering is often experienced during the evolution of the wisdom tooth, in consequence of its pressure upon the gums and neighboring struc- tures, which are frequently too small for its comfortable accommodation. The result is that the parts become Fig. 312. inflamed, swollen, ulcerated, and ex- cessively painful, causing, at the same time, great trouble in mastica- tion and deglutition, with a feverish state of the system. In the more formidable forms of the affection, there may be obstinate closure of the jaws, caries or necrosis of the coro- noid process, abscesses of the neck, face, or tonsils, and ulceration of the cheek and tongue. Fig. 312 repre- sents a specimen taken from a man who lost his life from this cause. vicious position of the wisdom tooth. The wisdom tooth projected for- wards, and lay horizontally instead of perpendicularly. The patient was unable to open his mouth, the face was enormously swollen, and a large abscess occupied the neck as far down as the clavicle. The remedy consists in a free division of the affected tissues, or, what is better, the prompt removal of the offending tooth, especially when there is not room enough for its full and rapid development; or when its direction is so vicious as to permit it to exert injurious pressure upon the tongue, cheek, or coronoid process. When the jaws are firmly closed, so as to prevent access to the tooth, means must be employed for their separation, as the interposition of gradually increasing wooden wedges, or the instrument de- picted in fig. 305, the patient, in the latter case, being under the influence of chloroform. 3. Vicious Position.—The front teeth, as they issue from their sockets, some- times take a vicious direction, thus materially interfering with the good look: of the patient, if not also with the comfort of the mouth. The causes under the influence of which such an occurrence may happen, are, first, imperfect development of the jaw, thereby crowding the teeth out of their proper posi- tion, and, secondly, the protracted retention of the first set, which thus arrest the progress of the second, as is so often witnessed in the superior maxillary bone of children. The treatment of this affection must depend upon circumstances. When the jaw is manifestly too small for the advancing tooth, the best plan will w to extract it, so as to afford more room for the development of its neighbors. TEETH—DISLOCATION AND FRACTURE—^ETAL CHANGES. 523 313. Fusion of the wisdom tooth and last grinder. otherwise, unless the malposition is very great and disfiguring, an attempt should be made, by means of pressure, to force the organ gradually into its natural situation. For this purpose, the patient should be instructed to push the tooth, with his fingers, several times daily towards the place which it is desired it should occupy; or, if this fail, as it will be likely to do in cases of long standing, the rectification should be effected by keeping the tooth firmly tied to an adjoining one with a gum-elastic thread, a procedure which is often followed by the most gratifying results. When the old teeth are at fault, crowding the new out of place, they should be promptly ex- tracted; when, sufficient room being afforded, the latter will generally soon assume their natural direction. The malposition of the teeth is sometimes congenital, and then it is, per- haps, not so easily remedied. Thus, in hare-lip and cleft palate, the upper incisors are almost always badly formed, and thrust out of their natural situa- tion. Instances also occur in which some of these organs are firmly united together by osseous matter; and Albinus has related a case where the crown of an eye-tooth was turned towards the max- illary sinus, the situation of the fang being reversed. A case precisely similar occurred in my practice, some years ago, in a young lady of twenty-three. The irritation which it caused in the jaw gave rise to a tumor requiring surgical interference. Pig. 313 represents the wisdom tooth of the upper jaw of the right side, inseparably fused with the fangs of the last grinder, the parts looking as if they had been ingrafted upon each other. The tooth was situated horizontally under the gum, by which it was nearly concealed ; it was extracted from a woman, aged thirty years. Cases occur in which the fangs of the teeth are very crooked, thus oppos- ing a great obstacle to their extraction. Such a malformation is represented in fig. 314, where two of the roots are nearly horizontal. In a second series of cases all the roots are remarkably divergent; while in a third, they are, perhaps, all soldered together by osseous matter. I have several specimens in my collection, in which the teeth are inseparably connected, in a similar manner, with the walls of their sockets. 4. Dislocation and Fracture.—A tooth is sometimes dis- located, or lifted out of its socket, in consequence of external violence, as a kick, blow, or fall. Occasionally the accident takes place during an awkward attempt at extracting a dis- eased tooth. However induced, the proper remedy is imme- diate replacement of the organ, the socket having been pre- viously cleared of blood, and retention being aided by accurate closure of the lower jaw by means of a bandage, until the parts have become reunited. The adhesion, however, is generally imperfect, and it is seldom that the tooth afterwards subserves any very useful purpose, as it is very apt to remain sore and tender, and, ere long, to drop out. The crown of a tooth, when broken, cannot reunite, but observation has Bhown that a fang may, the process being similar to that of a fractured bone, whose structure it closely resembles. The blood poured out at the moment of the accident being absorbed, lymph is effused, which thus becomes the basis of the new osseous substance. 5. JStal Changes.—The teeth experience important changes in consequence of age. As life advances they gradually lose their whiteness, and assume a peculiarly yellowish tint, which is often remarkably conspicuous in old people. neJ'become likewise more brittle, and the enamel exhibits an irregularly abraded appearance. These changes are produced by certain alterations Malformation of the 524 DISEASES OF THE JAWS, TEETH, AND GUMS. which take place in the anatomical constitution of the teeth, from the oblite- ration of their vessels, and their consequently diminished supply of blood. There is a singular affection of the teeth, described by dentists under the name of " the denuding process," the precise nature of which is still unex- plained. It consists in the gradual removal of the enamel, generally without the slightest discoloration or diseased appearance. It is most frequently ob- served in the incisors, especially the inferior, but occasionally attacks the whole dental arch. As the denuding process advances, the crown of the tooth is slowly worn away, the enamel first disappearing at the top, and sub- sequently at the sides, until the greater part is removed. The organ, in the meanwhile, changes its color, gradually becoming more yellow, and finally, when the enamel is completely destroyed, assuming a brownish aspect. The most curious circumstance in the history of this lesion is the beautiful pro- vision by which the cavity of the tooth is protected from exposure. This consists in a deposit of new bony matter, perfectly hard and solid, but so transparent that nothing but the closest examination can detect it. Thus a sort of permanent plug is formed, which effectually defends the delicate struc- ture within, and which exactly resembles the transparent layers of an aegose pebble, surrounded by a more opaque mass. In what this lesion essentially consists it is not easy to determine, though it is not improbable that it de- pends upon some original or acquired defect of the enamel, whereby it is made to yield more readily to the mechanical attrition to which the teeth are constantly subjected. It is witnessed at nearly eyery period of life, but is by far most common in old people. 6. Gangrene.—Necrosis of the teeth is usually caused by external violence interrupting their vascular connections, the effects of mercury, or a syphilitic taint of the system. In scurvy, too, they often lose their vascular relations, and ultimately perish. When affected in this way, they assume a dull, yel- lowish, brownish, or blackish appearance, and finally drop out of their sockets. In most cases, the death is universal, not limited to particular parts of a tooth. A necrosed tooth always acts as a foreign body, causing pain and inflam- mation in the surrounding soft parts, as well as absorption of the alveolar process. It is for this reason that it should always be promptly extracted. 7. Caries.—The most common, and generally also the most distressing disease of the teeth is what is termed caries; an affection whose true nature appears to be still imperfectly understood, notwithstanding the numerous attempts that have been made to investigate it. Many pathologists, con- vinced that even the enamel, where the lesion always begins, possesses a sort of life-power, maintain that it is strictly analogous to ulceration of the osseous tissue; while others, equally respectable, assert that it is wholly dependent upon chemical action, effected by the acid secretions of the mouth, and they further insist upon it, as an additional proof of their position, that these secretions, like the caries itself, are almost exclusively met with in dyspeptic persons, or individuals laboring habitually under disorder of the digestive apparatus. The arguments adduced by the advocates of this opinion are certainly very plausible; at the same time, however, it is so repugnant to our preconceived notions of the nature of morbid action generally that it is extremely difficult to adopt it. Perhaps it would be more philosophical to say that dental caries was the result partly of a vital, partly of a chemical, process ; or, what would probably be still nearer to the truth, that chemical action was the exciting and molecular disintegration the immediate cause of the disease. Caries always begins in the enamel of the teeth, at some point of the crown, in the form of a minute, opaque, brownish speck, which gradually extends towards the centre of the organ, assuming at length a blackish color, and becoming so soft and brittle as to be crushed on the slightest touch. Thus TEETH—CARIES. 525 a large cavity is exposed, whose existence perhaps had not previously been at all suspected. As it advances, the disease frequently destroys the entire crown, or converts it into a dark, pulverulent substance, without any trace of its primitive texture. The roots are usually the last to decay, and it often happens that they retain their vitality long after the other parts have com- pletely perished. In this condition, however, they act as extraneous bodies, exciting ulceration of the gum and alveolar processes, whereby they lose their connection, and are finally dislodged. Figs. 315, 316, and 317 exhibit some of the more ordinary forms of this disease, from specimens in my collection. Fig. 315. Fig. 316. Fig. 317. Different forms of caries of the teeth. The teeth most liable to this disease are the last grinders, probably from some defect inherent in their constitution in consequence of their late develop- ment. The upper central incisors are also frequently affected, as are likewise the first molar teeth, particularly those of the under jaw. The lower incisors, on the contrary, are rarely attacked. Every part of the crown appears to be equally liable to caries; and it often happens that the disease begins simul- taneously at several points. Persons of a tubercular constitution are very subject to this species of decay, which often sets in at a very early period of life, and proceeds until nearly every tooth is destroyed by it. The upper incisors of children are fre- quently attacked in this way within a short time after their appearance, aud occasionally, indeed, when they are still partially covered by the gum. There is sometimes an hereditary proclivity to this disorder; as is evinced by the fact that it often occurs in a considerable number of members of the same family, and in the children of parents who had been similarly affected. Among the indirect causes of caries are, disorder of the digestive organs, the inordinate use of mercury, a syphilitic taint of the system, and, in short, whatever has a tendency to derange the general health. Among the local or direct causes are accumulation of tartar upon the teeth, want of cleanliness of the mouth, and steady, persistent pressure of the teeth against each other. The effects of caries are pain in the teeth, and inflammation of the gums, jaws, and other structures. The pain may be very slight, or extremely violent; m general it is of a throbbing character, darting about in different directions, aggravated by recumbency, and attended with more or less soreness of the mouth and cheeks. Gum-boils are a frequent consequence of the disease. The treatment of caries must be regulated by the circumstances of the par- ticular case. If the disease is extensive, the only proper remedy is extraction of the affected tooth, especially if it be attended with much suffering. If, on the contrary, it is slight, and the patient can bear the pain, the tooth should by all means be preserved, the cavity being excavated by appropriate instru- ments, the object being the removal of every particle of the affected structure, and the filling of the hole with gold leaf. When the operation is properly executed, the plug being firmly inserted, so that not a particle of air or fluid 526 DISEASES OF THE JAWS, TEETH, AND GUMS. 318. shall afterwards enter by the side of it, the tooth may be preserved for an indefinite period, without any impairment of its usefulness. When there is a strong tendency to caries, much may be done, in preserv- ing the teeth, by way of attention to the general health and constant cleanli- ness of the mouth. The latter object is best attained by the daily use of a good, stiff brush, in the morning on getting up, and also after each meal, so that there shall be no chance whatever of the accumulation of tartar, food, alkali, or acid upon, around, or between, any of the teeth. The brush may be employed either alone with cool or tepid water, or, what is better, with a little soft toilet soap, prepared expressly for the purpose. When there is great tendency to the collection of calcareous matter, recourse must be had to some dentifrice, consisting mainly of prepared cinchona, chalk, orris root, and pumice stone, reduced to an impalpable powder. 8. Inflammation of the Lining Membrane___The membrane lining the cavity of the teeth, generally considered as of a fibrous nature, occasionally takes on inflammation, the other anatomical elements being apparently in a sound state. The disease, if allowed to go on, almost always leads to the formation of an alveolar abscess. In other cases, there is a pretty abundant deposit of fibrin, both within the canal of the affected organ and around its roots, the latter exhibiting a singular shreddy aspect, the plastic, organ- ized lymph hanging from the thickened periosteum in all directions, as in fig. 318. Occasionally, again, though this is not very common, purulent matter is poured out, forming an abscess analogous to what is sometimes observed in the interior of a bone. When the quantity of fluid is considerable, it is very apt, from its confined situation and consequent pressure, to pro- duce mortification of the lining membrane, with absorp- tion of the parietes of the cavity. By this means the pus gradually escapes at the extremity of the fang, the foramen of which is much enlarged. Ulcerative inflam- mation is next set up in the alveolar process and gum, which continues its ravages until the inclosed matter, now extremely offensive, obtains an outlet, the affected tooth meanwhile losing its vitality, and presenting a dull yellowish, dark, or brownish color. The exposure of the internal membrane from gangrene, fracture, or other causes, not unfrequently leads to the formation of fungous tumors, varying in volume between that of a pin-head and an ordinary pea, as seen in fig. 319. Of a pale reddish color, they are of a soft, fleshy consistence, and are essen- tially composed of a plexus of vessels, connected together by delicate cellular substance, and traversed by minute nerv- ous filaments. From their excessive vascularity, these growths are liable to bleed upon the slightest touch; and, although they are occasionally as insensible as healthy gum, yet in the majority of cases they are the seat of the most exquisite pain. The period required for their development varies from a few months to several years; but from the great suffering which they induce, they are seldom permitted to remain for any length of time. They appear to arise, for the most part, from the lining membrane of the fang, from which they proceed more or less rapidly until they fill the whole cavity of the organ. Occasionally, there is reason to be- lieve that they spring directly from the dental nerve, which becomes exceed- ingly vascular, elongated, and thickened, forming a species of neuroma. Tbe teeth most frequently affected with this disease are the central incisors and Fungous vegetations. Fungous tumor. TEETH—EXOSTOSIS — FORMATION OF TARTAR. 527 the large grinders. Such a tumor is occasionally the seat of periodical hemor- rhage, apparently vicarious of the menses. 9. Dental Periostitis.—The sockets of the teeth are invested by a fibrous membrane, which is reflected over the fangs and body of these organs, thus serving to maintain them in their proper position. The membrane, which is extremely vascular, is liable to inflammation and its several consequences, especially thickening and the formation of matter. The disease, anatomi- cally considered, is characterized by deep congestion of its vessels, and by a softened, pulpy state of the membrane, and frequently terminates in suppu- ration and abscess. As the inflammation pro- gresses the periosteum is detached at the most highly inflamed part, which is usually around the extremity of the fang, and the sac thus formed becomes the receptacle of the pus. The denuded portion of the tooth loses its vitality, thereby adding to the irritation of the socket, which, in consequence, takes on ulcerative ac- tion, followed by a fistulous opening, and the escape of the accumulated fluid. If the tooth be extracted after this occurrence, the sac will often come away in the form of a red, fungous Different forms of sac in alveolar mass, not unlike a small polyp. Fig. 320 and abscess. fig. 321 afford excellent illustrations of differ- ent forms of the sac in alveolar abscess. Dental periostitis sometimes occurs as an independent affection, but in most cases it is caused by the irritation of a decayed tooth, or by external vio- lence. However induced, the pain is usually excessive, pulsatile, and accom- panied with great swelling of the surrounding parts, especially of the face. Severe constitutional disturbance often attends, especially when matter is about to form. The fluid always collects on the outside of the gum, as if nature were averse to making an opening in any other part of the alveolar process. The treatment of this affection is strictly antiphlogistic; by leeches and purgatives, followed by anodynes and diaphoretics, fomentations and poultices. The leeches may be applied directly to the inflamed gum. If matter forms, it must be promptly evacuated, otherwise it will not only keep up the pain, but may cause extensive destruction of the periosteum and bone. 10. Exostosis.—The teeth, especially the grinders, are liable to exostosis; a circumstance not surprising when it is recollected that, with the exception of the enamel, they are essentially composed of the same anatomical elements as the bones. The substance which is thus added differs from the pre-existing structure principally in being of a denser consistence, and of a yellowish, transparent aspect, not unlike chalcedony. The deposit ordinarily takes place at the root of the organ, but in some instances it affects the body, and it may even extend as high up as the crown. Analogy would lead us to infer that the new matter is furnished exclusively by the vessels of the periosteum ; and this is, doubtless, generally the fact. The progress of this disease is always tardy, a long time elapsing before the bony tumor acquires much bulk. The symptoms of dental exostosis are too obscure to be of any diagnostic value. The pressure of the tumor upon the surrounding parts must neces- sarily cause more or less pain, which, however, it is impossible to distinguish 'rem that of ordinary toothache. The only remedy is extraction of the offending organ. 11. Formation and Accumulation of Tartar.—The teeth, from want of 0 ean'lness, as well as other causes, are very prone to become affected with 528 DISEASES OF THE JAWS, TEETH, AND GUMS. earthy deposits. Originally, the substance possesses the character of a soft, friable, porous paste, which by degrees acquires the consistence of hardened mortar, and then often scales off in large masses, having the shape of the organ around which it was formed. Its usual color is a dull whitish yellow, though in some cases it is dark brown, blackish, or slightly greenish. It is principally composed of phosphate of lime, in association with mucus and a small quantity of animal and fatty matter. The accumulation of this substance, vulgarly called tartar, often takes place with great rapidity, so that in a short time the dental arches are almost com- pletely incrusted with it. Calculous, gouty, and dyspeptic persons are par- ticularly liable to it; and it is also frequently witnessed during pregnancy and lactation. The deposit ordinarily begins around the necks of the teeth, just beneath the free margin of the gum. As it increases in quantity, it pro- duces the most disastrous effects, exciting irritation in the soft parts, which, in its turn, leads to absorption of the gum and alveolar processes, until the teeth, deprived of their support, are loosened, and at length drop out. It has been supposed that this matter is derived directly from the mucous secretions of the mouth, vitiated by chronic irritation ; but the more plausible opinion is that it is exclusively furnished by the salivary glands, being held in solution by the fluid which it is the office of these organs to elaborate. This view of the subject is not only supported by the analogy which obtains in the formation of urinary calculi, but by the fact that this substance is always most abundantly deposited upon the superior grinders and the inferior inci- sors, teeth which lie in the immediate vicinity of the orifices of the salivary ducts; and also by the circumstance that it is composed of the same elements as the salivary secretion. The treatment of this affection consists in its early reraoval by means of a brush and soft powder; or, if this be inadequate, by a suitable scaling instru- ment. If the matter be very firmly adherent, the operation must be performed with great care, otherwise there will be danger of loosening the teeth, as the point of the instrument is carried around their necks, between the gum and the concretion. Reaccumulation is avoided by diligent attention to cleanli- ness and to the general health. 12. Toothache.—This affection, technically known as odontalgia, is usually caused by caries of the teeth, leading to exposure of the nerve-pulp to the air, to the juices of the mouth, and to various kinds of extraneous matter. It may also be caused by inflammation and thickening of the dental periosteum, by necrosis of the teeth, exostosis, external injury, profuse salivation, and various morbid affections of the gums and jaws. There is a form of odon- talgia which occurs in gouty, rheumatic subjects, apparently unconnected with any organic lesion whatever of the teeth. Occasionally, again, the dis- ease is of a neuralgic character, coming on in violent paroxysms, which, how- ever, seldom observe any regularity in regard to the period of their recur- rence. However induced, odontalgia is generally characterized by atrocious pains, of a throbbing, jumping nature, deep-seated, and, although most severe at the seat of the (Jisease, darting with great violence along the branches of the fifth pair of nerves distributed to the affected jaw. In some cases, Jthe pain is dull, aching, or gnawing. It is always aggravated by exposure to cold, by disorder of the general health, by cold and hot drinks, by acid, alkaline, and saccharine matter, and by recumbency. Hence, it is almost always worse at night after the patient retires to his bed, the throbbing commencing the moment the head touches the pillow. In the more severe forms of odontalgia! the pain extends to the ear along the nervous cord of the tympanum; aim there is generally great soreness of the face, temple, and even the correspond- ing side of the head. Children, pregnant women, and dyspeptic persons EXTRACTION OF TEETH. 529 are extremely prone to suffer from toothache from the most trivial circum- stances. The treatment of odontalgia must depend very much upon the nature of its exciting causes. When it has been induced by caries, and the decay has advanced so far as to render the preservation of the tooth a matter of impos- sibility, the only proper remedy is immediate extraction, before there is any serious inflammation of the gum and jaw. The same course is pursued when a tooth is necrosed, or the seat of exostosis ; when there is chronic thicken- ing of the dental periosteum, with the repeated formation of abscesses; or, finally, when the affected organ has measurably lost its connection with the alveolar process, whether from disease in the organ itself, or in the jaw. If, on the contrary, the decay is comparatively trifling, an attempt should be made to retain the tooth, and with this view the cavity should be gently filled with cotton, wet with a strong solution of morphia, aconite, and tannin, which often arrests the pain in a few minutes. If the suffering is very severe, the patient should at once take an active cathartic, especially if there be con- siderable derangement of the general health. The medicine may be followed, if necessary, by a full anodyne and diaphoretic. Should there be much swell- ing of the gums, a few leeches may be applied, or, if these cannot be had, the parts may be freely divided with the knife. Pain in the ear is best re- lieved by laudanum, and of the face by a hop poultice, or, what is better, an ammoniated liniment, strongly charged with morphia and tincture of aconite. When the pain is dependent upon malarious influences, quinine and arsenic will be proper; if upon a gouty or rheumatic diathesis, relief will probably be afforded by colchicum. If matter form, it must speedily be evacuated. The offending tooth should not be extracted so long as there is much inflam- mation. If the organ can be saved, it should be plugged as soon as it can bear the necessary manipulation. Of the numerous domestic remedies for odontalgia, there is not a solitary one deserving of any attention ; most of them, in fact, are much more hurtful than beneficial. 13. Extraction of Teeth.—Extraction of the teeth may become necessary for various reasons, but more especially for the relief of pain consequent upon caries and necrosis of these organs, and on account of the irregularity of their position. In children, the operation is often required to make way for the permanent teeth. The deciduous teeth are always easy of extraction, owing to the partial absorption of their roots; the permanent, on the contrary, often demand great skill for their successful removal, especially when they are much decayed, when they are unusually brittle, or when their fangs are very firmly adherent, or widely spread out. In the former case, they will be very apt to break off, while, in the latter, it is sometimes impossible to dislodge them without fracturing the alveolar process. There is generally a great prejudice, even on the part of dentists, against the extraction of the deciduous teeth, on the supposition that it has a tendency to interfere with the development of the permanent set. I have been at much pains to inquire into this matter, and am satisfied that the idea is altogether erroneous ; on the contrary, the operation, so far from being injurious, will generally be found to be eminently beneficial, not only relieving pain, but conducing to the beauty and perfection of the future organs. The patient, during the operation, sits upon a chair or a low stool, as may be most convenient; if the surgeon stands behind, he himself, of course, sup- ports the head, otherwise this function is performed by an assistant. The office of the dentist is always furnished with a high-backed chair, for the accommodation of the head. If chloroform be given, the patient must be partially recumbent, and it will be well not to carry the anaesthetic effect to complete unconsciousness, lest harm should result. Ether is, however, on 'he whole, more safe for the extraction of the teeth, and should, therefore, be vol. ii.—34 530 DISEASES OF THE JAWS, TEETH, AND GUMS. preferred, especially as its administration does not require recumbency, or much care of any kind. If the patient be an adult, it will be proper, as a preliminary measure, to separate the gums carefully from the affected tooth, down to the very neck of the organ, with the twofold object of preventing laceration of the soft parts, and of facilitating the extraction; but in the child, no such precaution is ever required, as the connection between these structures is much less intimate than in the adult. The operation is readily performed with what is called the gum-lancet, represented in fig. 322. Fig. 322. Gum-lancet. The instruments required for the extraction of the teeth are the forceps, key, elevator, and hook, the latter two being particularly useful in the re- moval of stumps, and of loose, deciduous teeth. 1. Forceps.—The forceps should be provided with short, stout blades, variously shaped, with a view to their easy adaptation to the different classes of teeth, as well as the same classes in the two jaws, and be rather sharp at the edges, that they may be readily passed down between the gum and the tooth, in close contact with the border of the alveolar process. The instru- ment should be large in the handle, so as to afford a firm grasp for the hand. The annexed cuts, figs. 323, 324, and 325, represent the different forms of Fig. 323. Fit 324. Fig. 325. »§1 / ; #),' y \\ Different forms of tooth forceps. forceps usually found in the dentist's case; but the ordinary operator will rarely require more than two, one straight, for the incisors and cuspids, toe other curved, for the bicuspids and grinders. EXTRACTION OF TEETH — FORCEPS — KEY. 531 The incisors, cuspids, and bicuspids are extracted on the principle of rota- tion and traction, the first movement being intended to separate the tooth from its connections, and the second to lift it from its socket. Usually more force is required for the removal of the cuspids and bicuspids than for the dislodgement of the incisors. The rule is to apply the blades of the forceps as near as possible to the edge of the alveolar process, as seen in fig. 326. This procedure, which should not be deviated from in any case, is Fig. 326. particularly necessary when the .________-^Ster*- tooth is much decayed. The in- /? \H strument should be held firmly in the hand, but no more force should J^lJM be applied than is absolutely neces- sary to prevent it from slipping. If this precaution be neglected, Mode of seizing a tooth. there will be great danger of crush- ing the tooth, and so complicating the operation. In extracting a bicuspid, the organ should be loosened by pressing it several times outwards and in- wards, as it is, in great measure, insusceptible of rotatory motion ; as soon as it begins to yield, dislodgement is effected by elevating or depressing the hand, according as the tooth is a lower or an upper one. Extraction of the molar teeth or grinders is effected on the same principle as that of the bicuspids ; that is, the forceps are applied very firmly to the neck of the organ, which is then pressed several times outwards and inwards, until it feels decidedly loose, when it may be readily disengaged from its socket. The wisdom teeth, owing to the shortness of their roots, are always easily removed, comparatively little lateral motion and traction sufficing for the purpose. The most suitable instrument for the extraction of the lower wis- dom teeth is the scissor-bladed forceps, now generally used by dentists. 2. Key.—The key is now seldom employed for the extraction of the teeth; it is an awkward, clumsy instrument, and often does great mischief, bruising and lacerating the gum, splintering the alveolar process, and inflicting severe pain. Moreover, unless particular care be taken in its application, the ope- ration is very liable to be attended with fracture of the body of the tooth, leaving the fangs in their sockets, from which it will afterwards be extremely difficult, if not impossible, to dislodge them. The forceps, therefore, always deserve a decided preference. Nevertheless, there are circumstances which may render a resort to the key very proper, if not absolutely indispensable; especially when the teeth are unusually large, or very firmly imbedded in the jaw, and the operator does not possess the requisite strength for the efficient use of the forceps. The application of the key is conducted upon the same general principles as that of the forceps. The gum being well separated, the point of the instrument is pressed down between it and the neck of the tooth, which is then lifted perpendicularly, or nearly so, from its sockets, the whole procedure consisting in a forcible dislocation of the organ. If the key is too long, or applied too high up, it will almost inevitably break off the crown, or fracture the jaw. The Applicati(m 0f the proper position of the instrument is exhibited in fig. 327. key. lo guard against mishaps, the surgeon should be provided with several keys, of different shapes and sizes, so as to adapt them to the exigencies of each particular case. In operating upon the inferior bicuspids and the upper grinders, the ful- crum is applied to the inner surface of the jaw, and to the outer in operating 327. 532 DISEASES OF THE JAWS, TEETH, AND GUMS. upon the lower grinders, the wisdom teeth being always removed with the forceps. 3. Elevator and Hook.—The elevator, represented in fig. 328, is admirably adapted to the removal of stumps and fangs. Great care, however, is neces- Fie. 328. sary in its use, otherwise it might slip, and so inflict severe injury upon the mouth. Such an accident is best avoided by firmly steadying the patient's head, and planting the point of the instrument Fig. 329. securely against the projecting portion of the tooth, which is then forcibly raised from its socket. For the removal of small fangs, or fangs that Hook- are deeply buried in the jaw, the most suitable instrument is the one depicted in fig. 329. In order to facilitate dislodgement under such circumstances, it is sometimes necessary to cut away a small portion of the alveolar process, an operation which is easily done with a stout, narrow scalpel. 4. Hemorrhage after Extraction.—It is very unusual for extraction of the teeth to be followed by hemorrhage, the loss of blood rarely exceeding a few drachms. Occasionally, however, owing to idiosyncrasy, or to an unnatural disposition of the dental artery, the bleeding is both troublesome and pro- fuse, causing, perhaps, great anxiety for the patient's safety. 1 have myself seen several instances of this kind, and am familiar with the history of two in which the loss of blood terminated fatally. The hemorrhage occurs at various periods after the operation ; sometimes immediately, and at other times not until after the lapse of several hours, or, it may be, even several days. The blood may issue from one particular vessel, or ooze away from numerous points ; the latter form being the more common when the patient is laboring under a hemorrhagic diathesis. The treatment of this variety of hemorrhage consists in plugging the socket from which it proceeds with a piece of soft sponge, wet with a saturated solu- tion of alum and tannin, or, what is better, the persulphate of iron, the cavity having been previously well cleared. The sponge is confined by a thick, nar- row compress, and the jaws are firmly closed by a roller passed round the head. The patient is kept in the semi-erect posture in bed, and a full ano- dyne is administered to allay the heart's action. The diet and drinks must be cooling. If the hemorrhagic diathesis exist, recourse must be had to the exhibition of the persulphate of iron, with a view of promoting the coagula- tion of the blood. In obstinate cases, or where plugging is impracticable, on account of fracture of the alveolar process, the actual cautery may be necessary. In the eighth volume of the Medico-Chirurgical Transactions of London, will be found the particulars of a case in which Sir Benjamin Brodie tied the common carotid artery, on account of hemorrhage from the second branch of the internal maxillary, after the extraction of the second molar tooth of the upper jaw. The patient, however, perished. AFFECTIONS OF THE GUMS. 533 SECT. IV.—AFFECTIONS OF THE GUMS. The gums are liable to various accidents and diseases, of which the most important are wounds or lacerations, inflammation, ulceration, gangrene, scorbutic enlargement, and malignant disease. They are also occasionally the seat of congenital hypertrophy. 1. Wounds.—Wounds and lacerations of the gums require no particular attentiou in a work of this kind; they are usually the result of falls or blows, fracturing the jaws, or of the extraction of the teeth, and should be managed upon the same general principles as similar lesions in other parts of the body. A good deal of bleeding sometimes attends them, which, however, either ceases spontaneously or is easily arrested by astringent lotions, especially strong solutions of alum and tannin, or, what is still better, the persulphate of iron. 2. Inflammation.—Inflammation of the gums may be caused in various ways, as an accumulation of tartar around the teeth, disorder of the digestive apparatus, a depraved state of the blood, and the effects of mercury and phos- phorus. The symptoms are discoloration, with a soft and spongy state of the affected structures, more or less pain, and an increase of the mucous and salivary secretions. When the disease is severe or protracted, the teeth are apt to become loose, and the patient finds it difficult to masticate his food. The treatment must be regulated by the nature of the exciting cause. Cal- culous deposits must be removed, the condition of the digestive organs recti- fied, and the general health improved. The milder cases will ofteu get well spontaneously, or under the influence of a brisk cathartic and the use of an astringent mouth-wash. When the inflammation has been occasioned by mercury, the most appropriate remedies are purgatives, strong lotions of ace- tate of lead, and the liberal exhibition of chlorate of potassa, with leeches and warm poultices to the neck and jaws. In obstinate cases emetics of ipe- cacuanha will prove useful. 3. Ulceration.—One of the most frequent lesions of the gum is ulceration, produced by an accumulation of tartar around the necks of the teeth. The pressure that is thus exerted excites inflammatory action, leading to great thickening, sponginess, and discoloration of the gum, with erosion of its sub- Btance. In this way the teeth are entirely denuded at their necks, in conse- quence of which they often drop from their sockets, or become so loose as to be useless. The treatment consists in the removal of the offending tartar, and the use of medicated lotions, containing alum, tannin, and myrrh. The milder cases will generally rapidly yield under the application of powdered alum. 4. Mortification.—The gum, in common with the rest of the mucous mem- brane, is liable to mortification, from excessive mercurial action, the fumes of phosphorus, and probably also from causes which exert their influence chiefly through the constitution. Of this nature appears to be that variety of morti- fication which has been so ably described by the older writers under the name of "black canker," and by Dr. B. H. Coates, of this city, under that of the "gangrenous ulcer" of the mouth. Although it may begin at any part of the raucous membrane, yet, in by far the greater number of cases, it makes its appearance at the edges of the gum, over the neck of the central incisors of the lower jaw, in the form of a whitish, cineritious, or reddish ulcer, which varies in diameter from half a line to the eighth of an inch. In this state, the disease may continue for several weeks, if not several months; but more commonly it extends its ravages, affecting either a large portfon of the dental arches, or passing down in the direction of the sockets of the teeth, which, 534 DISEASES OF THE JAWS, TEETH, AND (JIMS. together with their periosteum and the alveolar processes, are gradually de- prived of their vitality. The soft parts, in the meanwhile, assume a dirty, blackish appearance; and, on being detached, leave a ragged, sloughing ulcer, which is the seat of a foul, sanious discharge, of so excessively acrid a nature as to excoriate whatever texture it may touch. In this manner, the disease appears to be frequently propagated to the mucous membrane of the cheeks and lips, where it generally spreads with great rapidity, until the parts are completely perforated, or a black gangrenous spot manifests itself upon the external surface. The true pathology of this disease is still involved in obscurity. It is almost wholly confined in its attacks to young, weakly subjects, and occa- sionally displays an endemic tendency. Thus, of 240 children observed by Dr. Coates in the Philadelphia Asylum, upwards of 70 were more or less affected with the primary ulcer at one time. In the early stage of the com- plaint there is little or no pain, the system is free from excitement, and the ap- petite and strength are scarcely at all impaired. When the sloughing process, however, has fairly commenced, the child suffers much local distress, and is harassed with constant fever. Dissection has thrown no light on this singular variety of gangrene. The treatment of mortification of the gums must be regulated by the nature of the exciting cause. Supporting measures, as quinine, ammonia, and brandy, with a nutritious diet, are indispensable, and do more than anything else to arrest the spread of the disease. The most appropriate local remedies are lotions of acid nitrate of mercury, nitrate of silver, chloride of iron, and sulphate of copper, along with the liquid chlorinated soda, for the purpose of allaying the excessive fetor. If the disease extends to the cheeks, recourse may be had to the topical use of iodine. 5. Inflammatory Enlargement.—Enormous enlargement of the gums is sometimes witnessed, especially in scurvy. When thus affected, they are of a red, livid, or purple appearance, and of a soft, spongy consistence, generally bleeding on the slightest touch, and forming two large ridges, in which the teeth, loose and discolored, are, at times, almost completely buried. The enlargement is of an inflammatory nature, and probably depends upon a depraved state of the system, produced by impoverished diet and other de- pressing influences. The treatment is constitutional and local. Tonics, as quinine and the mineral acids, and nutritious diet, with brandy, wine, or porter, are generally required. When there is a marked scorbutic state of the system, subacid vegetables and drinks are indicated. The swollen gums should be frequently scarified, or even partially cut away, and touched once a day with a strong solution of nitric acid. In a remarkable case of this disease, which was under my charge in the Louisville Hospital, in 1851, more benefit was ob- tained from this application than from any other of the numerous articles that were tried, including creasote, copper, iron, myrrh, and alum. The teeth should not be extracted, unless they are hopelessly loose, as they generally regain their hold during convalescence. Any tartar that may incrust them should, of course, be carefully removed. 6. Hypertrophy.—The gums are subject to congenital hypertrophy, some- times giving rise to remarkable deformity of the mouth and lips. The only case of the kind that I have ever seen came under my observation iu 1855, id a lad ten years old, remarkable for his stunted development, ill-shaped head, and large abdomen. The morbid growth affected the gums of both jaws, and was of a dense, fibroid structure. It first began to attract attention at the age of nine months, but there can be no doubt, from its history, that it had existed front birth. The gum of the upper jaw formed a tumor of a pale color, inelastic, per- AFFECTIONS OF THE GUMS. 535 Fig. 330. fectly insensible, and of firm consistence, presenting very much the appear- ance of the snout of a hog. It stood off very obliquely, and received but a very partial covering from the corresponding lip. It was rough on the sur- face, and was about an inch and a quarter in its antero-posterior diameter, its width having been about one inch and a half. At its free margin, which was quite irregular, was seen the tip of the left central incisor. Extending back from this tumor, on each side of the whole length of the jaw, was the enlarged gum, forming a thick, broad ridge, completely imbedding the teeth. At several points, particularly behind, the morbid growth was more than nine lines in width; in front and at the middle it was less. It was of a more florid color than the main tumor, but of about the same degree of consistence. Opposite the bicuspid teeth, on each side, it exhibited a remarkably granu- lated appearance, the excrescences having a pediculated form, and being folded upon each other. Projecting towards the roof of the mouth, it greatly encroached upon this cavity, lessening its capacity, and thus interfering with its func- tions, as well as with speech and respiration. The lower gum was in the same condition as the upper, being equally hard and in- sensible, but less developed. It was of a bluish florid complexion, and larger in front and behind than at the intermediate points; its free surface was uneven, and so prominent as to hide all the teeth, except the central incisors, the point of the right cuspid, and the cusps of each deciduous and first per- manent molars. This singular formation is well shown by the accompanying cut, fig. 330. The treatment consisted in thorough removal, by means of scalpels and scaling instruments. A good deal of blood was lost, and the operation, which had to be several times repeated, was necessarily tedi- ous. Dr. J. N. M. Lynch, of New Concord, Kentucky, who was kind enough to bring this patient to me four years ago, has lately informed me that the gums have again commenced to grow, and that there is marked disease of the heart, with considerable enlargement of the tonsils, arches of the palate, and the papillae of the tongue. 7. Cancroid Disease.—The gums are liable to carcinoma, generally of a secondary character, being caused by an extension of the disease from the lower lip and jaw. I have now under my care a man, aged fifty, in whom it began in the sublingual glands. Occasionally, however, it originates in the gum itself. In what is called epulis, described in a preceding page, the mor- bid action probably always, or nearly always, takes its rise in the periosteum of the teeth. Hypertrophy of the gums. 536 DISEASES OF THE MOUTH AND THROAT. CHAPTER XIII. DISEASES AND INJURIES OF THE MOUTH AND THROAT. SECT. I.—AFFECTIONS OF THE LtPS. The lips are liable to wounds, hypertrophy, encysted and vascular tumors, eversion of their mucous membrane, carcinoma, and congenital fissure. 1. Wounds.—Incised wounds of the lips, if treated with the twisted suture, readily unite by the adhesive process. To insure this, however, and also to prevent deformity from unseemly scars, the edges should be carefully cleansed, and approximated with the utmost accuracy. The bleeding may be considerable, but is effectually arrested by the twisted suture, which is always preferable in this situation, both on this account and on every other, to the interrupted. The ligature is just as improper here as it is in the ope- ration for hare-lip. Lacerated, punctured, and gunshot wounds of the lips are treated on the same principles as incised. 2. Carbuncular Inflammation.—The lip is occasionally the seat of a species of carbuncle, and if the case be misunderstood, or improperly treated, the results may be most disastrous to the beauty and symmetry of the features. The chief local remedy, of course, is free incision, made, if possible, on the side of the mucous surface, in order to avoid disfiguring scars. The appli- cation of iodine and suitable internal means will assist in preventing the spread of the disease. In the New York Journal of Medicine and Surgery for May, 1854, Dr. Willard Parker has described what he calls a "Peculiar Form of Inflamma- tion of the Lips and Face, resembling Malignant Pustule." In the three cases which illustrate his paper, the disease began in a pustule upon the lower lip, from which it gradually extended to the neighboring structures, as the cheeks, upper lip, nose, and neck, which soon became excessively hard, livid, painful, and greatly swollen, and finally the seat of gangrene. The affection was characterized by unusual depression of the vital powers, and two of the cases speedily terminated fatally. The patients were young men, of tempe- rate habits, and, at the time of the attack, in the enjoyment of good health, none having been exposed to any poisonous influence, either local or consti- tutional. From the symptoms which attended the disease, it is obvious that it bears a greater resemblance to carbuncle and malignant pustule, especially the latter, than to any other*known affection. For additional remarks upon this subject, the reader is referred to the communication of Dr. Parker, and also to one by Dr. F. D. Lente, in the American Journal of the Medical Sciences for April, 1859. 3. Ulcers.—Ulcers of the lips are by no means infrequent, and they may be either common or specific. The former usually present themselves in the form of shallow fissures, cracks, or excoriations, as the result of disorder of the digestive apparatus, and readily yield to simple remedies, as blue mass, and a proper regulation of the diet, aided by mildly-astringent lotions, Tur- ner's cerate, or weak citrine ointment. In the more obstinate cases, active AFFECTIONS OF THE LIPS. 53* purgation, and the occasional application of the solid nitrate of silver, may be necessary. The syphilitic ulcer of the lips is generally the result of direct inoculation, presenting itself as a primary sore upon the labial border. Occasionally, the disease begins at the commissure, and it would appear that the upper lip is more prone to suffer than the lower. The chancre, commencing either in the form of a little vesicle or fissure, soon spreads, involving the entire thickness of the lip, which becomes hard, stiff, and painful. The discharge is thin and unhealthy, and signs of constitutional involvement at length manifest them- selves, especially enlargement of the lymphatic ganglions at the chin and base of the jaw, and various cutaneous eruptions, as the papular and exanthetna- tous. The treatment must be conducted upon the same principles as that of chancre upon the penis. If the ulcer be of a consecutive character, the proper external remedy will be iodide of potassium with bichloride of mercury. 4. Hypertrophy.—Hypertrophy occurs almost exclusively in the upper lip, in young scrofulous subjects. I have seen it most frequently in females, but males are by no means exempt from it. The lip is hard, firm, rigid, and more than double the natural thickness; the subcutaneous veins are unusually con- spicuous, the skin is prone to ulceration; and the countenance has a singu- larly puffy and disfigured appearance. The disease is often associated with eruptions of the scalp, psorophthalmia, enlargement of the tonsils, and other marks of the strumous diathesis, and may last for months, and even years, before it is finally eradicated. The best diagnostic signs are the firm and rigid feel of the part, as ascertained by the thumb and finger, the persistence of the swelling, and the absence of disease of the gums and teeth, together with the peculiar state of the system just mentioned. Attention to the chylo- poietio organs, the exhibition of iodide of iron, and the topical use of tincture of iodine, or a weak ointment of iodide of lead, constitute the means which have succeeded best in my own hands. Occasionally, the cure is greatly ex- pedited by the application of a few leeches. In obstinate cases, a mild course of mercury may be required. The operations which have been proposed, and occasionally performed, for the relief of this affection, are entirely unnecessary. A very rare species of hypertrophy of the upper lip, apparently altogether unconnected with the strumous diathesis, is occasionally met with. It occurs chiefly, if not exclusively, in young subjects between the ages of eighteen and thirty, and, while it involves all the structures of the part, it-depends mainly upon a great increase of the mucous follicles, and their connecting cellular tissue. The glands vary in size from a mustard seed to that of a swan shot, and are so closely aggregated as to form a distinct tumor on each side of the middle line, of a deep red color. The inner surface of the tumor is dotted with numerous orifices, which are nothing but the mouths of the enlarged folli- cles, and which are constantly bedewed with mucous fluid, which stands upon them in small drops. The fibrous structure of the skin is remarkably deve- loped, and the lining membrane is not only thickened, but more or less chap- ped, ulcerated, or fissured. The lip has a hard, tough, leathery feel, is very prominent, and greatly everted at its free border. The external surface of the lip is generally natural. The affection is free from pain, but the part is stiff and devoid of feeling. The proper remedy is excision of an elliptical portion of the everted lip, including the enlarged glands, and approximation ot lhe edges of the wound with several points of the interrupted suture. o. Encysted Tumor.—The encysted tumor is almost peculiar to the lower »P, on the inner surface of which it has its seat, as seen in fig. 331, from one ot my patients. It is usually solitary, and depends essentially upon the ob- s ruction of one of the glands which are found in such abundance in this tuation. It is generally spherical in its shape, semi-pellucid, elastic, mova- Je, and from the size of a cherry-stone to that of a hazelnut. Its walls are 538 DISEASES OF THE MOUTH AND THROAT. Encysted tumor of the lower lip. thin, but rather firm, and its cavity is occupied by a thick, glairy fluid, similar to the white of eggs. The ropiness of this fluid is sometimes remarkable, and cases occur in which it resembles the vitreous humor of the eye. The cystic tumor ordinarily forms with- out any assignable cause; its progress is slow, and it is seldom productive of much pain, the chief inconvenience which the patient suffers being a certain degree of stiffness of the lip. Sometimes it ulcerates and discharges its con- tents, when it is apt to become sore and painful. So far as I know, the first account of this dis- ease was published in my Elements of Patho- logical Anatomy, in 1839. A similar but smaller tumor occasionally forms on the free margin of the lower lip. In the early stage of this affection a cure may occasionally be effected by the application of the tincture of iodine, especially if the tumor has been previously punctured, so as to afford an opportunity for the escape of its contents; but, in general, the most certain remedy is incision with enucleation of the cyst, which, as I know from experience, is always easily accomplished with the forceps. In old cases, when the cyst has contracted firm adhesions to the surrounding structures, a portion of it may be cut away, and the re- mainder cauterized with the nitrate of silver. Unless perfect removal is effected, reproduction of the disease may be anticipated. When the tumor is seated on the free margin of the lip, the preferable operation is excision, on account of the difficulty of enucleation. 6. Vascular Tumors.—Both lips, but more particularly the upper, are liable to vascular tumors, principally of the nature of congenital nevus. In one case, perhaps, there is a predominance of the arterial, in another of the venous element, while in a third they are nearly equally balanced. When the arterial material abounds, the disease may possess all the characteristic features of aneurism by anastomosis, pulsating synchronously with the heart, and expanding under the influence of the passions. The morbid growth may be limited to the skin or mucous membrane, or, as is more commonly the case, involve all the tissues of the lip, forming sometimes a mass of consider- able extent and bulk. It is easily distinguished by its history, its soft, erectile character, its scarlet or purple color, and its freedom from pain and malig- nancy. The proper remedy is ligation when the tumor is small and superficial; excision, when it is large and deep-seated. 7. Cancer.—It is a very singular and inexplicable fact that, while the upper lip is the exclusive seat of hare-lip, the lower lip is almost the exclusive seat of carcinoma. This disease, which is peculiar to those of advanced years, occurs in both sexes, and may begin in a small, bluish, shot-like tumor, just beneath the mucous membrane, in a dark, warty excrescence, or in a small cleft, chap, or fissure. The probability is that it generally takes its rise m one of the raucous follicles, or in the submucous cellular tissue, from which it gradually extends to the other component elements of the lip, which often, in consequence, acquires an immense bulk. The part, at first, feels stiff and uncomfortable, it then becomes hard and rigid, and, finally, giving way at one or more points, it forms a large ulcerated mass, having a foul, bleeding, fungous appearance. The pain, from the start, is characteristic, being lanci- nating, pricking, aching, burning, or scalding, darting about in various direc- tions with the rapidity of lightning. The ulcerated surface is the seat of a sanious, fetid, and irritating discharge, and, at times, of considerable hemor- rhage. As the malady progresses, it gradually invades the gums, jaws, an neighboring lymphatic ganglions; the teeth become loose and finally drop AFFECTIONS OF THE LIPS—CARCINOMA. 539 Fig. 332. from their sockets, the countenance exhibits a peculiar cadaverous aspect, the body becomes rapidly emaciated, and the poor patient is ultimately worn out by hectic irritation. The period at which death occurs is subject to considerable diversity; but, in general, it ranges from nine to eighteen months from the commencement of the malady. The annexed sketch, fig. 332, shows this disease in its earlier stages, as a small, hard tubercle. Fig. 333, taken from one of ray private cases, exhibits cancer of the lip in an open form, long after the occurrence of ulcer- ation. The microscopical characters of the ma- lady are displayed in fig. 334, from a drawing by Dr. Da Costa. The causes of cancer of the lip are unknown. Writers and teachers who profess to be deeply versed in the etiology of the affection have gravely referred its origin to the habit of smoking with a short clay pipe, which, becoming heated, irritates the mucous structures, and thus lays the foundation of the disease. Such an opinion would be entitled to respect, if it were not for the fact that the subjects of cancer cf the lip often do not use tobacco in any form whatever. While we are Epithelioma of the lower lip in its earlier stages. Fig. 333. Fig. 334. Epithelial cancer of the lower lip, in an advanced stage. a. Papilla taken from an epithelial cancer, magnified 250 diameters, b. Separate epithelial cells. ignorant of the real cause of the disease, it is interesting to know that it is no* always so fatal as carcinoma in other parts of the body. This circum- stance is due to the fact that the malady is often of the epithelial kind, which, as was stated elsewhere, is generally much less malignant than true cancer, and, consequently, much more amenable to treatment. The only reliable remedy for this disease is excision, performed early and freely, while the local mischief is still, as it were, in its infancy. All other treatment here is as unavailing as in similar disease elsewhere, the only benefit which it can Fig. 335. afford being palliation. When the tumor is superficial, and limited mainly to the prolabial surface, it may be removed by circumscribing it with an elliptical incision as in fig. 335, the edges of which are afterwards neatly approximated by the interrupted suture; the parts heal by the first intention, and the cure is followed by hardly any etormity. When the involvement is more extensive, embracing the entire 540 DISEASES OF THE MOUTH AND THROAT. Epithelial cancer of the lip. thickness of the lip, ablation is effected by two incisions, one on each side of the tumor, extending from the prolabial margin down towards the chin, where they meet at an acute angle, like the lines of Fig. 336. the letter V, as in fig. 336. Provided the resulting chasm is not very great, the raw edges are placed in exact apposition, and retained by the twisted suture, as in the operation for hare-lip. The bleeding, which is sometimes considerable, is temporarily controlled by the finger of an assistant, and permanently by the contact of the abraded tissues. Occasionally it is necessary to cut away nearly the whole lip, and yet it is remarkable what little deformity is produced. In such cases, approximation is, of course, not sought for; the bleeding vessels are secured by ligature; and the gap is left to granulate, like a common suppurat- ing wound. The period at which recurrence may be looked for after excision of this disease does not, in general, ex- ceed five or six months. In a few instances I have known it to exceed two years. Hannover has related the case of a man in whom relapse did not occur for upwards of twelve years. He was operated upon, for the first time, in May, 1834, the disease having then already existed for two years. In 1846, the second excision was performed, the third in 1849, and the fourth in 1850, with good results up to 1852. 8. Eversion of the Mucous Membrane.—This affection is peculiar to the upper lip, and may exist either as a congenital vice, as a consequence of sim- ple hypertrophy from the habit of biting the Fig- 337. part, or as a result of a preternatural elon- gation of the labial frenum. However in- duced, it presents itself in the form of a narrow horizontal fold when the individual laughs, and gives the part the appearance of a double lip, as in fig. 337, from one of my patients. The deformity is remedied by re- moving an elliptical portion of the lining Double up. membrane, along with some of the glandu- lar structure, and tacking together the edges of the wound with the interrupted suture. The operation is best done with the scissors. If the frenum alone is at fault, it should be duly abbreviated. 9. Hare-Lip.—Hare-lip is a congenital cleft, so termed on account of its supposed resemblance to the lip of the hare. It exhibits itself in several varieties of form, from the merest fissure to the most horrible and disgusting chasm. It may be single or double, simple or complicated. The relative frequency of these different varieties is not determined; but it is certain that they are sufficiently common, and they should, therefore, be studied with great attention. The upper lip alone is their seat, and they affect the left side much oftener than the right. A mesial fissure is extremely rare; and pro- bably never occurs without being accompanied by a lateral one. In the most simple form of the defect, there is merely a fissure in the lip, extending from its inferior border as far up as the gum; its edges, of which the outer is always more or less oblique, are rounded off, covered by mucous membrane, and of a florid red color. Their consistence is considerably greater than that of the other labial structures, and, on being held toge- ther, they are seen to form, by their divergence below, a sort of triangle, the base of which corresponds with the free margin of the lip. In another class of cases the cleft is not only wider, but it extends considerably higher up, HARE-LIP. 541 perhaps even into the nose, which, in consequence, is usually somewhat flat- tened at the side, as seen in fig. 338, from a clinical case. The jaw in this, as in the former variety, is entirely normal. Fig. 338. Fig. 339. Double hare-lip. In double hare-lip, represented in fig. 339, there are, as the name im- plies, two fissures, with an interme- diate central piece, which varies much in size, shape, and direction, being sometimes broad and quadrangular, but more generally narrow, elongated, orraammillated. The framework of this part consists of two distinct portions, corresponding with the incisive bones of the inferior animals, and forming a rounded knob, connected by a narrow neck to the nasal septum. It is commonly very oblique, sometimes, indeed, almost horizontal, in its direction, is often very imperfectly covered by skin, contains the rudiments of the central incisor teeth, and almost invariably co- exists with cleft palate and deformity Simple hare-lip. Fig. 340. Fig. 341. of the nose. The fissures bounding this knob are not always of the same size and shape; on the contrary, one is frequently much wider, as well as longer, and more curved, than the other. They may both extend into the nose, or one may do so, and the other, perhaps, not reach higher up than the. gum. Figures 340 and 341 represent the more common forms of the septum. The complications of hare-lip are various, and deserving of attention. One of the most simple is that in which the labial fissure is blended with a depression, prominence, or cleft in the alveolar process of the jaw-bone. The cleft may be partial or complete; in the latter case, it is generally, if not always, connected with flattening and deformity of the corresponding side of jhe nose, and, not unfrequently, also with fissure of the palate. In double hare-lip, the openings in the soft structures are almost always associated with malformation of the roof of the mouth. They pass round the central knob, at the posterior surface of which they become continuous with the palatine nssure, which generally extends both through the hard and soft parts as far »s the extremity of the uvula. Hare-lip is sometimes associated with other congenital malformations. I Deformity of the nasal septum in hare-lip. 542 DISEASES OF THE MOUTH AND THROAT. have witnessed its co-existence with club-foot, bifid spine, and scrota] hernia, and lately I saw an instance where, along with a horrible cleft in the palate, there was great deformity of the hands, one of which was deprived of three fingers, and the other of one finger and the thumb. Of the causes of hare-lip we are entirely ignorant. That it is a result of an arrest of development is certain ; but how this arrest is produced is a cir- cumstance in the history of foetal life which has not been satisfactorily ex- plained. I am not aware that any statistics exist in regard to the relative frequency of the affection in the two sexes. In my own practice I have seen it nearly as often in one as in the other. Hare-lip occasionally occurs in several members of the same family; and a case has been communicated to me by Dr. R. A. Lightfoot, of Maysville, Kentucky, in which this malformation has shown itself in four successive generations, mostly in its double form. Hare-lip, besides being very unseemly, and, consequently, an object of con- stant attention and remark on the part of others, interferes materially with sucking, deglutition, and articulation. In the worst grades of the affection, as when the fissure is double, or associated with cleft-palate, it is often ex- tremely difficult for the child to obtain the requisite amount of nourishment, much, if not most, of what is attempted to be swallowed regurgitating by the mouth. As he grows up, he finds himself unable to pronounce labial sounds, and thus, unless the defect is early remedied, his education must necessarily suffer, if, indeed, it be not entirely neglected. The malformation under consideration can be relieved only by operation; and the question, consequently, arises at what period should it be performed, whether almost immediately after birth, within the first few months, or not until the child has attained the age of two or three years ? There are few subjects in surgery which have been more frequently or more thoroughly dis- cussed than this during the last quarter of a century. I am not certain, however, that the numerous controversies that have grown out of it have been of much benefit in settling the point; for my opinion is that, in prac- tice, most surgeons are governed, in this matter, more by the results of their own experience than by the writings of their professional brethren. As in most other cases, so in this, the probability is that a middle course is the safest; at all events, it is the one which I have myself generally pursued, and thus far I have seen no reason to regret it. My opinion has long been that the most eligible period is from the third to the sixth month, or a short time before the appearance of the first teeth ; the operation is then usually borne well, there is no danger of convulsions, and the adhesive process generally proceeds most kindly. In very simple cases, I do not hesitate to attempt it earlier; and, on the other hand, in double, or very complicated hare-lip, I almost always postpone it until the child has attained its second or third year. The operation for this variety of hare-lip is a very serious one; there must always necessarily be more or less loss of blood; the shock is frequently severe ; and the resulting inflammation may be over-active; valid reasons, I conceive, for the exercise of caution and judgment. In the few cases in which I have performed the operation under such circumstances, the issue has been anything else than gratifying. It need hardly be added that, in an under- taking of so much importance as this confessedly is, it is of vast consequence that the general health should be as good as possible; a feeble, irritable, or anemic state of the system is little favorable to the adhesive process. The operation being determined upon, the child is wrapped up in a strong apron, in order to render it as passive and helpless as possible while its differ- ent stages are gone through with. If he be very young, he is placed upon the knees of an assistant, the head being nearly perpendicular, and held firmly by another assistant standing behind. Secured in this manner, he will not be HARE-LIP. 543 likely to suffer any inconvenience from the bleeding, as the blood will not be so apt to flow into the throat. If he be very unruly, he may be put partially under the influence of chloroform, but the full effect of the medicine is never necessary. The operation, as it is usually performed, may be divided into three stages. In the first, the lip is extensively detached from the gums, sometimes as high up even as the nose, especially in bad cases. This I regard as a step of the greatest importance in regard to the form and beauty of the new lip, for so, in truth, it may be called. The second stage consists in paring the edges of the fissure, and the third in approximating them with the twisted suture. The instruments required are a narrow, sharp-pointed scalpel, a pair of scis- sors, forceps, a sponge-mop, and a few small pins with glass heads. Everything being arranged, and the child firmly secured, the lip is care- fully dissected off the gums, after which the edges of the fissure are pared with the same instrument, or, what will usually answer equally well, a pair of scissors. If the knife be used, it is inserted at the upper angle of the cleft and brought out at the lower, the surgeon cutting towards himself. In exe- cuting this part of the operation, the serious error is frequently committed of removing too little substance, in consequence of which, when the edges are approximated, there is an unsightly notch at the prolabial surface of the wound, which nothing short of another operation can efface. My invariable practice is to cut away the whole of the rounded portion of the fissure, and also, whenever there is a sufficiency of substance, to impart to the incisions a slightly curvilinear direction, so that the notch alluded to shall be effectually prevented, and the lip receive its proper length. Malgaigne, with a view of preventing the prolabial notch, which is so apt to follow the ordinary operation, especially when carelessly done, has proposed to pare the edges Fig. 342. of the fissure in such a manner as to leave two angular flaps below, which, when brought to- gether, shall effectually obviate the defect. The procedure will be readily understood by a refer- ence to fig. 342. If, when the parts are healed, the flaps should be found to be redundant, they can easily be retrenched with the knife or scis- sors. Professor March, of Albany, accom- plishes the Same Object by means Of a pair Of Malgaigne's operation. The dotted forceps, each blade of which terminates in a mnes mark the fissure. transverse jaw, convex at its free extremity, and serrated within, so as to secure a better hold upon the lip. The hemorrhage attendant upon the paring of the edges of the cleft is easily controlled by the thumb and finger of an assistant, or by pressure upon the facial artery as it passes over the body of the lower jaw. If any blood falls into the mouth, it is at once removed with the finger, or a suitable sponge-mop. The edges of the fissure having been thoroughly refreshed, or, more pro- perly speaking, excised, are accurately approximated, and retained by the twisted suture, the only one which, in my judgment, should ever be employed in this operation. Three pins are generally required; they should be from an inch and a quarter to an inch and a half in length, according to the width of the gap, strong and well tempered, yet delicate, very sharp, and provided each with a glass head. The first instrument is inserted on a level with the red border of the lip, about three lines from the raw surface, and is brought out at a corresponding point on the opposite side, at least two-thirds of the thickness of the lip being in front of it. A strong silk thread, properly "axed, is then wrapped round the pin, not in the form of a figure 8, as is 544 DISEASES OF THE MOUTH AND THROAT. usually recommended in the books, but elliptically, as in fig. 343, and neither so firmly, on the one hand, as to create undue tension, nor Fig. 343. so loosely, on the other, as to prevent perfect apposition. Another pin is passed, in the same manner, through the middle of the wound, and, finally, a third near its upper extremity, just below the nose. Sometimes two pins are - quite sufficient, while, at other times, as many as four may be required. The pins having all been wrapped, the ends of the threads may be passed from one to the other across the interstices, being thus made to subserve the purpose of adhesive strips. All that now remains to be done is to cut off the point of each instrument with a pair of pliers, lest they should become entangled in the pillow, or the little patient hurt his hands. In performing this apparently trivial part of the operation, the sur- geon makes moderately firm pressure on the centre of each pin, otherwise it may, if not well tempered, break in the substance of the lip, and thus neces- sitate the introduction of another. Some surgeons give the preference, in performing this operation, to the common interrupted suture, and there is no doubt that a good cure may be effected in this way, especially if the treatment be aided by a few narrow adhesive strips. I must say, however, that, after long experience, I consider the operation above described as altogether superior. No dressing is required after the operation. The part is kept cool and quiet, to insure adhesive action; and the child is fed with the spoon, the most suitable diet being milk, arrowroot, or chicken broth with soft-boiled rice. The upper and middle pins are withdrawn at the end of the second day, and the lower in twenty-four hours after. The threads, which soon become per- manently glued to the lip by plastic lymph, are permitted to drop off spon- taneously, as they often perform excellent service in maintaining apposition after the more efficient means have been removed. If any portion of the wound remain open, it is touched lightly with a pencil of nitrate of silver; or, if the gap be considerable, apposition is effected by the twisted suture, as in the first instance. If the chasm is very large, additional support is fur- nished by carrying a long and rather stout pin completely through the lip, at the distance of at least half an inch from the wound. Such a proceeding will be found to be much more efficacious than the use of an adhesive strip, stretched from one cheek to the other. The operation for double hare-lip, although conducted upon the same prin- ciples as that for single, must necessarily vary according to the nature of the concomitant deformity. If the intervening piece is vertical, or nearly so, completely covered by skin, and of proper length, all that is required is to close the fissures in the usual manner; not, however, at one time, but after an interval of several weeks. If, on the contrary, it is very oblique, or almost horizontal, it must be removed. This may be done either with a pair of bone- nippers, a strong scalpel, or a small saw. Smart hemorrhage, from the divi- sion of the artery of the nasal septum, occasionally attends this stage of the operation, but, in general, soon ceases spontaneously, or with the aid of a little pressure with the finger. Should it prove troublesome, it may be necessary to touch the bleeding orifice with a heated probe, or to apply a graduated compress and roller. In the latter case, the paring of the edges of the now large and single cleft must be postponed until the child has re- covered from the effects of the first operation. Removal of the intermaxillary septum in double hare-lip is not unattended with danger. I bave heard of at least one instance in which the operation occasioned death. It has been proposed, in double hare-lip, to rectify the vicious position ot the central piece by systematic compression, made either with the finger or DOUBLE HARE-LIP. 545 a spring-truss, not unlike the instrument used in the treatment of umbilical hernia. In my own practice, however, I have seen no benefit from the pro- ceeding, and I believe that it will generally be found inapplicable, or wholly inefficient. In removing this structure, great care should be taken not to encroach too much upon the nasal septum, otherwise the lip will be certain to have a flat and depressed appearance. Indeed, it is a good plan, in most cases, to retain a portion of it, for the purpose of supporting the soft parts; and this can always be easily enough done if the bone be divided perpendicu- larly through the alveolar process, the teeth, if any protrude, having been previously extracted. When the patient has reached the proper age, the piece thus retained can be easily retrenched, and the chasm filled with an artificial jaw. Another circumstance, not to be neglected where removal of the intermediate body is demanded, is to save a portion of its cutaneous covering; this should be properly shaped, and fastened, at the close of the operation, by several short, delicate needles, to the nasal septum, which it thus serves to render more prominent and seemly. When the chasm is uncommonly large, as often happens when the inter- vening substance is removed, the ten- sion of the parts may be so great as to require support; when this is the case, the most suitable contrivance for the purpose will be found to be that sketched in fig. 344. It was devised by Mr. Devvar, of Scotland, and is so arranged as to press each cheek over towards the middle line. When the malformation is asso- ciated with a cleft in the alveolar process of the jaw, an attempt should be made to obliterate the latter, pro- vided it is not very large, before we operate for the cure of the former. This can often be accomplished, espe- cially if the treatment be commenced within a few days after birth, very satisfactorily by the plan originally suggested by Dr. Hullihen. This consists in the application of several layers of adhesive strips to each cheek, the inner ends of which extend across the lip beneath the nose, where they are drawn together by ligatures, daily tightened until the opposite edges are brought into contact. The dressing, which need not be renewed oftener than once a week, does not interfere with sucking, and usually effects its u'ject in from one to two months. When this treatment succeeds, Dr. Fundenberg, of Maryland, advises that the borders of the cleft should be carefully pared, and approximated by a strong ligature, passed through each side of the jaw, one-third of an inch from the edge of the fissure, and tied as firmly as possible while the two bones are pressed forcibly together by an assistant. The suture is retained for e|gnt or ten days, the cheeks being supported in the interval by adhesive stnps, arranged as already indicated. This mode of treatment is highly inge- nious, and deserving of a fair trial. It is, of course, to be resorted to only " rCf^ 70un? children, before the osseous tissue has acquired much solidity. had occasion, in 1849, to see a very singular, and, so far as I know, vol. n___35 Dewar's compressor. 546 DISEASES OF THE MOUTH AND THROAT. unique case of hare-lip. The patient was a stout, healthy boy, four years of age. The cleft, which was congenital, Fig. 345. occupied the left side of the cheek and the corresponding commissure of the mouth, being about one inch in length, by three-quarters of an inch in breadth. Its edges were rounded off, hard, red, and covered with mucous membrane, as in ordinary hare-lip. The child was unable to articulate distinctly, and ex- perienced much difficulty in controlling his saliva, food, and drink, to say no- thing of the disagreeable aspect which Fissure of the cheek. the fissure imparted to the features. The parts being pared in the usual manner, were approximated by three points of the twisted suture, and united beautifully by the first intention. The improvement of the face was most satisfactory. The annexed sketch, fig. 345, gives an accurate idea of the face prior to the operation. 10. Lower Lip.—It is extremely rare to meet with malformations of the lower lip. I have myself never seen a case of congenital fissure here, and, with the exception of that of Nicati, I do not know that there is one on record. In this instance the eleft seems to have been mesial. A very curious malformation of the inferior lip, presenting the form of two little sacs, one on each side of the middle line, is described by Dr. Jardine Murray, in the British and Foreign Medico-Chirurgical Review for October, 1860. It occurred in four members of the same family, in three of which it was associated with hare-lip. The pouches, which occupied the margin of the lip, were half an inch in depth, of a crescentic shape, moistened with glairy mucus, and capable each of receiving a split pea. The proper remedy for such a defect, which, probably, essentially consists in a malformation of a muciparous gland, would be thorough excision. 11. Cheiloplasty.—Extensive destruction of the lips sometimes occurs; generally as a result of malignant disease, accident, or sloughing from inor- dinate mercurialization, carbuncular inflammation, and other affectious. The deficiency thus occasioned may generally be efficiently closed by an autoplastic operation, performed upon the same principle as in making a new nose, the integumental flap being borrowed from the immediate neighborhood of the gap. When the upper lip is affected, the flesh is generally taken from the cheek, or partly from the cheek and partly from the neck. A similar proce- dure may be adopted when the outer portion of the lower lip is to be repaired, whereas, when the deficiency exists at its middle, the skin should be taken from the chin, the incisions, if need be, being carried as low down as the hyoid bone. After removal of the lip on account of cancerous disease, an excellent sub- stitute may generally be made by raising two quadrilateral flaps from the lower part of the face and the upper part of the neck, by carrying an in- cision on each side obliquely downwards, beneath the jaw, from the base of the gap, and then obliquely upwards and backwards, some distance beyond the commissure of the lip. A triangular piece of skin is thus left at the middle line, the apex of which is directed upwards, and serves to mark the point of junction of the two flaps, after they have been dissected up, and stitched in place. The adjoining fig. 346 affords a good idea of the lines of incision, while fig. 347 exhibits the appearance of the parts after they have been united. The operation, which I have successfully performed in several TONGUE — WOUNDS—GLOSSITIS. 547 Lines of incision in cheiloplasty. instances, is usually known as that of Mr. Syme. 12. Contraction of the Mouth.— This defect is sometimes congenital, but much more frequently a result of disease, particularly of profuse and destructive ptyalism. The contrac- tion may amount almost to complete closure. However induced, it is both unseemly and inconvenient. In re- gard to the treatment of such a con- dition, no special rules can be laid down; the skill of the surgeon will generally indicate the course to be pursued in each particular case. SECT. II.—AFFECTIONS OF THE TONGUE. The principal surgical affections of the tongue are, wounds, inflammation, hypertrophy, carcinoma, and malformation of its frenum. 1. Wounds.—Wounds of the tongue are most commonly produced by the teeth during epileptic convulsions; but they may also be inflicted by balls, and by design with sharp instruments. The hemorrhage, which, from the great vascularity of the organ, is often copious, is to be commanded by liga- ture and styptics, unless it proceed from the posterior portion of the tongue, when it may be necessary to use the actual cautery. The edges of the wound are approximated by the interrupted suture, the only retentive means of which the parts admit; inflammation is kept in abeyance by antiphlogistics. Cases occasionally occur in which the tongue is almost completely severed, or jn which the anterior extremity hangs only by a few shreds. Our duty obviously is to attempt to save the parts, not to cut them off; and with this view they are closely approximated by numerous stitches, thus placing them in the most favorable position for speedy reunion. When there is a tendency in the tongue to fall back into the throat, so as to threaten suffocation, or where it has lost its support from the destruction of its muscles, as occasionally hap- pens in gunshot and other injuries, means must at once be adopted to fasten it to the teeth until the danger is over. In gunshot wounds the ball occasionally lodges in the substance of the tongue, where it may be undetected for a long time, the only evidence, per- haps, of its presence being a fistulous aperture, as in the case narrated by Boyer, where a body of this kind had been retained for four years. A similar instance has been reported by Moizin. The proper remedy, of course, is excision. 2. GYosmWs.—Inflammation of the tongue, fig. 348, technically called glos- sitis, of a severe character, is often caused by lacerated wounds, and by the contact of hot water, steam, and various kinds of acids. Not unfrequently the organ suffers secondarily, from extension of the disease in the surrounding Parts, as the tonsils, palate, gums, and salivary glands. In common ptyalism, Fig. 347. Cheiloplasty. 548 DISEASES OF THE MOUTH AND THROAT. Fig. 348. glossitis always exists ; sometimes in a most violent degree. In the old method of treating syphilis, the tongue was often excessively inflamed, and so large as to protrude several inches beyond the teeth. How- ever induced, the disease is frequently very severe, and productive of immense distress, from the great swelling and tenderness of the parts, and the at- tendant suffocative symptoms. The patient is hardly able to talk or swallow, he pants for breath, and is an object of great pity. The tongue sometimes enlarges very suddenly, to a great and an alarming Glossitis. extent, almost completely filling the mouth, and occasioning excessive embarrassment in respiration. The cause of the attack, which occurs chiefly in middle-aged and elderly sub- jects, is generally inscrutable. In some of the reported cases it was ap- parently dependent upon the effects of cold, or a sudden suppression of the cutaneous perspiration combined with gastric disorder. The swelling is characterized by copious and rapid effusion of serum and lymph. The treatment of glossitis is strictly antiphlogistic. If the patient is young and robust, blood is taken freely from the arm, the bowels are thoroughly evacuated, and the system is brought under the full influence of nauseants. The best topical applications are leeches beneath the base of the jaw, followed by large emollient poultices. Bleeding from the ranine veins is sometimes beneficial. In the milder cases the disease often promptly yields to astringent lotions and to counter-irritation to the neck, in the form of embrocations and ammoniated liniments. When the inflammation is of an erysipelatous charac- ter, the tongue may be painted several times in the twenty-four hours with a weak solution of iodine, or pencilled once effectually during that period with the solid nitrate of silver. When suppuration, gangrene, or asphyxia is threatened, deep incisions are made, to favor disgorgement of the overloaded vessels and the escape of the effused fluids. The operation, although followed by what might appear to be an alarming flow of blood, is free from danger, and is the only remedy which, in such an event, is worthy of reliance. The glossitis consequent upon ptyalism is often very painful and intrac- table; the tongue is generally much swollen, and of a fiery redness; patches of lymph form upon its surface, and not infrequently ugly ulcers make their appearance, thus adding greatly to the patient's suffering. The treatment consists in the daily use of mild aperients, warm applications to the head and neck, and astringent gargles, of which the best, according to my observation, is a solution of acetate of lead, in the proportion of two drachms' of the salt to a pint of water. With this the mouth and throat should be freely gargled every hour, or even oftener, care being taken always to retain the fluid for a few minutes in contact with the affected parts. The only disadvantage of this gargle is that it discolors the teeth, an effect which, however, generally disappears in a few days after the discontinuance of the remedy, and which, considering its great efficacy, is really a matter of no moment. When the lead disagrees, or proves inefficient, weak solutions of sulphate of copper and tannin, sulphate of zinc, iodide of iron, or sulphate of alumina may be em- ployed as a substitute. When the tongue is very red and painful, ulcerated, or covered with lymph, the most suitable remedy, in general, is the nitrate of silver, drawn lightly over the affected surface once a day. In the sudden and violent forms of glossitis, resulting from cold or gastric disorder, relief should be attempted by copious bleeding at the arm, speedily followed by an active emetic ; the bowels should be freely opened, leeches applied to the chin and side of the jaw, and the tongue deeply scarified. TONGUE — ULCERS—DIPHTHERITIS 549 these measures fail, or there is impending suffocation, laryngotomy is per- formed. 3. Ulcers.—Ulcers of a syphilitic, strumous, mercurial, and simple character often exist on the tongue, and require much judgment on the part of the practitioner both for their discrimination and treatment. The history of the case, the habits of the individual, and various other circumstances, will gene- rally afford important information respecting the true nature of the malady. The simple ulcer is frequently assopiated with derangement of the digestive apparatus, and is usually easily distinguished from the other varieties of the affection by its superficial surface, by the slight discoloration of the adjacent parts, by the absence of induration, and by the readiness with which it yields to treatment. The syphilitic ulcer has a hard base, a foul, irregular surface, more or less discharge, and a copper-colored appearance of the mucous mem- brane around, with great swelling, pain, and stiffness of the tongne. The strumous ulcer is not always easy of recognition, but its existence may be suspected when there is an obstinate sore on the edge of the tongue, near its centre, with a tumid state of the upper lip, an enlarged abdomen, and other evidences of the strumous diathesis. The treatment of ulceration of the tongue is regulated by the nature of the disease upon which it depends. The syphilitic form is best managed by the exhibition of iodide of potassium, in combination with bichloride of mercury, and the application of nitrate of silver, or dilute acid nitrate of mercury. In strumous ulceration the chief remedies are cod-liver oil, and the different pre- parations of iodine, either alone, or in union with mercury. The mercurial variety generally requires no constitutional treatment, a cure being often effected in a few days by the topical use of nitrate of silver, sulphate of copper, acetate of zinc, and other astringent lotions. Similar means, especially the former, with attention to the state of the digestive organs, often succeed in the ordinary form of ulcer of the tongue. In all cases, whatever may be the nature of the exciting cause, the strictest attention should be paid to the diet, bowels, and secretions. This, indeed, is frequently of itself sufficient to effect a cure, while without it no treatment, however well conducted, will be likely 'to be of much avail. 4. Diphtheritis.—A diphtheritic state of the tongue is sometimes observed. It is noticed most frequently in the latter stages of chronic diseases of a malig- nant or incurable character, accompanied with an anemic condition of the system. It is evidently of an inflammatory nature, and is nearly always asso- ciated with soreness of the fauces and pharynx. The tongue is usually some- what tender and swollen, with a feeling of rawness, or a sense of scalding ; and is covered with a thin layer of adherent lymph, of a whitish, grayish, or drab color. The crust sometimes extends over the whole surface of the organ, at other times it occurs in small spots, strips, or patches. The gums, cheeks, lips, roof of the mouth, and even the fauces, occasionally participate in the deposit. On removing this substance, the mucous membrane is found to be somewhat rough, and heightened in color, with, perhaps, here and there a slight fissure, abrasion, or ulcer. A diphtheritic state of the tongue is occasionally produced by salivation. The treatment of this affection is mildly antiphlogistic, the reliance of the practitioner being placed mainly upon local measures. Weak washes of sulphate of copper and tannin, with honey, nitrate of silver, and sulphate of zinc, are generally sufficient to detach the diphtheritic crust and to remove the inflammation which causes it. Very frequently the best effects follow the employment of a strong gargle of biborate of soda, or the application of equal parts of this substance and of powdered sugar, aided by the exhibition of chlorate of potassa. 55U DISEASES OF THE MOUTH AND THROAT, 5. Hypertrophy.—Hypertrophy of the tongue may be limited to its mus- cular substance, to its papilla?, or to its raucous investment; or, as not un- frequently happens, all these structures may Fig. 349. be effected simultaneously, as exhibited in fig. 349, constituting general hypertrophy. In the latter case, which alone concerns the surgeon, the organ is abnormally dense, rigid, and so large as to protrude considerably be- yond the teeth, causing serious obstruction to the functions of the mouth, and a wasting discharge of saliva. The prolapsed part is from a few lines to three, four, and even five inches in length, by several inches in breadth and thickness, rough on the surface, prefer- naturally firm, and of a dark color. The papilla? are often five or six times as large as in the normal state, and the mucous cover- Hypertrophy of the tongue, ing has more of the character of bark-than of sound structure. The affection, which is more common in females than in males, generally comes on early in life, being now and then, if, indeed, not always, congenital. The exciting cause is un- known, though occasionally it is directly traceable to inflammation. It is sometimes associated with unusual shortness of the branches of the lower jaw, with great separation of the incisor teeth. Enlargements of this kind are often extremely vascular, from undue development of their minute vessels; and dissection shows that their muscular fibres are transformed into a pale, dense, fibrous substance, with hardly any trace of the normal structure. The nature of this disease is always easily detected by simple inspection. Its progress is generally tardy, and free from pain and inconvenience, save what results from the bulk of the affected part. When this is considerable, the saliva dribbles constantly from the mouth, and the patient finds it difficult to articulate, chew, and swallow. The countenance has an unseemly aspect, the inferior incisors are forced into a horizontal position, and the jaw itself is not unfrequently considerably altered in its shape. The general health is remarkably prone to derangement, and a not uncommon symptom is disorder of the digestive apparatus. Yery little is to be expected from purely medical treatment in this affection, especially when fully developed. In the milder grades marked benefit occa- sionally follows regular and systematic purgation, low diet, and the exhibi- tion of iodide of iron, iodide of potassium, or Lugol's solution. When the disease is of inflammatory origin, alterative doses of mercury may occasionally be advantageously conjoined with these remedies, but in the congenital variety little is to be expected from such a union. The most valuable local applica- tions are leeches, punctures, or small incisions, and tolerably strong solu- tions of iodine, sulphate of copper, and other kindred articles. I had lately under my care a lad, aged six years, affected with congenital hypertrophy of the tongue, who has been materially benefited by lotions of pyroligneons acid, in the proportion of one drachm to the ounce of water. Under its influence the protruded portion of the organ has become much softer, as well as considerably reduced in volume. Lassus derived great benefit from systematic compression of the tongue by means of a bandage, and a case which was treated successfully upon this plan was related, not long ago, by Professor Syme. If these means fail, the exuberant structures are removed by* knife or ligature, as in carcinoma. . 6. Cancer.—Cancer of the tongue usually exhibits itself in the form ot TONGUE — CANCER—ERECTILE TUMORS. _ 551 scirrhus; encephaloid is extremely rare, and colloid is entirely unknown. The same is true of melanosis. Scirrhus of this organ is most common in males after the age of forty, and generally arises without any assignable cause. The contact of a carious tooth or broken fang, and of the stem of the pipe in smoking, has been accused of originating it, but the idea is far-fetched and insusceptible of proof. The disease is most commonly situated towards the centre of the tongue, midway between the raphe and one of its edges, where it begins either as a minute, hard, and inelastic tubercle, a small fungous excresceuce, or a little sore, chap, or fissure. However this may be, it gradually spreads, and at length degenerates into a foul, excavated ulcer, with indurated, jagged, and elevated edges. The parts around are hard and firm, and not unfrequently the whole organ is as stiff and immovable as a board. The pain, which is sharp and pricking, or dull and aching, is particularly severe at night, and generally radiates about in different directions, especially along the cheeks, ears, and temples. Sometimes it is of a neuralgic character. The size of the affected organ is liable to much diversity; sometimes it is normal, but more commonly it is considerably augmented ; and sometimes, again, it is a good deal dimin- ished. In a case recently under ray observation, it presented itself as a firm, hard, immovable mass, which accurately filled the trough formed by the dental arch of the lower jaw. At times the organ is so large as to project beyond the lips, and to encroach seriously upon the buccal cavity. Its color is usu- ally somewhat heightened, and its edges are often indented by the teeth. As the malady advances, deglutition becomes embarrassed, from the fact that the food can no longer be collected and carried back into the throat; articulation is impaired; and sputation is performed with so much frequency and difficulty as to constitute a source of real suffering. By and by, the lymphatic gan- glions at the base of the jaw enlarge; the gums swell, and exhibit a red, spongy aspect; the teeth loosen and fall out, and the system exhibits all the marks of the cancerous cachexia. Thus day by day the ruthless malady proceeds, until it has effectually accomplished its work of destruction. Some- times other organs are involved in its progress, but most commonly the car- cinomatous action is limited to its original site. The diagnosis of carcinoma of the tongue can seldom be mistaken. The mode of origin of the malady, its slow but steady progress, its resistance of treatment, the peculiar character of the resulting ulcer, the nature of the pain, the age of the patient, and the sure contamination of the adjacent parts, as well as of the general system, always serve to distinguish it from other affec- tions incident to this organ. The treatment of this affection has generally, at least until lately, been by ablation, either by the knife or ligature. The utility of such a proceeding, however, admits of great doubt, and my own opinion has long been that the less we interfere with the disease in this way the better. The results of ex- perience are certainly strongly corroborative of this conclusion. The ordi- nary means for improving the general health, allaying pain, and preventing the spread of the disease, are, of course, not neglected. These means are already familiar to the reader, and need not, therefore, be again mentioned. With judicious management, it is astonishing how long, in many cases, the disease may be kept in abeyance, and the final issue warded off. 7. Erectile Tumors.—The tongue is occasionally the seat of the erectile tumor. Its most common site is the anterior extremity of the organ, where "■ presents itself as a soft, elastic structure, of a bluish color, variable in form and size, free from pain, and subject to temporary enlargement under mental emotion. The disease is most frequent in young subjects, and is occasionally associated with similar developments in other parts of the body, as the lip and cheek. The tumor seldom acquires a large bulk, but now and then an 552 DISEASES OF THE MOUTH AND THROAT. Expansion of the lower jaw; the result of pressure by the tongue, enlarged by erectile tissue. instance is seen in which it greatly en- croaches upon the mouth, and by its pres- sure expands the jaw, as in fig. 350, push- ing the teeth out of their natural position and even from their sockets. If seen in time, the morbid growth is readily amenable to treatment. The best application is the Vienna paste, used as in making an issue, only with more caution, the organ being drawn forward and steadied the while by a volsella. Or, if the abnor- mal structure be limited and accessible, it may be removed by ligature, in the same manner as a carcinomatous tumor. Deli- gation of the lingual arteries has been practised, but with no encouraging re- sults. In one case, at least, the operation was followed by fatal sloughing. 8. Wart-like Excrescence.—A wart-like excrescence sometimes grows from the tongue; generally from its sides or tip, of a red color, firm consistence, painless, benign, tardy in its development, and seldom exceeding the volume of a small pea or raspberry. It is usually attached by a narrow pedicle, and is somewhat rough on the surface; its structure being of a fibroid cha- racter, intermingled with a large number of epithelial cells. The mi- croscopical appearances of a growth of this kind, which I removed last January from a patient at the Jef- ferson College Clinic, are repre- sented in fig. 351, from a drawing by Dr. Packard. The proper remedy for the wart- like tumor of the tongue is excision, or ligation, if there is reason to anticipate much bleeding. When small and recent, it generally yields '\(f^?Tk ^li^JA^^A^M^ very reao^y nnder the application ^X/Sid w/Vt^x^n KfJj.s^Zi / 0f chromic acid. 9. Cystic Disease.—This affection of the tongue is rare. It consists, as the name implies, of serous vesi- cles, single or multiple, occupying the muscular substance, and elevat- ing the mucous investment in the form of little tumors, of a serai-transparent appearance, and occasionally quite sensitive. They vary much in size, but usually do not exceed the volume of a cherry-stone, and their number some- times amounts to several dozens. Occasionally, a solitary cyst of consider- able dimensions is observed. The most reraarkable case of the kind I have ever witnessed was sent to me at the Jefferson College Clinic, in 1859, by Dr. Turnbull, of this city. The subject was a small, puny child, aged three weeks, whose tongue was so large as to project fully two inches from tin1 mouth, forming a thick, ungainly-looking mass, pellucid, soft, fluctuating, and effectually preventing sucking. The contents of the tumor were of a thick, ropy consistence, and of a whitish hue. . Cystic disease of the tongue is of obscure origin, and not always easyo recognition. Indeed, it is only when the vesicles approach the surface tna its true character can be indubitably established. In cases of uncertainty, Epithelial tumor of the tongue, magnified 472 diameters. TONGUE — MALFORMATIONS—ABLATION. 553 the exploring needle should be used. The treatment is by incision, injection, or seton, according to the age, structure, and volume of the tumors. 10. Malformations of the Frenum.—The tongue is sometimes restrained in its movements by malformation of its frenum, impeding, at first, suction, and, afterwards, articulation. The defect may consist in a short, indurated, and thickened condition of the part, or the little membrane may be prolonged so far forward as to interfere with the action of the tip of the organ; in either case demanding instrumental treatment. The operation, although simple, should not be performed wantonly, particularly as it is occasionally followed by hemorrhage. When necessary, the child's head is embraced between the knees of the surgeon, who, elevating the tongue with the index and middle fingers of the left hand, carefully divides the frenum to the requisite extent with a pair of narrow-bladed scissors, the points of which are directed down- wards, away from the ranine vessels, the great source of danger. The little patient is watched for some time after the operation, lest undue bleeding should ensue. The frenum of the tongue is sometimes entirely absent, allowing the organ to fall back into the fauces, where, when the parts are quiescent, it looks like a fleshy tumor, attached to the pillars of the palate by a reflection of the mucous membrane. Bransby B. Cooper met with two instances of this kind in the same family. One of the children died from suffocation, at the age of eighteen months, and the other had been repeatedly threatened with the same accident, the respiration being particularly embarrassed during sleep. When sucking, the muscles seemed capable of retaining the tongue in its proper position. In such a case, an attempt might be made, after paring the lower surface of the organ, to stitch it to the floor of the mouth, though it is not probable that the operation would be successful. 11. Morbid Adhesions.—The tongue, in consequence of injury of the jaw and of its own substance, is liable to form adhesions to the floor of the mouth, thus greatly impeding its functions. The bands may be single or multiple, and they vary in consistence from that of fibrous tissue to fibro-cartilage, according to their age and other circumstances. Relief is afforded with the knife, a tedious, bloody, and painful dissection being sometimes necessary to accomplish the object. Reunion is prevented, during the cicatrization, by the interposition of charpie, or, what is better, tin foil. 12. Partial Immobility.—The muscles of the tongue are liable to a species of contraction, similar to that which occurs in wryneck and other affections. The cause is generally inflammation, attended with plastic deposits, followed, ultimately, especially when the case is protracted, by fatty or fibroid degene- ration, and inducing thus more or less impediment in the moveraents of the organ. In a case recently under my care, the patient found it difficult to seize and masticate his food, owing mainly to the contracted and indurated state of the stylo-glossal and hyo-glossal muscles, the subcutaneous division of which at once relieved the parts of their constraint, and restored the tongue to its primitive mobility. Care must be taken, in performing operations of this kind, not to interfere with the proper lingual arteries. 13. Ablation of the Tongue.—Ablation of the tongue is sometimes required. Ihe operation may be performed with a knife or ligature, as may seem most expedient. If the affected part is small, and involves the anterior extremity ot the organ, it may be included in two incisions, meeting behind at an acute angle, like the lines of the letter V. The edges of the wound are brought together by the common interrupted suture, which serves the double purpose of a retentive and hemostatic agent. If, on the other hand, the disease, from its remote site, is less accessible, a decided preference is given to the ligature, as Us use is unattended with hemorrhage. An instrument, such as that re- 554 DISEASES OF THE MOUTH AND THROAT. presented in fig. 352, and armed with a strong, well waxed, double ligature, or a stout needle, slightly curved, and fixed in a movable handle, is passed Fig. 352. Curved needle for ablation of the tongue. through the tongue, from below upwards, on the inner side of the tumor; the noose of the cord having been cut, one portion of it is tied forcibly in front, and the other behind, thus completely isolating and strangulating the diseased structure, as seen in fig. 353. The effect will be the more rapid if the parts to be ligated be previously a little notched with the bistoury; and the pain of the operation may be greatly lessened by the adoption of Mr. Hilton's suggestion of dividing, as a preliminary step, the gustatory nerve. In a few days the eschar separates, leaving an extensive ulcer, which fills up rapidly with granulations. The remarkable feat of excising the whole tongue has recently been per- formed several times in Europe. The operation affording the most easy access to the affected organ is that of Regnoli. It consists in making, as will be seen by a reference to fig. 354, a semilunar incision along the base of the lower Fig. 353. Fig. 354. Ligation of the tongue. Excision of the tongue. jaw extending nearly from one angle to the other, and thoroughly detaching the muscles and other soft structures from the bone. The mouth being thus freely exposed, the tongue is drawn out, and excised by carrying the knife through the sound tissues. If the tumor is very large, it may lie necessary to increase the opening by a vertical incision down to the hyoid bone. The vessels are secured as fast as they are divided, and the parts are approxi- mated in the usual manner. AFFECTIONS OF THE SALIVARY GLANDS — PAROTID. 555 Fig. 355. In order to avoid the hemorrhage attendant upon this operation, Chas- saignac has proposed the substitution of the 6craseur, fig. 355, for the knife, and it may readily be perceived that if there be any cases in which such an in- strument is applicable, this is one of them. The patient, being under the influence of chloroform, would experience no pain, and the ablation being performed slowly would be almost bloodless. The result of the ablation of the entire tongue may easily be imagined. So cruel a procedure could hardly have any other than a fatal termination, death occurring, if not from shock and hemorrhage, from oedema of the glottis, pneumonia, erysipelas, or pyemia. As to any ultimate or even temporary good it might produce, it is difficult to perceive it. There is a possibility, it is true, that the pa- tient's life might be prolonged for a few days, nay, perhaps, a few weeks or even months, but this would hardly compensate him for so terrible an ordeal. Removal of the tongue with the ecraseur. SECT. III.—AFFECTIONS OF THE SALIVARY GLANDS. The salivary glands are not often the subject of disease or accident. Their protected situation and the peculiarity of their functions are, doubtless, the chief causes of this immunity. PAROTID GLAND. The principal surgical affections of the parotid are inflammation, abscess, and certain tumors, chiefly of a malignant character. Its excretory duct is occasionally the seat of earthy formations, of wounds, and fistules. 1. Parotitis.—Inflammation of this gland, as an idiopathic affection, is almost wholly confined to the young, constituting what is vulgarly called the mumps. It is sometimes seen later in life, and in a few rare instances it is witnessed in elderly persons. It is more common in males than in females, generally prevails as an endemic, or epidemic, and, like most diseases of this class, seldom attacks the same individual more than once. It may occur at any period of the year, but winter and spring are its favorite seasons. Both glands usually suffer, though not always in an equal degree. The disease commonly begins with some degree of stiffness in the temporo- maxillary articulation, which rapidly increases in severity, and thus materially interferes with mastication. The swelling is particularly conspicuous just in front of the ears, which are often seriously implicated in the morbid action, and is almost always attended with a good deal of pain and constitutional disturbance, without any local discoloration. In most cases, it extends down the neck and along the base of the jaw, imparting thus a singular expression lo the features. As the inflammation progresses, the other salivary glands ur,e aPt ^ suffer; and, in the more aggravated forms of the disease, difficulty of deglutition is experienced, from involvement of the tonsils and arches of 'he palate. It usually reaches its height in about four days, when it begins o decline, and in a few days more terminates in resolution, rarely in suppu- ration or gangrene. A peculiarity of this variety of inflammation is its tend- ency to leave the organ primarily affected, and to fasten itself suddenly upon 556 DISEASES OF THE MOUTH AND THROAT. the testicle or mamma. How this transfer is established is utterly inexpli- cable by any known law of the animal economy, the more so as there is nn connection either direct or indirect between these parts. It is most apt to occur in young men, at a period varying from a few days to a week from the invasion of the malady. A violent parotitis, liable to terminate in abscess, and even in mortification, occasionally follows erysipelas, certain forms of fever, as typhoid and scarlet, and the abuse of mercury. Mumps is generally not a dangerous disease, but it may become so when it extends to the brain and testicle; in the former case, it may destroy life, in the latter it may induce atrophy and loss of function of the affected organ. Several examples of the latter termination have fallen under my observation. When both testes suffer, impotence may be the result. Parotitis seldom requires much treatment. In general, it is easily managed by rest and light diet, aided by aperients and diaphoretics, with warm appli- cations to the affected parts. Sometimes a warm cataplasm promptly relieves the pain and swelling; at other times, great benefit is experienced from the use of slightly stimulating embrocations, as soap, iodine, or volatile liniment, with a thick covering of raw cotton. Cold applications should be carefully avoided, on account of their repellent tendency. In violent attacks, recourse is had to the lancet, or, at all events, to leeches, active purgatives, and anti- monials. When much gastric disturbance exists, along with pain in the back and limbs, a brisk emetic will be useful. When the testicle is threatened by a translation of the malady, a blister should at once be applied over the parotid, in order to re-invite the inflammation. When the disease is fully established in the testicle, the usual antiphlogistic remedies are indicated, and should be employed without delay, lest structural lesion take place. Occa- sionally a good deal of hardness remains in the parotid region after the violence of the morbid action has disappeared. The proper way to meet this is to use stimulating embrocations and unguents, aided, in obstinate cases, by the constitutional effects of mercury. 2. Abscess.—Abscess of the parotid is nearly always of an acute character, being usually a result of simple inflammation, local injury, erysipelas, typhoid fever, smallpox, and other eruptive affections. The presence of matter is indicated by discoloration of the skin, circumscribed swelling, and high con- stitutional disturbance. The parts pit on pressure, the pain is excessive, and the patient is unable to open his mouth. Sometimes the swelling is remark- ably diffused. The fluctuation is generally very obscure, on account of the manner in which the contents of the abscess are bound down by the cervical fascia and capsule of the gland. Owing to this circumstance, the true nature of the disease is apt to be overlooked, and the pus allowed to burrow about in different directions; thus producing the most serious mischief, opening, perhaps, after having induced the most violent suffering, into the auditory tube, or- extending down the neck along the great vessels, and causing ex- tensive havoc in the connecting cellular tissue. In some instances the fluid passes round the trachea, and finally destroys life by bursting into the chest. To prevent these disastrous effects, and to relieve the horrible pain which always attends the disease, an early and free incision should be made vertically into the most prominent, and also, if possible, into the most dependent, part of the swelling, and kept open by means of a tent, until the cavity of the abscess is in great measure obliterated. The system, meantime, must be pro- perly supported by stimulants and anodynes. 3. Gangrene.—Mortification of this gland occurs chiefly in erysipelas typhoid fever, scarlatina, and smallpox. Sometimes it follows violent saliva- tion. Fortunately, however, it is very rare in any form of disease. l"e sloughing is usually most extensive in the connecting cellular tissue, but occa- sionally it affects the glandular substance also, which it may completely ue- AFFECTIONS OF THE SALIVARY GLANDS — PAROTID. 551 stroy, as I have had occasion to observe in several cases. In one of these not a vestige of the organ was left, its former site presenting a deep hollow, ex- tending down to the ramus of the jaw and the auditory tube. When gangrene is impending, or has actually taken place, free incisions should be made, followed by the application of the yeast or port wine poultice, and appropriate constitutional means. 4. Morbid Growths.—Tumors of a fibrous, scirrhous, melanotic, and ence- phaloid character, are sometimes developed in the parotid, or in the cellular and adipose tissue enveloping it. In most cases they appear to originate in ■the lymphatic ganglions imbedded in its substance, placed upon its outer surface, or situated in its immediate vicinity. The precise nature of the dis- ease can rarely be determined by outward inspection, or manual examination. Such tumors usually grow rather slowly, but they are almost always accom- panied by severe pain, from their pressure on the adjacent nerves ; the deformity is great, sometimes hideous, and the patient is unable to masticate and open his mouth. In their volume they vary from that of a walnut to that of a foetal head. The largest are usually the encephaloid and melanotic, the scir- rhous and fibrous rarely attaining much bulk. Their tendency is to destroy life, either by constitutional irritation, or by ulceration and profuse discharge. These tumors, especially the encephaloid, occasionally show themselves at a very early period, and, in this event, they usually run their course with great rapidity, often destroying life in eight, twelve, or eighteen months. The scirrhous form is most common in elderly subjects, and is distiugnishable by its extraordinary hardness, by its tardy progress, and by its comparatively small bulk. The melanotic tumor is, in general, easily recognized by its peculiar complexion, by its lobulated surface, and by its march, which is intermediate between that of scirrhus and encephaloid. It appears at vari- ous periods of life; but is most common in young adults. 5. Extirpation.—Considering the narrow space in which the parotid gland is situated, and the complexity of the relations which it sustains to the sur- rounding structures, is it possible to extirpate it in the living subject ? This question, so interesting in every point of view, has been answered differently by different writers. Allan Burns thought the operation impracticable, and a similar opinion has been strenuously advocated by other authorities. Not- withstanding this, however, it has, undoubtedly, been repeatedly performed successfully within the last thirty years, as every one familiar with the history of surgery well knows. In a recent communication by Dr. Brainard, ninety- one cases, including two by himself, are given, in which, he affirms, there was no doubt whatever of the extirpation of the entire gland. I should there- fore, in the present state of the science, consider it great folly either to doubt its possibility, or to deny its propriety. That the operation is difficult of execution, requiring the most accurate knowledge of the anatomy of the parts, and the most consummate skill, is certain, and unless the surgeon is fully possessed of these important qualities, failure, if not disgrace, will be sure to attend his efforts. It should be added, however, for the encouragement of all, that it is much easier, in almost every instance, to remove a diseased than a healthy gland of this kind. In the former case, its fibrous envelop is usually so much condensed as to inclose and circumscribe the organ, rendering it thus perfectly distinct and separate; whereas, in the latter, it is a soft, ill-defined mass, which it is extremely difficult, even in the dead subject, to disengage from the surrounding structures by the most patient and cautious dissection. In performing the operation, the patient lies upon a table, on the sound side of his face, with the head and shoulders well elevated. When the tumor is small, not exceeding the volume of an egg, a single incision, extending obliquely down in front of the ear from a short distance above the zygomatic arch of the temporal bone to an inch below the angle of the jaw, will usually 558 DISEASES OF THE MOUTH AND THROAT. afford sufficient space for our purpose; but in all other cases it should be crucial, elliptical, or T-shaped. The form of the incision, however, is of little moment, provided it is large enough to admit of free access to the diseased mass. The flaps having been dissected up in the usual manner, the tumor may next be lifted from its bed, either from above downwards, or, what is better, from below upwards. Whichever plan be adopted, the utmost caution is necessary in liberating the deep-seated parts, on account of the danger of wounding the internal carotid artery and the jugular vein, with their accom- panying nerves. In executing this step of the operation, more reliance should be placed upon the handle of the knife than upon its point, which can hardly be employed, in a situation so deep, narrow, and full of important structures, without the risk of injury. When the connecting tissues are unusually soft or brittle, the tumor may be partly wrenched from its bed with the fingers; but such a proceeding is always objectionable, since it is liable to be followed by undue inflammation. The digastric muscle is frequently expanded over the tumor, and requires division. The extirpation of this organ, for whatever object it may be undertaken, must necessarily be attended with loss of blood; but this is never, or, at least, rarely, very great, if its dislodgement be effected from below upwards instead of in the opposite direction. By this procedure the external carotid will be exposed at an early stage of the dissection, and may, therefore, be readily commanded either by the finger or the ligature. I can see no reason for securing this vessel as a preliminary measure ; for, in the first place, it is not always divided, and, in the second, the expedient is often impracticable on account of the great volume of the tumor. In the latter case, advantage might be derived from compression of the common carotid. The removal of the parotid is always followed by paralysis of the corre- sponding side of the face, in consequence of the division of the motor branch of the seventh pair of nerves. The loss of power may last during life, or it may gradually disappear, at least in part. The resulting inflammation is generally severe, and requires the greatest vigilance of all concerned in the management of the case. The patient may perish from the shock of the operation, from loss of blood, or from inflammation of the throat and larynx. 6. Tumors over the Parotid.—Tumors, principally of the nature of degene- rated lymphatic ganglions, not unfrequently form upon and around the parotid gland. They often acquire a considerable bulk, and, enlarging in different directions, choke and compress the proper substance of the organ, thus caus- ing it to waste and shrink. Excision, under such circumstances, may induce the unwary to suppose that the parotid has been removed, when, in fact, the morbid growth was altogether of an adventitious character. There is reason to believe that many, if not all, of the earlier operations practised upon this region were of this description. I have repeatedly extirpated diseased lym- phatic ganglions from this situation. A few years ago, I removed from a gentleman, aged fifty-eight years, a melanotic tumor, which had attained the volume of a hen's egg, and required a very tedious dissection on account of its cystic structure, and its intimate relations with the surrounding parts. In extirpating morbid growths in this region, care should be taken to guard against injury of the branches of the portio dura, and also of the duct of Steno, the integrity of which should never be disturbed in any case what- ever. The operation should be conducted upon the same priuciples as in excision of the gland itself. 7. Affections of the Duct of Steno.—This canal occasionally suffers in wounds of the face. The proper treatment is to put the edges of the divided structures in their natural relations, and to maintain them thus by several points of the twisted suture, aided by perfect quietude of the cheek. The object is to effect accurate parallelism between the two ends of the divided AFFECTIONS OF THE SALIVARY GLANDS—DUCT OF STENO. 559 *ube, and, when this is done, there is little danger of any untoward occur- a. Earthy concretions are now and then met with in this tube. They are generally of an ovoidal shape, of a whitish color, rough on the surface, and composed of phosphate and carbonate of lime in union with a little animal matter. After having lain dormant for an indefinite period, their presence finally awakens severe pain, and sometimes even a great deal of constitutional excitement. In a case that was under my charge several years ago, in a man, aged thirty-nine, there was excessive swelling of the cheek, with a ridge-like elevation in the course of the excretory tube, and a diffused, erysipelatous discoloration of the skin. The parts were very hard and tender, the jaw was moved with extreme difficulty, and there was high inflammatory fever. Being satisfied that there must be a salivary calculus, I made a free incision into the orifice of the distended duct, on the inside of the mouth, but nothing followed, except a small quantity of a whitish, glutinous substance, intermixed with a few drops of pus. The concretion did not escape until the next day. The pain and swelling rapidly subsided, but for nearly six months the canal con- tinued to be greatly distended, in consequence of the partial closure of its orifice, which required occasional puncture and dilatation to effect a perma- nent cure. When the inflammation caused by the foreign body is very severe, leeches, cataplasms, purgatives, and other antiphlogistic means are indicated. Extrusion is effected as soon as the diagnosis is established, by a free incision into the duct, on the inside of the mouth. Sometimes the calculus presses, as it were, through the orifice of the canal, and in this case the forceps take the place of the knife. b. A fistule of the duct of Steno is often a very grievous affair, and may be caused by wound, ulceration, abscess, or gangrene. Some of the very worst forms of the lesion that I have ever witnessed were produced by sloughing from ptyalism. Such an occurrence is always to be deplored, inasmuch as it often involves great deformity of the features, and irremediable chasms of the soft substance. A fistule of this duct is not ouly unseemly and inconvenient, but it is attended with the loss of a fluid that plays an important part in the ani- mal economy. The principles of treatment are very simple, for they consist merely in changing the direction of the abnormal orifice, and in closing the fissure in the cheek. When the occurrence depends upon a recent wound, all that is, in general, required is the use of the twisted suture, and a compressing band- age; but if some time have elapsed, it becomes necessary, in addition, and as a preliminary step, to pare the edges of the opening, in order to place them in a condition favorable to the adhesive process. In fistule caused by abscess, ulceration, or suppuration, a cure may sometimes be effected by cau- teriziflg the parts with nitrate of silver, acid nitrate of mercury, or a heated probe. A slight eschar is thus formed, and, granulations subsequently spring- ing up, the saliva gradually resumes its natural channel. In the more obsti- nate forms of the affection, the plan suggested by the late Dr. Horner may be adopted, as holding out a fair prospect of success. It is both simple and easy of execution. The external orifice having been previously elongated a little in the direction of the zygomatic muscle, the head is supported upon the breast of an assistant, and a broad wooden spatula is introduced into the mouth, opposite to the site of the fistule. With a large, sharp saddler's punch the whole of the diseased structures, tube and all, are then removed, when the opening in the integuments is immediately closed with the twisted suture. Cold water-dressing is applied until the completion of the union, which usually happens in a few days. When the fistule is very large and ob- stinate, as when it depends upon a loss of substance, autoplasty may become "ecessary. 560 DISEASES OF THE MOUTH AND THROAT. SUBMAXILLARY GLAND. The submaxillary gland, from its protected position, and the manner in which it is isolated by the cervical fascia, is seldom the subject of disease. Of the malignant affections, to which, in common with the parotid, it is liable, scirrhus is the most frequent, though it is in reality extremely rare. The few- cases in which it has hitherto been observed occurred in elderly persons, rather as a secoudary than as a primary malady. In carcinoma of the lower lip, in epulis, and in cephaloma of the lower jaw, it occasionally becomes in- volved during the progress of the original disease, or after this has been removed by operation. Sometimes the gland becomes enlarged and indu- rated from interstitial deposits, caused by the irritation of a tooth, cancer of the tongue, or disease of the surrounding lymphatic ganglions; but such an affection is very different from true scirrhus, and generally subsides with the cessation of the exciting influence. Scirrhus usually begins in the form of a small, hard tumor, which gradu- ally increases in size until it acquires the bulk of a hen's egg, or even of a large orange. It is slow in its progress, has an irregular surface, and is the seat of a constant darting, pricking, or lancinating pain. In time, the adja- cent lymphatic ganglions enlarge, the gland contracts firm adhesions, the integuments ulcerate, and the general health declines, just as in scirrhus in other parts. When the tumor encroaches upon the mouth it interferes with speech and mastication, if not also with deglutition. As the diagnosis cannot always be certainly established between this affec- tion and simple enlargement of the gland, sound judgment imperatively dic- tates the propriety of a thorough investigation of the disease, and the remo- val, if possible, of all sources of irritation, before we resort to so serious an undertaking as an operation. If the enlargement and induration are the re- sult of ordinary causes, the mildest measures will often be sufficient to effect a cure, after attention to this circumstance. The removal of a carious tooth, or a dead piece of jaw, with a few doses of aperient medicine, will generally enable the gland promptly to regain its original characters. When the malady is malignant, excision alone promises any relief, but this, unfortunately, is seldom permanent. The operation necessarily involves the facial artery, and, therefore, requires some degree of dexterity. One incision, extended hori- zontally over the centre of the tumor, in the direction of the lower jaw, will generally suffice. The facial artery will usually be found at the posterior part of the diseased mass, and should always be tied before it is divided. By this procedure the operation is rendered almost bloodless. The sublingual artery and the hypoglossal nerve must be carefully avoided. In separating the gland from its deep connections, the finger and handle of the knife will afford good service. When the tumor is uncommonly large, the horizontal incision is intersected by a vertical one, the two representing the lines of the letter T. Ordinary tumors, as enlarged lymphatic ganglions, occasionally require removal from this region. In general, they yield to anti-strumous remedies, aided by proper regimen ; but when they resist these measures, and give rise to serious symptoms, nothing short of excision will avail. Such an opera- tion is usually sufficiently simple, requiring less skill on the part of the sur- geon than anatomical knowledge. Sometimes the tumor is immovably fixed in its situation, and then, if it be of large size, a tedious and careful dissec- tion becomes necessary. The course which I generally adopt is to make a horizontal incision along the base of the jaw, an assistant holding the facial artery out of the way with a blunt hook In an operation of this kind, a few years ago, the vessel escaped the knife, but secondary hemorrhage ensued after the application of the dressings, apparently from one of the nutrient AFFECTIONS OF THE SALIVARY GLANDS—RANULA. 561 branches of the submaxillary gland. This was readily secured, and the patient soon recovered. Several years ago, I met with a remarkable case of cystic tumor iu the sub- maxillary gland, the patient being a middle-aged, married lady, the mother of several children. It had made its appearance about seventeen years pre- viously, and was somewhat larger than a hen's egg; it was soft and fluctuating, free from pain, and unaccompanied by any enlargement of the subcutaneous veins. Upon being punctured, a thick, viscid fluid escaped, rendering it probable that it consisted merely of altered saliva. Had the patient been willing to submit to an operation, I should have evacuated the contents of the cyst, and injected it with a weak solution of iodine. The excretory duct of the submaxillary gland, like that of the parotid, is not unfrequently the seat of calcareous concretions. They occur in both sexes, chiefly in middle-aged and elderly subjects, though the young are not wholly exempt from them. Their composition is phosphate and carbonate of lime, cemented together by a small quantity of ani- mal matter. A calculus of this description of the left Fig. 356. submaxillary gland, removed from a young Pole, is sketched in fig. 356. It is of a pyriform shape, rough, and of a whitish color; its length is upwards of one inch. Its presence was productive of a great deal of pain and swelling at the side of the tongue, attended, for several weeks, with inability to masticate, and ex- Salivary calculus. cessive difficulty of swallowing. The diagnosis of the case was perplexingly obscure, until the concretion protruded at the orifice of the duct, from which it was finally withdrawn with the thumb and finger. SUBLINGUAL GLAND. The principal disease of the sublingual gland is ranula, a peculiar form of tumor caused by obstruction of its excretory ducts, and the retention of its peculiar secretion. The swelling seldom exceeds the volume of a pigeon's egg; but it may be so large as to encroach seriously upon the surrounding parts, impeding articulation and deglutition, pushing the tongue against the roof of the mouth, displacing the teeth, and bulging out underneath the chin. It has a grayish, translucent aspect, like the belly of a frog, whence its name; is of an irregularly.oval shape, and contains a glairy, ropy fluid, like the white of eggs. Sometimes the contents are thin and watery, sometimes thick and pultaceous, and sometimes, again, of a yellowish, oily nature, similar to the synovial liquor of the joints. Particles of gritty matter, probably a mixture of phosphate and carbonate of lime, are occasionally interspersed through them. Most of the cases of ranula that I have seen occurred in young subjects between the ages of eighteen and thirty. The disease, however, is not pecu- liar to this period of life. It is generally slow in its march, causes little or no suffering, and is unattended with derangement of the general health. Ihese circumstances, together with its singular appearance, and its situation beneath and by the side of the tongue, always serve to distinguish it from other affections. The croaking state of the voice is observed only in cases °f long standing and large bulk, and, as it is liable to attend other diseases tne mouth, is of no diagnostic value. Where any doubt exists, it will be promptly dispelled by the introduction of the exploring needle. It is not difficult to conceive how ranula is produced. It is essentially an encysted tumor. The orifices of the excretory canals of the glands being 'osed, either by direct adhesion, or by the interposition of some adventitious u stance, the proper secretion, instead of passing off as fast as it is furnished, vol. ii___36 562 DISEASES OF THE MOUTH AN.D THROAT. accumulates in the interior of the organ, causing, by its pressure, the absorp- tion of a considerable portion of its substance, and thus forming a tumor which possesses all the properties just assigned to it. The retained fluid itself, as has been seen, undergoes most important changes. The treatment of ranula must depend upon circumstances, as the age and volume of the tumor. In recent cases, it has been proposed to afford relief by removing the obstruction with a probe, frequently introduced into the orifices of the affected ducts; but all such attempts, if not futile, are exceed- ingly tedious and uncertain, and hardly worthy of trial. In my own hands, the most satisfactory results have uniformly attended excision of a portion of the sac, in the form of an oval flap, with a hook and a pair of scissors. The wound soon suppurates, and gradually heals by the granulating process. Some surgeons rely upon the seton; and lately it has been advised to inject the tumor with tincture of iodine, on the same principle as in hydrocele. Both methods are feasible, and usually effective. When the ranula is very bulky, or transformed into a solid, gristly mass, extirpation will be necessary, and it is well to know that the operation is, in general, neither difficult nor dangerous. A few years ago, I dissected out a growth of this kind, fully as large as a hen's egg, from the mouth of a young lady, who had long been the subject of paraplegia and dyspepsia. It was quite hard and solid, of a pale- yellowish color, not unlike a mass of fat, and was productive of no other inconvenience than that which resulted from its bulk. Making a longitudinal incision along the side of the tongue, the flaps of mucous membrane were reflected to each side, when the tumor was easily enucleated with the handle of the scalpel. The parts speedily healed, and there was no return of disease. The sublingual gland is liable to calculous formations, but the occurrence is extremely rare. I have seen but one specimen of the kind, which I removed from a man, aged fifty-four, after it had caused, for several weeks, severe local distress, attended with great difficulty in moving the tongue. Pare met with a case of ranula in which he found five of these concretions, the largest of which was as big as an almond. The irritation occasioned by their presence had produced an immense abscess under the tongue. Carcinoma of this gland is occasionally observed, possessing all the cha- racteristic features of this disease Fig. 357. as it occurs jn other parts of the body. The affection is very un- common, and I have seen only one case of it. The patient was a laborer, aged fifty-six, who had always been in good health up to May, 1858, when he noticed a swelling on each side of the mid- dle line, just below the tongue. When he came to the Jefferson College Clinic the following No- vember, the tumors were exces- sively hard, and the size that of a small almond; the pain was of a sharp, shooting character, and the movements of the tongue were much restrained. Excision being effected, a portion of the growth was subjected to micro- scopic inspection by Dr. Packard, who kindly furnished me with the annexed sketch, fig. 357, of its minute structure. The disease reappeared in three weeks, and gradually extende( Scirrhus of the sublingual gland; minute structure. Magnified 472 diameters. AFFECTIONS OF THE PALATE — CLEFT PALATE. 563 t0 the gums and jaw, forming a large tumor, exhibiting all the external marks of scirrhus. The glands along the base of the jaw were enlarged, and the general health was becoming rapidly undermined. SECT. IV.—AFFECTIONS OF THE PALATE. The principal surgical affections of the palate are wounds, inflammation, ulceration, and congenital deficiencies, analogous to those of the upper lip. 1. Wounds.—Wounds of the palate, both hard and soft, may be incised, lacerated, punctured, or gunshot, and usually exhibit the same phenomena as similar lesions in other parts of the body. Considerable hemorrhage is some- times present, but this commonly ceases of its own accord, or is easily arrested by astringent lotions. When there is no loss of substance, and, consequently, little or no gaping, mere rest of the palate for a few days will generally be sufficient to effect a cure; when the reverse is the case, the interrupted suture may be necessary, the principle on which it is introduced being the same as in the operation for cleft-palate described below. 2. Inflammation.—Inflammation of the soft palate is usually associated with inflammation of the uvula and tonsils; it may be common or specific, and the treatment, consequently, must be modified according to the nature of the complaint. In the ordinary form of the disease, the principal remedies are purgatives, leeches to the neck, astringent gargles, and the application of the nitrate of silver; in the specific, these remedies are conjoined with con- stitutional treatment, embracing the milder preparations of mercury, and the iodide of potassium. 3. Ulceration.—Ulceration of the palate is generally dependent upon a syphilitic taint of the system. The sores, at first superficial, often extend through the entire thickness of the curtain and arches of the palate, and usually exhibit a foul, unhealthy aspect, with a copper-colored appearance of the surrounding surface. The breath is fetid, the patient is obliged to clear his throat frequently of inspissated mucus, and there is derangement of the general health, with, perhaps, syphilitic eruptions of the skin, iritis, and other evidences of constitutional contamination. The diagnosis is determined mainly by the history of the case, and by the peculiar features of the ulcer- ative process. The treatment is decidedly constitutional; aided, if the patient be robust, by venesection and leeching. Excitement having been subdued, a mild course of mercury is instituted, and the sores are touched effectually once a day with the dilute acid nitrate of mercury, nitrate of silver, or sul- phate of copper. The hard palate may suffer in the same manner as the soft. The worst form of ulcer usually met with occurs in children and young persons, as the result of a strumous, syphilitic, or mercurio-syphilitic taint of the system. The patient looks pale and sickly, aud the disease manifests an obstinate dis- position to spread, sparing neither mucous membrane, fibrous structure, nor bone, which are often destroyed to a most serious extent. The mischief thus produced can frequently be repaired only by artificial means. 4. Cleft Palate.—The palate is subject to congenital deficiency, analogous to hare-lip, and bifid spine, with which, especially the former, it not unfre- quently co-exists. The defect occurs in various degrees, being sometimes very trifling, at other times exceedingly great. In the most simple form, which is, however, not the most common, it presents itself as a small, tri- angular fissure, illustrated in fig. 358, extending through the uvula and the posterior portion of the velum, the remainder of the palate being perfectly natural. Sometimes, indeed, the uvula alone is affected. In a second series of cases, the cleft involves the whole of the soft palate, or this structure, and, 564 DISEASES OF THE MOUTH AND THROAT. Cleft palate. perhaps, a part of the palhte bone. In a third variety of form, both the soft and hard parts are deficient, the slit reaching from one end of the palate to the other. Fourthly, the cleft is occasionally as- sociated with a cleft in the alveolar process of the maxillary bone, on one or both sides, and even with hare-lip. Finally, cases occur, though rarely, in which the hard palate alone is implicated. The width of the gap, like its length, is subject to considerable diversity. Thus, it may not ex- ceed a few lines, or it may be so great as to con- stitute a hopeless deformity. When it is limited to the soft palate, it is always of a triangular shape, the base being below, and the apex above. When it involves both the soft structure and the roof of the mouth, it is generally of an oblong quadrilateral figure, the nasal septum extending along its centre, and dividing it, as it were, into two equal parts. The edges of the fissure, what- ever may be its size and form, are always rounded off, and of a firm, fibrous consistence, being often pared with much difficulty. The effect of this condition of the palate, during infancy, is interference with suction and deglutition, and afterwards with mastication and articula- tion. The degree of the impediment is generally in proportion to the extent of the cleft. In the more severe forms, much of the food passes into the nose, where, causing irritation, it excites sneezing, inflammation, and even ulceration. From the imperfect control which such persons have over the muscles of the palate, both fluids and solids are very lia- ble to descend into the wind- pipe. The speech is guttural and nasal, and frequently so indistinct as to render it, in great degree, incomprehensi- ble. The milder forms alone of this affection admit of cure by operation. When the gap is very wide, or extends the en- tire length of the palate and mouth, the only thing that ean be done, in the generality of cases, is to recommend the use of an obturator, which, by clos- ing the opening between the mouth and nose, will enable the individual to masticate and swallow with more facility, and also somewhat improve his speech. Such a contrivance, of which fig. 359 conveys 8 sufficiently accurate idea, may be readily supplied, with or without teeth, by any ingenious dentist. Its great requisites are lightness and accurate adaptation. When the case is a suitable one for surgical interference, the operation is not performed at once, but, instead of this, the patient is subjected to a course Obturator for the palate. AFFECTIONS OF THE PALATE — CLEFT PALATE. 565 of preliminary training, to enable him to bear the necessary manipulations. With this view, the palate is frequently touched with the finger, or rubbed with a toothbrush, probe, or spoon, until it no longer resents the contact of the foreign body, but is perfectly calm and quiet under the most protracted procedure. This treatment may occupy several weeks, or even a longer time, depending upon the irritability of the parts, and the courage of the patient. But this, important as it is, is not all. Another point, equally necessary, is the co-operation of the patient; without which, success will be entirely out of the question. The operation has occasionally been performed upon sub- jects under twelve years; but, in general, it is best to wait until after the age of fifteen. Even then, it should not be attempted unless there is the strongest reason to believe that the individual will be entirely passive during the per- plexing and fatiguing ordeal to which he is obliged to submit. It is hardly necessary to add that, at the time of the operation, he should be perfectly well and free from cough. The operation, technically called staphylorraphy, may be considered as con- sisting of three stages. In the first, the surgeon pares the edges of the fissure; in the second, he introduces the requisite number of sutures; and, in the last, he ties the ligatures. The patient sitting on a chair with a firm back, his head is supported upon the breast of an assistant, and held in such a manner as to allow the light to fall in a full stream upon the palate. The jaws being widely sepa- rated, and the tongue duly depressed, either by the patient's own efforts, or by another assistant, the first stage of the operation is begun. The most suitable instruments, according to my experience, for seizing and paring the parts, are a pair of long, slender forceps, and a knife similar to Beer's cata- ract knife, only much longer in the handle. If the fissure is very wide, as little of the edges should be removed as possible; but when the reverse is the case, a piece not less than a line in breadth is sliced off on each side. The knife is entered at the upper angle of the cleft, and drawn steadily down- wards, until it cuts itself out below. The process is then repeated on the opposite margin, the forceps being employed, meanwhile, for putting the parts gently on the stretch. Some bleeding necessarily attends this stage of the operation, but this is commonly over in a few minutes, and should never be treated with astringents, as they have a tendency to impair adhesive action. A respite is now afforded, that the patient may recover from his fatigue, and regain his self-possession, which, although this part of the operation is neither painful nor protracted, is often severely tried. The second stage of the operation consists in introducing the sutures, of which three, placed equidistant from each other, are generally sufficient. If the refreshing of the edges of the fissure was troublesome, the arrangement of the sutures is still more so. In truth, it may be regarded as the most difficult part of the whole procedure. It is executed with a needle, of the size and shape represented in fig. 360, armed with a well-waxed silk thread, Fig. 360. The author's forceps. °r, what is far preferable, silver wire, and held in the jaws of a pair of for- ceps, constructed for the purpose. The oue which I am in the habit of using 566 DISEASES OF THE MOUTH AND THROAT. is here delineated, and is an unexceptionable instrument. The forceps of Schwerdt, seen in fig. 361, if properly constructed, are also well adapted to Fig. 361. the object. The first suture is introduced at the inferior extremity of the cleft, the needle being carriejl across from left to right, entering aud issuing nearly a quarter of an inch from the abraded margin. The next suture is applied near the middle of the gap, and the third within a few lines of the superior angle. During their introduction, the palate is rendered somewhat tense by grasping the uvula with a pair of forceps, and as soon as the needle has transfixed the parts, it is seized at its point, drawn out, and reinserted into the instrument. The ends of each ligature are brought out at the cor- ners of the mouth, where they are held by an assistant. When the patient is sufficiently docile, this stage of the operation is neither fatiguing, protracted, nor painful. The arrangement of the ligatures is exhibited in fig. 362. Situation of the sutures in staphylorraphy. Showing the manner in which the sutures are tied. All that now remains to be done is to fasten the sutures, and this is, un- doubtedly, one of the most delicate steps of the whole procedure. Taking hold of the long ends of the inferior thread, as they lie at the corners of the mouth, they are tied into a reef-knot, and cut off within a line of its surface. The other sutures are then secured successively in the same manner, the upper one being always tied last. These appearances are exhibited in fig. 363. If the ligatures have been well waxed previously to their introduction, they can generally be easily tied with the fingers alone, but when this precaution has been neglected, or the gap is inordinately wide, the loop may slip unless held with the forceps until the knot is completed. If wire be used, the ends may be fastened by torsion or with small shot. The same rules are adopted here in regard to the approximation of the edges of the fissure as in hare-hp; care being taken, on the one hand, that it is not too close, and, on the other, that it is not too slight. In paring the edges of the fissure, as well as in the subsequent steps of the operation, the sponge-mop will generally afford useful aid in clearing away AFFECTIONS OF THE PALATE—CLEFT PALATE. 567 Fig. 364. blood and mncus. At least two such instruments should be at hand in every undertaking of the kind. In most of the operations performed for the cure of this defect, it is neces- sary, as suggested by Mr. Fergusson, to divide the palato-pharyngeal and elevator muscles, ou account of the resistance which they offer to the approxi- mation of the edges of the fissure. When the chasm is unusually large, or the irritability of the palate very great, this should always be done immedi- ately after the process of abrasion ; but under opposite circumstances it may advantageously be postponed until the stitching has been done, and in the more simple forms of the affection, it may, as I know from experience, be very properly omitted altogether. The division is easily effected with the knife used for paring the edges of the fissure, the parts being previously put, if necessary, on the stretch with a pair of forceps. When the uvula is abuormally long, it may be advantageously retrenched at the close of the operation; and occasionally I have found it convenient to stitch the opposite halves together, in order to insure their more accurate adhesion. The operation being over, the patient sits up, or lies down, as he may find it most agreeable, absolute recumbency being rarely necessary. The great point is to keep the parts perfectly at rest; hence, talking, laughing, hawk- ing, spitting, coughing, and sneezing, are to be most carefully avoided. The diet must be perfectly bland and simple, yet sufficiently nourishing ; consisting entirely, until the adhesive process is pretty well advanced, of ice water, lemonade, thin custard, thickened milk, and soft jelly; not swallowed, but allowed to trickle down the throat, as often as the necessities of the case may seem to demand. If the resulting inflammation be so severe as to be likely to mar success, blood is taken from the arm, or by leeches from the base of the jaw, and the bowels are freely opened by enemata. The sutures are not disturbed as long as they appear to do good ; gene- rally they are not removed before the fifth clay, and the inferior one often not until twenty-four hours later. If the union is imperfect, as evinced by the gaping between the sutures, either additional stitches are employed, or an attempt is made to effect closure by the repeated, but gentle application of the nitrate of silver. If it fail entirely, the operation is re- peated, time being afforded the parts to recover from the shock and irritation of the first. Some- times a small gap, as in fig. 364, remains at the upper angle of the wound, which nothing can close. Staphylorraphy was first performed by Roux, of Paris, early in the present century. Since then it has been repeated by numerous other practitioners, and now ranks among the established operations in surgery. In this country, the names of the two Warrens, Stevens, Hosack, Smith, Mettauer, Gibson, Miitter, Pancoast, and others, are honorably associated with it, either on account of their successful exploits, or their invention and application of useful instruments. When the fissure involves the hard palate alone, it may occasionally be closed, provided it be very narrow, by dissecting up a flap of mucous membrane on each side, between the edge of the chasm and the alveolar process of the jaw, and then stitching the parts together with several points of the inter- rupted suture, as in the ordinary operation. A similar procedure may be necessary when the roof of the mouth has been perforated by disease or acci- dent. Upwards of twenty years ago I performed an operation of this kind Unclosed fissure in the palate after staphylorraphy. 568 DISEASES OF THE MOUTH AND THROAT. upon a young gentleman, since deceased, with the most satisfactory results, The opening was fully half an inch in diameter, and the union was perfect in less than a week. Dr. J. M. Warren, to whom the credit of devising the operation is usually ascribed, has also performed it successfully. The nature of the procedure will readily be understood by a reference to figs. 365 and 3GG. Fig. 365. Fissure of the hard palate. Fissure of the hard palate, closed by suture. The acquisition of the power of speech after staphylorraphy is generally very slow; a circumstance of which the patient and his friends should be fully apprised beforehand, otherwise it may lead to sad disappointment and even reproach. Much may be done, in every case, by a regular, systematic course of training, persisted in, if necessary, for several years. Abscess of the soft palate is not uncommon, and may exist by itself or in union with suppuration of the tonsils. Indeed, there is reason to believe that the former is often mistaken for the latter, owing to the intimate connection of the two organs, and the fact that inflammation of the one is extremely prone to extend to the other. The treatment is the same as in tonsillitis, au early and free incision being made to let out the matter. Solid, semi-solid, and cystic tumors are liable to form in the soft palate, and may acquire such a bulk as seriously to impede mastication, deglutition, and respiration. Perhaps the most common of these growths is the recurring fibroid, of a pale yellowish appearance, and of a tolerably firm consistence, its intimate structure being of a wavy, fibrous nature, with here and there an oil cell. It is sometimes surrounded by a distinct cyst, and generally returns soon after extirpation. Malignant disease, properly so called, of the palate, is very uncommon. The proper treatment of these various formations is early excision, and the procedure will be greatly facilitated if the tumor be previously seized and drawn forwards with a volsella, or stout hook. No apprehension need be entertained respecting hemorrhage, as no large vessels are in the way. Should bleeding prove troublesome, recourse must be had to styptics, and, if need be, to the actual cautery. SECT. V.—AFFECTIONS OF THE TONSILS. The diseases of the tonsils are few and simple, consisting mainly of inflam- mation and hypertrophy. Scirrhus and encephaloid have been noticed in them, but never, or, at all events, very rarely, as independent affections. I" all the recorded cases of which I have any knowledge, they were associated with similar formations in other parts of the body. To obtain a good view of these bodies, the patient is seated in a strong light, the mouth being opened as widely as possible, and the tougue depressed Fig. 366. AFFECTIONS OF THE TONSILS. 569 Fig. 367. Tongue depressors. with a book-folder, a wooden spatula, the handle of a spoon, or, what I generally prefer, a common grooved director. In chronic disease, the latter instrument may be advantageously used for un- covering the affected parts, by lifting off the anterior arch of the palate, and also for ascertain- ing the degree of their consistence. Holding the tongue perfectly quiet, while the patient is taking a long inspiration, will bring the tonsils fully into view, and at the same time prevent the unpleasant retching so liable to follow the contact of a foreign substance. When the tongue is unusually unman- ageable, as it often is in children, aud even in adults, the best depressor is the one represented in fig. 367. The instrument, depicted in fig. 255, and invented by Dr. Church, of New York, will be found to be of great assistance in tedious opera- tions about the mouth, or when it is necessary to make unusually careful examinations of the throat, depressing not only the tongue, but also separating the jaws. In acute as well as in chronic affections, it is often necessary to bring our remedies in immediate contact with the tonsils, gargling, as it is called, being in most cases either ineffectual, or wholly inadmissible. The articles most commonly employed are the tincture of iodine and nitrate of silver, either in substance or solution. Lotions, of whatever description, should be applied by means of a mop, consisting of a piece of soft sponge, about four lines in diameter, and secured to the end of a thin cylinder of wood, eight inches long. The sponge, being thoroughly wet, but not distended, with the fluid, and the tongue depressed in the man- ner above directed, is passed down into the throat, and pressed gently, but effectually, against every portion of the suffering surface, not only of the tonsils, but of the uvula and the arches of the palate, which, as will presently be seen, generally par- ticipate in the disease. Solid substances, as sulphate of copper and nitrate of silver, are best applied in a long quill, or special carrier, the end being previously rounded off with a knife. The inhalation of the vapor of hot water, either simple or medicated, may often be used with immense benefit in affections of the tonsils, palate, fauces, larynx, and Eusta- chian tubes, and may readily be accomplished with a very cheap and simple apparatus, as that, for example, repre- sented in fig. 368. The materials of which it consists are, a large glass bottle with a wide mouth, a soft, closely-fit- ting cork, and two glass tubes, the one straight, and in- tended to convey the external air below the surface of the liquid, the other curved, and intended to serve as a mouth- piece, or inhaler properly so called. The articles commonly used for medicating the water are laudanum, spirits of camphor, creasote, guaiacum, and iodine, the latter two in the form of tincture. ^unification of the tonsils is occasionally performed for the relief of inflam- IJlatory engorgement. The operation is effected by drawing a sharp bistoury, guarded to within a line of its point, rapidly across the mucous membrane in 'a a dozen different directions. Discharge is encouraged by gargling freely with warm water. If clots form irr the incisions, they are removed with the moP, huger, or director. Scarification of the tonsils and palate, although a Fig. 368. Inhaler. 2969 570 DISEASES OF THE MOUTH AND THROAT. favorite practice with some, has usually disappointed my expectations, and I, therefore, seldom employ it, except when there is inordinate oedema of the submucous cellular tissue. Even in such cases, however, more prompt relief will generally follow the application of the dilute tincture of iodine, or a strong solution of nitrate of silver. When the swelling is great and urgent, a few tolerably deep incisions will be advantageous. 1. Acute Tonsillitis.—Acute inflammation of the tonsils is exceedingly common, especially in young persons of a delicate, strumous constitution, and is often induced by the most trivial causes, of which the most frequent is exposure to cold. It occurs at all periods of life, in both sexes, and at all seasons of the year, being most common, however, in winter and spring. The attack is generally rather sudden, and is apt, if unchecked, to proceed with considerable rapidity. To a sense of soreness and stiffness in the throat, with a disagreeable, but indescribable, feeling, which marks the stage of invasion, are soon superadded great difficulty of swallowing, severe pain, and a con- stant desire to clear the fauces of mucus, which is always very ropy, adhesive, and abundant, and the effort to detach which constitutes a source of real suffer- ing. The pain soon extends to the face, ears, and neck, and, the mechanical obstruction increasing, the breathing becomes much embarrassed, sometimes, indeed, almost to the extent of suffocation. If the patient attempts to drink, the fluid regurgitates by the nose, and often nearly strangles him; his head is thrown backwards, in order that the mouth and larynx may be brought more into a straight line; and, during sleep, he snores with a loud noise. The lymphatic ganglions, at the base of the jaw, are frequently swollen and tender; and there are few cases of any severity in which there is not high fever. On inspecting the mouth, which is often done with great difficulty, the tonsils are found to be very much enlarged, and of a deep, almost fiery red color, with here and there a speck, patch, or streak of firmly adherent lymph. From its peculiar color and shape, this substance frequently gives the glands an ulcer- ated appearance ; but a careful examination soon serves to dispel the illusion The arches of the palate, uvula, fauces, and root of the tongue, always par- ticipate in the morbid action, being red, tumid, and painful. Generally both tonsils are involved, though comparatively seldom in the same degree. The treatment of acute tonsillitis is by antiphlogistics, early and vigorously employed, aud persisted in until there is decided abatement of morbid action. When robustness of the system obtains, blood is taken by a large orifice from the arra, and by leeches from the neck, directly opposite the inflamed organs; the bowels are thoroughly evacuated; and, if there be much mechanical ob- struction, a brisk emetic is administered. When the disease is very mild, or at its inception, prompt relief generally follows the use of the foot-bath, a full dose of Dover's powder, and the wet towel round the neck. In violent cases, besides the means already mentioned, scarification and even incision may be required, to remove tension and vascular engorgement. As to gargles, little reliance is to be placed upon any of them in any form of the disease, or in any of its stages, owing to the difficulty of bringing them in contact with the inflamed surfaces. When such remedies are indicated, it will always be better to mop the parts well with the dilute tincture of iodine, or to touch them very gently with the solid nitrate of silver. The former application is particularly beneficial in the cedematous variety of tonsillitis, in which it often acts like a charm in relieving the mechanical obstruction caused by effused fluids. The proper proportions, except in young children and very delicate persons, are equal parts of the tincture and of alcohol. One application fre- quently suffices, but sometimes several are required, at intervals of ten or twelve hours. When the inflammation is diffuse and urgent, warm applications to the neck, in the form of thick cataplasms, will be serviceable. When the tumefaction is very great, the tonsils may nearly fill up the TONSILS — GANGRENE — ULCERATION — ABSCESS. 511 fauces, and encroach so much upon the epiglottis as to interfere materially with respiration. In such an emergency, prompt relief must be afforded, or the patient may perish from suffocation. The plan to be pursued is to excise a portion of the affected glands at the middle line; or, this failing, to open the larynx. To let a man die from such a cause is hardly less criminal than to kill him. If the operation be delayed too long, death may occur from the shock sustained by the system, in consequence of the struggles to maintain the respiratory functions. 2. Gangrene.—Gangrene of the tonsils is most frequently met with in con- nection with scarlatina, smallpox, and syphilis; as an event of ordinary in- flammation, it is extremely rare. A fetid state of the breath, a foul, livid appearance of the affected glands, and a dark, sanious discharge from the throat, with difficulty of deglutition, severe pain, and high fever, are the cha- racteristic symptoms. The surrounding structures, as the uvula and arches of the palate, usually participate in the mischief, exhibiting similar appear- ances, and augmenting the suffering. The treatment, as a general rule, is by stimulants; by brandy and quinine internally, and by the acid nitrate of mer- cury, nitrate of silver, or sulphate of copper locally. If the gangrene has been induced by syphilis, for which a course of mercury has been employed, the remedy is at once suspended, lest the destructive process be promoted instead of diminished. 3. Ulceration.—Ulcers, both common and specific, are liable to occur in the tonsils, or in these organs, the arches of the palate, and the mucous mem- brane of the fauces. The former are rare, and usually recognize derange- ment of the digestive apparatus as their exciting cause ; they are small, irregu- lar, superficial, and associated with a reddish, flabby condition of the throat, with a tendency to the formation of aphthae or plastic deposits. Removal of the exciting cause, by purgatives and alterants, is generally sufficient for their cure; aided, if necessary, by light applications of the nitrate of silver. Of the venereal ulcer of the tonsils there are several varieties, as the exca- vated, the diphtheritic, and phagedenic; but, as these have already been de- scribed, no particular account of them is required here. 4. Abscess.—Acute tonsillitis now and then terminates in abscess; the matter is seldom abundant, but often very offensive, and the symptoms are usually very urgent, from the mechanical obstruction caused by the inflamed and tumefied organs. The formation of pus is generally ushered in by an aggravation of the local and constitutional distress, as throbbing pain, livid discoloration of the mucous membrane, and rapid increase of swelling, to- gether with rigors and high fever. On looking into the mouth, the tonsils, especially if both suffer in an equal degree, are found to touch each other at the middle line, leaving, perhaps, merely a small interval at their upper ex- tremity, which is itself often nearly entirely closed by the enlarged and pendu- lous uvula. The patient breathes with immense difficulty, and appears as if he were in imminent danger of suffocation. The matter generally forms within the first five days after the commencement of the attack, and, in rare cases, even considerably earlier. It may form simultaneously in both glands, or be limited to one. The treatment is rigorously antiphlogistic; and spontaneous evacuation, which might permit the matter to fall into the larynx, and so cause suffoca- tion, is anticipated by early and free incision. A long, straight, sharp-pointed bistoury, wrapped to within a third of an inch of its extremity, is passed into the mouth, with the back towards the tongue, until it reaches the swelling, 'uto the centre of which it is thrust with the requisite degree of force, the opening being afterwards enlarged to the desired extent by inclining the in- strument over towards the median line. The head of the patient is held urmly by an assistant, lest he should push it forwards or to either side, and 572 DISEASES OF THE MOUTH AND THROAT. so endanger the internal carotid artery. For the same reason, the knife is kept away from the angle of the jaw. In the natural state, the tonsil is at least five or six lines from this vessel; but, when the gland is much tumefied, the distance between them is sensibly diminished. Smart bleeding, from the division of the tonsillary artery, occasionally follows the operation, and is generally decidedly advantageous in allaying inflammation; it commonly ceases in a few minutes, and is always, if necessary, easily arrested by astrin- gent gargles. 5. Hypertrophy.—Hypertrophy or chronic enlargement of the tonsils, represented in fig. 369, is exceedingly common, and is met with almost ex- clusively in young, strumous subjects. I Fig. 369. have seen it repeatedly in children under three years of age, and in several instances that have fallen under my observation, there was every reason to believe that it was con- genital, the affection having been noticed within a few days after birth. It rarely makes its appearance after the thirtieth year, unless it has existed earlier in life, and been only partially relieved. Old per- sons are entirely exempt from it. From its history and progress, it is obvious that it is always of a scrofulous nature. It oc- curs, at least so far as my experience ex- tends, with equal frequency in both sexes. Enlarged tonsils. The disease usually takes place slowly; and, although both glands are commonly involved, it is not often that they are both affected in the same degree. Generally speaking, they enlarge in every direction, and as they do so they encroach more or less upon the surrounding parts, as the base of the tongue, the arches of the palate, the larynx, and Eustachian tubes. Not unfrequently they touch each other at the middle line, leaving, perhaps, merely a small chink above and below for the passage of the air. Their color and consist- ence are liable to considerable diversity. In young subjects they are usually quite red, and so soft as to give way under the slightest pressure and traction. At this age I have occasionally met with a peculiar foliaceous arrangement of the gland, its substance being spread out in distinct strata, of a red color, very vascular, and remarkably friable. In cases of long standing, and, in- deed, as a general rule, the organs are of a bluish, pink complexion, and of a tough, firm consistence. At other times, again, although this is rare, they are almost of scirrhous hardness. Their follicles are Fig. 370. ordinarily much enlarged, and often contain plugs of lymph, inspissated mucus, curdy matter, or calcareous concretions. When the orifices of these little bodies are very patulous, they impart to the surface of the hyper- trophied tonsil the appearance of the lid of a pepper- box, as seen in fig. 370, from a clinical case. The shape of the gland is generally irregularly elongated, but now and then it is almost globular. The uvula, the arches Hypertrophy of the of the palate, and the mucous membrane of the fauces, tonsil. almost invariably participate in the diseased action. It is questionable whether the tonsils would ever he- come chronically enlarged, or, at any rate, whether they would remain long in this condition, if there were not always a constitutional predisposition to it. It has already been remarked that the affection is of a strumous character, and it certainly does not, in the present state of pathological science, require HYPERTROPHY OF THE TONSILS. 573 any proof to demonstrate the fact. The experience of every practitioner furnishes daily illustrations of its truth. When this predisposition exists, the slightest exciting cause, as exposure to cold, suppression of the cutaneous perspiration, and derangement of the digestive apparatus, will be sufficient to produce an attack of the disease. The frequent recurrence of the act maintains and re-excites the inflammation and the effusion of lymph, which are the immediate causes of the enlargement and induration from which the affection derives its distinctive features. Whether there is often, or ever, any deposit of tubercular matter in the interstices of the hypertrophied organs has not been demonstrated ; but that the enlarged follicles occasionally contain a substance of this description, or of one very closely resembling it, the results of my examinations abundantly attest. Enlargement of the tonsils, unless considerable, is not necessarily attended with any unpleasant symptoms; the only inconvenience experienced being, perhaps, a sense of fulness and occasional soreness in the throat. These effects are always aggravated whenever the patient takes cold, or labors under derangement of the general health. In the more confirmed forms of hyper- trophy, however, the local suffering is always proportionately great, being such as necessarily arises from the mechanical obstruction from the enlarged glands. The voice is husky, nasal, and disagreeable; the respiration is im- peded; and there is an uneasy feeling in the throat, with a reraarkable ten- dency to inflammation. When the tonsils are so large as almost to approach each other at the middle, the distress is greatly aggravated. During sleep a low moaning is usually present, accompanied with snoring and stertorous breathing, and the head is strongly retracted, so as to bring the mouth on a line with the windpipe, evidently for the purpose of facilitating the ingress of the air. In cases of very long standing, distortion of the features is apt to arise; the nostrils are habitually dilated ; the mouth is half open ; and the whole countenance has a dull, vague expression. Partial deafness, from ob- struction of the Eustachian tube, occasionally exists; and the chest is liable to become arched behind, flattened in front, and contracted at the sides. This deformity is sometimes present in a surprising degree at an early period of life. I have seen several well-marked examples of it in children under six years of age.' A great variety of means has been tried for arresting the progress of this affection, and for promoting the absorption of the interstitial deposits of the glands, so as to restore them to their primitive condition. Yery few of them, however, are found to have the desired effect, especially when the disease is fully established. The remedies most worthy of reliance are iodine and kindred articles, administered internally, and applied to the affected parts. The tincture of iodine, with an equal quantity of alcohol, and a weak solu- tion of the iodide of iron, applied once every other day by means of a soft amp, are both valuable sorbefacients, and may occasionally be used with ad- vantage. The nitrate of silver is also beneficial, especially in its fluid form. Ihe proper strength, in children, is from fifteen to twenty grains of the salt to the ounce of water; in adults, at least double that. Numerous and repeated punctures with the point of a delicate bistoury have sometimes been attended with good results in my hands: they serve to disgorge the capillary vessels, and to promote the absorption of effused lymph ; two most important indications in the treatment. Lately frequent compression of the enlarged gland with the finger has been suggested; but the trials that I have made with it have disappointed my expectations. With these means may be con- joined, sometimes with advantage, the application of leeches, embrocations, wia stimulating unguents to the neck. In all cases, due attention is paid to le state of the general system ; the diet is carefully regulated; the bowels 574 DISEASES OF THE MOUTH AND THROAT. are maintained in a soluble condition; and, when there is any evidence of debility, tonics, especially iron and quinine, are freely exhibited. The above treatment failing, as, unfortunately, it is too apt to do, the only way of getting rid of the enlarged bodies is to excise them, or, rather, a con- siderable portion of them, in order to enable the air to enter the lungs with its accustomed freedom. The operation performed with this view consists in seizing each gland with a double hook, fig. 371, and cutting off all that part of it which lies exterior to the arches of the palate with a curved, probe- Fig. 371. Volsella. pointed bistoury, seen in fig. 372. The instrument is carried from below up- wards, with the back towards the tongue, excision being effected almost in Probe-pointed bistoury. an instant, with hardly any pain or hemorrhage. The hook and knife, with which it is my custom to perform the operation, and which are here repre- sented, are altogether superior to the tonsillotomes of Physick, Gibson, Fah- nestock, and other surgeons. They are each about eight inches in length. The great objection to the tonsillotome is that the ring, at its distal extremity, is rarely sufficiently large to receive the hypertrophied gland in its embrace, so as to allow us to cut off as much as is necessary. In children I have occa- sionally used the instrument with excellent effect. The neatest tonsillotome is that of Fahnestock, represented in fig. 373. When both tonsils require removal, and the surgeon is not ambidextrous, the operation may be per- formed very easily with the right hand. Excision of the tonsils is easy enough in the adult, but in the child it is often attended with immense difficulty, on account of his cries and struggles. Indeed, there are few operations which, under such circumstances, are more annoying and perplexing than this. To overcome this difficulty the best plan is to wrap up the child firmly in an apron and to have hira well supported by assistants ; or, what I prefer, to administer a small quantity of chloroform, just enough to produce partial insensibility. In this manner one tonsil being removed, the little patient is allowed time to clear his throat, when, the agent being again inhaled, the operation is completed by excising the other. The best depressor of the tongue is the surgeon's index finger. The interposi- tion of a piece of cork between the teeth is an awkward and unnecessary proceeding. The operation above described, although generally free from hemorrhage, is not so always. In 1849 I performed it upon a boy, aged eleven years, in whom the bleeding was not only copious, but absolutely alarming. Both tonsils were much enlarged, and were accordingly excised ; the right bled hardly any, but from the left the blood issued from numerous points, and was spat up every few seconds in large mouthfuls. Much also was swallowed, and afterwards ejected by vomiting. The entire quantity amounted, I am satisfied, to nearj SEROUS CYSTS OF THE TONSILS — POLYPS. 575 twenty ounces. The boy, although for a short time very pale, feeble, and nauseated, soon recovered from the effects of the operation. The remedies used for arresting the hemorrhage were, first, sulphate of copper, and afterwards powdered alum, applied freely by means of a sponge-mop, ice to the neck, and a full dose of laudanum, with thorough elevation of the head, and exposure of the body to a current of cold air. The lad slept well the following night, without any recur- rence of the bleeding. There was no evidence of a he- morrhagic diathesis. An equally remarkable case of bleeding from excision of one of the tonsils fell, many years ago, under the observation of my friend and former colleague, Professor Cobb, in a youth of fourteen. The portion of gland removed did not exceed the volume of a pigeon's egg; but the flow of blood was so copious as almost to induce syncope. Since the publication of the first edition of this work, I have met with two other cases of severe bleeding after this operation ; one in a youth of eighteen, and the other in a man of thirty, neither of them presenting any- thing peculiar prior to the excision. The hemorrhage was quite copious, but finally yielded to the application of the tincture of the chloride of iron, aided by a full anodyne. The man lost upwards of a quart of blood. When the hemorrhage proceeds from the division of the tonsillary artery, it may be necessary, in the event of the failure of styptics, to seize and compress the bleeding orifice with a light pair of forceps, retained temporarily in the mouth. Erichsen refers to a case in which the hemorrhage was effectually arrested, after the failure of all other means, by a gargle of spirits of turpentine sus- pended in mucilage. Prudence dictates the propriety, after removal of the tonsils, of confining the patient for several days to a moderately warm apartment; at all events, he should avoid the cold air, and, if necessary, on account of the se- verity of the resulting inflammation, he should take an active cathartic. For want of this precaution several lives have been lost that might otherwise have been saved. 6. Serous Cysts—The tonsil is occasionally, though very rarely, the seat of a serous cyst, filled with a thin, watery fluid, or a thick, ropy substance, resembling the white of eggs. The tumor is usually small, and may be suspected to exist when the gland has a whitish, trans- ient appearance, with a sense of fluctuation on the application of the finger. ^o pain attends its formation, and the only inconvenience which it produces wises from its mechanical obstruction. The treatment is by incision, followed oy the application of nitrate of silver, tincture of iodine, or chromic acid. 7. Polyps.—The tonsils are now and then the seat of a fibrous polyp. A case ot this kind came under my observation, in 1860, in a man, aged thirty- uve years, affected with chronic asthma. The tumor, which was of a whitish sped, and of the shape of the kidney, was very firm aud dense, of a fibrous ttot i5\ UneS in lenSth> and attached, by a hard, narrow pedicle, about e tweltth of an inch long, to the centre of the right tonsil, which was other- «e apparently quite sound. The man had not been aware of the presence 01 tlle t"mor until its removal. Fahnestock's tonsillo- tome. 576 DISEASES OF THE MOUTH AND THROAT. 8. Chronic Abscess.—The chronic abscess, as it is termed, sometimes forms in the tonsil, as a result, evidently, of the strumous diathesis. In the few cases in which I have seen it, it occurred in young persons, in association with tuberculosis of the lungs. The abscess, which is usually very tardy in its progress, and free from pain, seldom exceeds the volume of a pigeon's egg, and may generally be easily recognized by the whitish, grayish, or drab color which it imparts to the surface of the gland. Its contents are charac- teristic. The proper remedy is a free incision. 9. Malignant Disease.-—Scirrhus and encephaloid have been observed in these bodies, but so rarely as hardly to deserve even passing notice. They always co-exist with similar deposits in other organs, pursue the same course, are characterized by similar phenomena, and are equally uncontrollable by treatment. Surgical interference is justifiable only when the gland acts ob- structingly to respiration and deglutition, with a hope of very brief ameliora- tion. I am not aware that melanosis or colloid has ever been witnessed in this situation ; certainly not as an independent affection. SECT. VI.—AFFECTIONS OF THE UVULA. The principal affections of this body are acute inflammation and chronic enlargement. In the former, which frequently co-exists with acute disease of the tonsils and palate, the organ is swollen, and of a fiery red, or pale ash color, elongated, and cedematous. Its free extremity is sometimes expanded into a kind of watery bag, which, if there be at the same time great tumefac- tion of the tonsils, often alarmingly obstructs the respiration, and necessitates the promptest interference. The treatment consists in touching the part effectually with the dilute tincture of iodine, nitrate of silver, or powdered alum and capsicum. When the enlargement is excessive, or decidedly cede- matous, scarification may be required, or even excision of the free extremity of the organ. The uvula, from debility, inflammation, and other causes, is liable to chronic enlargement, especially elongation. The elongation varies in extent from the slightest increase of the part to several times the normal length. I have repeatedly seen it amount to an inch and three-quarters, and, in some rare instances, it has been known to exceed these dimensions by six or eight lines. An increase of length is usually associated with an increase of thick- ness ; but this is by no means necessarily the case, for an elongated uvula is occasionally remarkably narrow and tapering. Chronic enlargement of this organ may occur at any period of life, but is most common in young and middle-aged subjects, and is generally the result of repeated attacks of cold, operating upon a delicate and feeble organization. It is frequently conjoined with inflammation of the palate, tonsils, and fauces, with derangement of the digestive apparatus and a strumous diathesis. Very disagreeable effects may be produced by an elongated uvula. Thus, . the affected organ may project down into the rima of the glottis, occasioning aphonia, or a change in the tone and power of the voice, and a sense of strangulation. I recollect one case where the patient had repeated attacks of nightmare from this cause, which were promptly cured by excising a por- tion of this organ. The more common effects, however, are obstinate and protracted cough, with frequent desire to clear the throat, titillation of the fauces, dryness of the mucous membrane, and a feeling of constriction and frequent hawking. When the affection continues long, tubercles sometimes form in the lungs, and the patient ultimately dies under all the symptoms of confirmed phthisis. The uvula is occasionally productive of disagreeable effects from mere AFFECTIONS OF THE PHARYNX AND C3SOPHAGUS. 577 relaxation of the soft palate, independently of any particular disease of its own substance. The palate, thus affected, hangs down into the fauces, and thereby permits the organ to infringe upon the larynx and root of the tongue in the same manner as in real elongation. Such a state of things is very common in dyspeptic and consumptive subjects, in whom it often constitutes a source of great annoyance. The proper remedy for this affection is excision of the uvula. All astrin- gent lotions, washes, and gargles are perfectly useless, and, therefore, no time should be wasted in their employment. The patient sitting upon a chair, opposite a good light, the surgeon depresses the tongue, and with a pair of polypus-forceps seizes the apex of the uvula, which is then cut off with a pair of probe-pointed scissors, slightly curved upon the flat. Not more than about one-third of an inch of the organ should be left, otherwise the elonga- tion may be reinduced at some future period, and so demand another ope- ration. In a few instances I have removed nearly the whole of this body, without, so far as I could discover, producing any injurious effects of any kind. It has been asserted that, when the excision is performed near the base of the uvula, there will occasionally be a serious change in the voice, but of this I have never seen an example. If I were obliged to operate upon a professed singer, I should certainly limit myself to the removal of a very small portion of the elongated organ, lest unpleasant consequences of this nature might arise. The operation, as above advised, is so simple that any one may perform it. No hemorrhage need be looked for, nor is the excision attended with any pain. The diet for the first few days must be chiefly liquid, and care should be taken that the patient do not take cold. SECT. VII.—AFFECTIONS OF THE PHARYNX AND CESOPHAGUS. The affections of these two tubes, which, in point of structure and function, are intimately associated, may be conveniently considered together. The most common and important of them are, inflammation, abscess, wounds, strictures, malignant growths, and foreign bodies. 1. Pharyngitis.—Inflammation of the pharynx occasionally exists as an independent affection; but, generally speaking, it is associated with, or a con- sequence of, disease of the palate and tonsils. It may be the result of ordi- nary causes, as suppression of the cutaneous perspiration, or the lodgment of a foreign body ; or it may be induced by the syphilitic poison, by a strumous taint of the system, or by the contact of an erosive substance, as nitric, sul- phuric, or hydrochloric acid. The inhalation of steam and the swallowing of hot water are often followed by intense inflammation, both of the pharynx and oesophagus. The symptoms of the disease will be more or less urgent, according to the violence aud duration of the morbid action. Impediment in deglutition, a frequent desire to clear the throat, and a copious secretion of thick, ropy mucus are, in general, the most conspicuous phenomena. In the more severe forms of the disease, the patient often experiences severe pain and spasm, especially in his attempts to swallow liquids, which frequently regurgitate by the mouth and nose; the voice is hoarse and croaking; and there is occa- sionally not a little embarrassment in the breath, from an extension, appa- rently, of the inflammation to the windpipe. Considerable swelling, chiefly of a glandular nature, sometimes exists in the neck, along the base of the jaw, and in the gutter below the ears. The lining membrane of the pharynx is of a deep-red color, its follicles are much enlarged, and its surface is covered with thick, ropy mucus, and, here and there, even with plastic matter. In severe cases, the inflammation extends up into the nose, forwards over the vol. n.—37 578 DISEASES OF THE MOUTH AND THROAT. palate, and down into the larynx. The constitutional symptoms vary with the intensity of the local action, and need not, as they exhibit no peculiarities, be described. The treatment is antiphlogistic ; by the lancet and antimonials, if there be much local and constitutional excitement, by purgatives, diaphoretics, and anodynes, and by leeches to the neck, with tepid, acidulated gargles, and scarification, especially if the inflamed surface be within reach, and by the application of the nitrate of silver, either in substance or strong solution. When the tube is loaded with ropy mucus, attended with a frequent desire to clear the throat, great relief will follow an emetic. Warm applications to the neck, in the form of poultice or fomentation, and the inhalation of the steam of warm water, are occasionally beneficial. If gangrene be threatened, the parts are promptly and efficiently touched with nitrate of silver, or, what is preferable, a weak solution of the acid nitrate of mercury. 2. Abscess.—An abscess, generally of a strumous nature, occasionally forms in the upper part of the pharynx, beneath the mucous membrane in front of the cervical vertebra?, which are often involved in the morbid action. The disease is usually very stealthy in its mode of invasion, and tardy in its pro- gress, there being commonly an entire absence of the ordinary symptoms of inflammation. The first thing, perhaps, that attracts attention is slight im- pediment in deglutition and breathing, with an inclination to snore, and to sleep with the mouth open. Upon looking into the throat, a tumor is de- tected, bulging forwards into the fauces, of a reddish, livid, or purplish color, irregular in form, and imparting a distinct sense of fluctuation under the pressure of the finger. The matter is of a scrofulous character, and every- thing about the disease is denotive of this peculiar action. In the advanced stage of the affection, there is often caries of the superior vertebrae, and ulce- ration of their connecting cartilages. The contents of this variety of abscess occasionally disappear spontaneously, under the influence of sorbefacient remedies, or nature's unassisted efforts; but, in general, they require to be let out artificially, and the sooner this is done the better, as their long reten- tion cannot fail to exert an injurious influence upon the surrounding parts. To perfect the cure, a course of anti-strumous treatment should be instituted, and persisted in until the desired object is attained. A phlegmonous abscess sometimes forms in this situation, giving rise to violent local distress, as well as severe constitutional disturbance. The symptoms are bold and well marked. The pain is deep seated and pulsatile, the parts are red and intensely inflamed, the difficulty of swallowing is very great, the breathing is much embarrassed, and the patient is unable to lie down. The swelling, which is easily seen and felt, should be punctured at the earliest possible moment to prevent death from suffocation, which, if the case be neglected or misunderstood, will be almost certain to happen from the pressure of the matter upon the glottis or its sudden escape into the air- passages. 3. Diphtheritis.—There is a form of inflammation of the pharynx to which the term pseudo-membranous is applied, as it is characterized by the deposi- tion of plastic matter upon the free surface of the mucous membrane. It is very common in certain localities of Europe, particularly at Paris, where it often prevails as an epidemic, sometimes spreading over considerable districts. It is supposed by many to be infectious, inasmuch as it now and then rans through entire families ; and is most frequently met with in weakly, ill-fefl children, between the second and tenth year. As an accidental disease, it ia occasionally noticed in smallpox, scarlatina, measles, and typhoid fever. The plastic matter appears either as a continuous membrane, spread over the surface of the pharynx, or in the form of patches, of variable size ana shape. However this may be, it is of a grayish, whitish, or pale yellowisD OTJNDS OF THE OZSOPHAGUS AND PHARYNX — STRICTURE. 579 color, of a tough consistence, and more or less firmly adherent. It seldom consists of more than one thin layer. When the inflammation is violent, the lymph frequently extends upwards over the tonsils and palate, downwards into the oesophagus, and forwards into the larynx. Under such circumstances, too, it is occasionally of a dirty drab color, or cineritious appearance, from the admixture of sero-sanguinolent secretion. The deposit is usually pre- ceded, for a day or two, by slight fever, and often extends with great rapidity. The subjacent mucous membrane, which furnishes it, is deeply injected, thick- ened, and of a deep scarlet color: in the more severe forms of the malady, it is softened, ecchymosed, rugose, and ulcerated, the lymph lying, perhaps, in immediate contact with the denuded muscular fibres of the part. The mncous follicles are uncommonly large and well developed; the tonsils are softened, tumid, red, and infiltrated with various fluids; and the submaxillary glands and the lymphatic ganglions of the neck often sympathize in the morbid action. The treatment of this affection, especially in its endemic forms, is very un- certain, and the consequence is that many of those who are attacked with it die. The most reliable remedies, particularly at the commencement of the disorder, are gentle emetics and purgatives, followed by diaphoretics, and calomel, carried to the extent of slight ptyalism. As local applications, the most efficacious articles are acid nitrate of mercury, hydrochloric acid, and nitrate of silver, all in strong solution, employed once or twice in the twenty- four hours. The chlorate of potassa has been a fashionable remedy in the disease, but its effects have seldom been encouraging. Tonics, as quinine and milk punch, are generally required to sustain the strength. Change of air often proves highly beneficial. 4. Wounds.—Wounds of the pharynx and oesophagus, already incidentally treated of elsewhere, are always serious accidents, on account of the import- ance of the functions of these tubes, and their complicated relations with other structures, which are liable to be injured at the same time. They may be transverse, oblique, or longitudinal, as it respects their direction, and in- cised, lacerated, contused, or gunshot, as it respects the nature of the vulner- ating body. Their existence, which is commonly sufficiently evident, is always, in cases of doubt, easily determined by the escape of ingesta in eating and drinking. Whenever they are accessible, -or can be rendered so by a proper enlargement of the external opening, their edges should be approximated by the interrupted suture, carried through the entire thickness of the tube, and placed at intervals not exceeding the fourth of an inch. The ends are tied into a double knot, and cut off close to the surface of the wound, to afford the loops an opportunity of falling into the passage, and thus descending into the stomach. That this is the most certain and rational method of managing these injuries is sufficiently evident from analogy and observation, and it is only surprising that it has hitherto been so seldom adopted. 5. Stricture.—Of stricture of the oesophagus—for the affection rarely occurs m the pharynx—there are two varieties, the spasmodic, and the organic. a. Spasmodic stricture of the oesophagus is altogether a very singular dis- ease. It is most common in nervous, excitable girls, soon after the age of puberty, though I have repeatedly witnessed it in very young children of both seses. Old maids and married women about the decline of the menses are w Par.t'cu'ar'y prone to it. It is produced by a great variety of causes, of .ICQ disorder of the uterine functions, derangement of the digestive organs, spinal irritation, and obstruction in and around the tube, as that occasioned 7 the presence of a foreign body, disease of the larynx, or the pressure of an neurism, an abscess or enlarged lymphatic ganglion, are the most common. is often intimately associated with hysteria, recognizing the same origin, forming merely, as it were, one of the complications of that Protean 580 DISEASES OF THE MOUTH AND THROAT. affection. Instances have occurred in which it was produced by the irrita- tion of hemorrhoidal tumors, the removal of which promptly cured the dis- ease. The characteristic symptoms are, severe pain in the oesophagus, or in the oesophagus and pharynx, a sense of constriction as if a cord were drawn firmly round the chest, great difficulty or utter impossibility of swallowing, embarrassment of breathing, and intense mental anxiety, with a feeliii"- of impending suffocation. The attacks often come on suddenly and unexpect- edly, and occasionally they disappear in the same mysterious manner • their intensity and duration are subject to much diversity, being now mild and short now severe and protracted. Cases occur in which the disease manifests a periodical tendency, coming and going very much like a paroxysm of inter- mittent fever. The treatment of this disease must be regulated according to the nature of the exciting cause, which should, therefore, always be carefully inquired into. Nothing, of course, can be done in the way of permanent relief when it .de- pends upon the pressure of an aneurism of the aorta, innominate or carotid, a bulky goitre, or a mass of enlarged lymphatic ganglions, whether cervical or intra-thoracic. When the difficulty is caused by an abscess, or the impac- tion of a foreign body, the remedy is sufficiently obvious, and so also when it is produced by organic disease of the larynx, or by the presence of a polyp in the fauces, pharynx, or oesophagus. In exploring the tube with a view of ascertaining the source of the obstruction, the greatest caution should be used in the passage of bougies and other instruments, lest we should lacerate the gullet, or, in case of the existence of an overlying aneurism, perforate its sac, and thus occasion instant death. The general health is, in all cases, amended by suitable means; the bowels are constantly maintained in a soluble condition ; the secretions are corrected and restored ; spinal irritation is removed by leeches, cupping and vesication; and proper attention is paid to'the diet, exercise Fig. 374. an(* other hygienic measures. In the purely nerv- ous form of the affection, the patient will be im- mensely benefited by systematic purgation, by chaly- beate tonics, either alone or in union with quinine, by the shower bath, and by gentle exercise in the open air. During the attack, relief is attempted by anodynes, assafoetida, valerian, and the compound spirit of ether, sinapisms to the spine, the warm bath, and the passage of the probang, which often acts like a charm, removing the pain and suffering almost in an instant, obviously upon the same principle as the bougie does in spasmodic stricture of the urethra. In obstinate cases the parts at the seat of the obstruction are carefully mopped with a weak solution of nitrate of silver, repeated every fourth day. b. Organic stricture of the oesophagus is rare. It may occur in any portion of the tube, but its most common site is just below the cricoid carti- lage, or near the junction of the oesophagus and pharynx, as seen in fig. 374. It is seldom that more than one stricture of this kind is observed in the same person. The immediate cause of the dis- ease is inflammation, whether produced spontane- Stricture of the gullet, at its , . , . . , , r , i *l,0 most ordinary site, with a bou- ously> by external injury, by hot water, or by toe gie passed through it by the contact of acrid substances, as alkalies and acids. mouth. Most of the cases that I have met with have occurred ORGANIC STRICTURE OF THE OESOPHAGUS. 581 in subjects under thirty years of age ; but it is liable to arise at all periods of life and is equally common in both sexes. I am not aware that occupation engenders any predisposition to the disease. If a dissection be made of a person that dies of organic stricture of the oesophagus, it will be seen that the principal seat of the malady is in the lining membrane and the submucous cellular tissue, which are unnaturally hard, firm, and resisting, and of a grayish, whitish, or slightly bluish appear- ance. It is only in the more aggravated cases that there is any serious in- volvement of the muscular fibres. The contraction may be limited to one side of the tube, or it may embrace its entire circumference, which, in fact, is most common; in its depth it varies from a few lines to several inches. The degree of obstruction ranges from the slightest diminution of the caliber of the tube, to almost complete occlusion, as in organic stricture in other raucous canals. The oesophagus, immediately above the seat of the coarcta- tion, is usually dilated into a kind of subsidiary pouch, which, in severe cases of long standing, is sometimes capable of containing from six to ten ounces of fluid or ingesta. The mucous membrane is generally somewhat attenuated, occasionally opaque and thickened, and, now and then, even ulcerated. The portion of the canal below the stricture is commonly normal. The symptoms of this disease are not, at first, characteristic, being usually such as are denotive only of impeded deglutition, with a sense of uneasiness in the neck, chest, or precordial region. As the disease progresses, the patient finds it more and more difficult to swallow both solids and fluids, but especially the former, which are often arrested in considerable quantity just above the stricture, from which they either gradually descend into the sto- mach, or they are at length ejected by vomiting, or, more properly speaking, by regurgitation. Not unfrequently the deglutition is suddenly interrupted by spasm of the part, which compels the patient to desist from further efforts, until the action has subsided. At times, again, he suddenly experiences a sense of suffocation, attended with a feeling of constriction in the chest, palpi- tation of the heart, and great mental anguish. When the malady is fully established, there is always serious disorder of the digestive apparatus, as flatulence, acid eructations, and constipation of the bowels; the flesh and strength decline; the countenance has a wan, sallow, pinched appearance; the extremities are habitually cold; the surface is easily impressed by atmo- spheric vicissitudes; and the poor sufferer, a prey to the worst forebodings, at length dies completely exhausted. The diagnosis of organic stricture can be determined only by a thorough exploration with the bougie, of which one of gum-elastic is the best. In the absence of such an instrument, however, a piece of whalebone, surmounted with a short cylinder of ivory, may be used as a convenient substitute. The head being thrown backwards against the breast of the surgeon, so as to bring the mouth on a line with the fauces, the bougie is carried down to the obstruction, the precise seat of which is thus at once ascertained. To deter- mine its consistence, it is only necessary to note the degree of resistance offered to the passage of the instrument; if this be slight, it may be inferred that the stricture is slight also, and conversely. To obtain a definite idea °f its extent, both longitudinal and peripheral, the bougie is carried, not only into, but through, the stricture. Organic stricture of the oesophagus is generally a very obstinate and in- tractable disease, setting at defiance the best directed efforts of the surgeon lor its relief. In particular is this the case when it has been caused by loss °t substance, as a wound, ulceration, or gangrene, or when it has been the result of high inflammation occasioned by the contact of an acrid substance, as an alkali or acid. The affection is also, in general, more difficult to cure '" the old than the young, and in such as have been injured by previous dis- 582 DISEASES OF THE MOUTH AND THROAT. ease, intemperance, and other kinds of indulgence, than in those of a healthy, robust constitution. As this disease consists essentially in a deposition of plastic matter in the mucous and submucous tissues of the oesophagus, the principles of the treat- ment will easily be understood. The leading indication, of course, is the removal of this substance, so as to afford the parts an opportunity of regain- ing their normal caliber, consistence, and resiliency. First of all, the general health must be amended, for this is usually considerably deranged, by atten- tion to the diet, bowels, and secretions. In this manner is laid the foundation for the more successful operation of the remedies, local and constitutional, to which the more immediate office of removing the abnormal deposits is con- fided. This preliminary treatment need seldom occupy more than ten, twelve, or fourteen days. At the end of this period a slight course of mercury is commenced, either in the form of the iodide, mild chloride, or bichloride, the choice of the article being influenced by the peculiar features of each case. Very slight ptyalism is encouraged, and persistently maintained for several weeks. Concurrently with this treatment the bougie is used, at first once every fourth day, then every other day, and finally every day, the instrument being retained, if possible, a few minutes at each introduction, and its size gradually increased as the stricture yields under the dilating process. Much caution is necessary in both these particulars, lest further effusion instead of absorption take place. Cauterization with nitrate of silver may be necessary when the parts are unusually irritable, but, in general, it should be avoided; it is best performed by means of an instrument constructed on the same prin- ciple as that used for the urethra, and moved about in such a manner as to bring the substance as gently as possible in contact with every portion of the affected surface. In very obstinate cases, depending upon the presence of an inordinate quantity of fibroid, or fibro-carti- laginous tissue, scarification might be employed, but such an operation should never be under- taken without great care and deliberation. Restoration of caliber being effected, the labor of the patient and surgeon is not ended; on the contrary, vigilant supervision of the general health is steadily maintained, and the insertion of the bougie is repeated at gradually increas- ing intervals until all danger of relapse is safely passed. 6. Carcinoma.—Malignant disease of these tubes usually presents itself in the form of scir- rhus, as in fig. 375, commencing as an infiltra- tion in the submucous cellular tissue, and gradually extending to the other structures, especially the raucous. Encephaloid is exceed- ingly rare, and I am not aware that any ex- ample of colloid has ever been met with. The most common site of the heterologous deposit is the oesophagus just behind the larynx, but it may occur in any portion of the canal, and occasionally, though very rarely, it has been known to occupy the pharynx. Old persons are most prone to this disease, and females suffer more frequently than males. The symptoms are those of dysphagia, attended with pain, and a sense of constriction in the chest. The swallowing becomes more and more difficult, and at length even liquids can hardly be forced across the obstruction. The pain is usually of a sharp, pricking, Ian- Fig. 375. Carcinoma of the oesophagus. POLYPS OF THE OESOPHAGUS. 583 cinating character, and darts about in different directions, up towards the head and fauces, down towards the stomach, and back towards the spine. The flesh gradually wastes, the countenance exhibits a sallow, cadaverous aspect, obstinate hiccup supervenes, and the patient, worn out by protracted suffering, finally perishes from inanition. In some in- stances, especially when ulceration is present, life may be destroyed by hemorrhage; while occasionally, again, though this also is very rare, the fatal event is produced by the escape of ingesta into the windpipe, the mediastinum, or the pleuritic cavity. The causes of carci- noma of the pharynx and oesophagus are similar to those of malignant growths in other parts of the body. The diagnosis can, in general, be early determined by the history of the case and by a thorough exploration of the affected parts with the bougie. The ulcerated form of scirrhus of the oesophagus is well represented in fig. 376, from a specimen in my collection. The treatment, of course, is palliative ; the strength is sustained by nourishing broths, taken by the mouth or rectum, and pain is allayed by anodynes. 7. Polyps.—The pharynx and oesophagus, especially the former, are occasionally, though very rarely, the seat of polyps, similar to those in some of the other mucous outlets. The most commou variety is the pedunculated, the tumor being attached, as the name implies, by a narrow footstalk, sometimes of extraordinary length, while its body, which is usually pyriform, lies loose in the interior of the tube. When situated high up, it is sometimes pro- jected into the fauces and even into the mouth when the patient coughs or retches, and by this circumstance alone the disease can commonly be readily distinguished from other growths. Dysphagia, from mechanical obstruction, of course exists when the tumor is large, either alone, or, as is more com- monly the case, in union with pain, dyspnoea, and suffocative sensations ; but the general health remains good much longer than in scirrhus, the progress of the malady is comparatively tardy, and there is always an absence of can- cerous cachexia. When the morbid mass becomes fixed, the diagnosis will be more difficult, and its decision will then hinge mainly upon a correct appreciation of the history of the case. The structure of these tumors is still involved in obscurity. In the most common form of the affection, however, it is of a cellulo-fibrous nature, soft, inelastic, and of a reddish color, not unlike that of a cherry. Small straggling vessels generally ramify over its surface, and are apt to give way under rude manipulation, furnishing thus occasionally quite a smart hemorrhage. The proper substance of the tumor itself, however, is not very vascular, and hence it rarely bleeds much during removal. If the polyp be within reach, it may generally be readily seized with the forceps, and twisted off at its point of attachment to the mucous membrane. In case it is situated a considerable distance down the tube, removal may be attempted in the same manner, but in this event it will be necessary to em- ploy a longer instrument, and one that is curved somewhat on the flat; or, instead of this, the growth may be noosed with a silver wire, passed by means of a double canula, and broken off by a gentle rotation of the tube, aided by Ulcerated scirrhus of the oesophagus, 584 DISEASES OF THE MOUTH AND THROAT. cautious efforts at extraction. Unless their base is very broad, or their seizure very imperfect, few tumors of this kind would be likely to resist such a procedure. Failure, however, is possible, and then, provided the polyp be situated in an accessible part of the tube, cesophagotomy might be necessary. Excision of the tumor is inadmissible, on account of the subsequent hemor- rhage, which it might be very difficult to stop. 8. Paralysis.—Paralysis of these tubes is sometimes met with, chiefly in old persons affected with palsy of other parts of the body. The character- istic symptom is simply dysphagia, without mechanical obstruction, and, consequently, without any impediment to the passage of the bougie. The disease is usually of unfavorable import, especially when of gradual accession, and the result of organic lesion of the brain, or of the brain and spinal cord. When the attack is sudden, as when the paralysis is induced by apoplexy, or external violence, the danger is not so great, and ultimate recovery may, in many cases, be reasonably hoped for. The treatment is regulated by the nature of the exciting cause, and does not, therefore, admit of specific detail. In the more chronic forms, our chief reliance is upon systematic purgation, gentle but persistent ptyalism, iodide of potassium, strychnine, and counter- irritation of the dorso-cervical portion of the spine, by blister, issue, or moxa. When the strength is much reduced, electricity, the shower bath, either cold or tepid, the use of the flesh brush, tonics, and other invigorating measures will be required. Until the oesophagus has regained its muscular powers, the requisite amount of food and drink must be introduced into the stomach by means of an elastic tube. 9. Foreign Bodies.—Foreign bodies are liable to lodge upon the root of the tongue, between the arches of the palate, in the mucous follicles of the tonsils, around the mouth of the larynx, in the pharynx, and in the oesopha- gus. They generally consist of fish and chicken bones, a crust of bread, fragments of the kernels of fruit, pins, needles, bits of meat, cartilage, or tendon, pieces of coin, and other analogous substances. In cleaning the teeth, the bristles of the brush often fall out, and become entangled in the throat. In fact, substances of every form and character are liable to be ar- rested in these passages, and it is only surprising, when we consider the com- plex structure of the fauces, that accidents of this kind are not more common. Whatever may be their nature, their presence usually awakens a considerable degree of uneasiness, if not of actual pain, with a sense of soreness, and a frequent desire to swallow and clear the throat. Occasionally, there is a marked increase of the salivary secretion, an abundant flow of ropy mucus, and an alteration of the voice, which is hoarse and guttural. If the foreign body remains for any length of time, inflammation will be almost certain to take place, and may run so high as to induce the greatest distress, and even endanger life. When the extraneous body is of large size, and impacted in the lower part of the pharynx, or in the upper extremity of the oesophagus, a prominent symptom will be difficulty of breathing, caused by spasm of the glottis. When the pressure is very great, or long-continued, suffocation may take place in the same manner as when a foreign substance is lodged in the windpipe. Desault mentions a case in which a woman lost her life in three minutes from strangulation, occasioned by the impaction of a piece of bone in the middle of the pharynx. Many similar examples are recorded. Clearance is attempted as early as possible after the accident, with the finger, forceps, or emetics, according to the exigencies of each particular case. If the intruder be within sight, it may often be reached with the finger; or, this failing, it may be extracted with a pair of polyp-forceps, the tongue being previously depressed with an appropriate instrument. When this organ is unsteady, or absolutely rebellious, quietude is first insured by the inhalation FOREIGN BODIES IN THE 03SOPHAGUS. 585 of a moderate quantity of chloroform. Not a little trouble is sometimes ex- perienced in finding the extraneous substance, especially when it is very diminutive, or when it is lodged in one of the mucous follicles of the tonsils, between these bodies and the arches of the palate, or in the pouches at the root of the tongue. When this is the case, a thorough exploration is made with the finger, aided with a grooved director, a long probe, or a large spoon, with a long, slender handle, with which the parts are pushed gently asunder, and exposed to light. Should the attempts at extraction fail, relief is sought in emetics, of which the most prompt and efficacious are alum, ipecacuanha, and mustard, their action being pro- moted by large draughts of water, during Fig. 377. Fig. 378. the regurgitation of which the intruder is often safely ejected. It should be re- membered, as a circumstance of great practical moment, that, although the for- eign body may have been expelled, yet the irritation awakened by its presence often remains for a considerable time after, thus inducing the impression in the mind of the patient that he is still unrelieved. I have frequently noticed this curious fact in my own cases. When the foreign body is lodged in the oesophagus, or in the inferior part of the pharynx, extrusion is often readily effected with a pair of long, slender gul- let forceps, such as those represented in figs. 377 and 378, invented by Dr. Bond, of this city, which are most admirably adapted for the purpose. It will be per- ceived that, besides being very light and curved, they are beveled off at the edges, an arrangement which effectually pre- vents them from seizing and pinching the mucous membrane, an occurrence which is so liable to happen in the use of the ordinary instrument. Moreover, it ad- mirably fits them for withdrawing nee- dles, pins, and other sharp-pointed bo- cEsophagus forceps. dies, which, while they are firmly held by the blades, fall into the groove at their sides, and thus slide along the passage without seriously injuring its walls. An excellent instrument, in some respects superior to that of Dr. Bond, Fig. 379. Burge's oesophagus forceps. was recently devised by Dr. Burge, of Brooklyn, and is delineated in fig. »'»• It is so constructed that a gentle movement of the thumb and index unger causes the blades to open and shut, while the rest of the instrument 586 DISEASES OF THE MOUTH AND THROAT. remains apparently motionless. This is effected by the rolling character of the hinge which connects the blades, and which extends throughout the whole length of the straight portion of the forceps, a distance of about six inches. The blades, which are at a right angle with the handles, are rounded and smooth externally, but flat and slightly roughened internally, and form, when closed, a simple style of the most convenient size and shape. In performing the operation, the patient sits upon a low stool, with his head thrown backwards and supported upon the breast of the surgeon. The instrument, well oiled and warmed, is then passed down into the tube, and used as a searcher; as soon as it is Fig. 381. brought in contact with the extraneous substance, its blades are expanded over it, and extraction is effected in as gen- tle a manner as possible. Generally no after-treatment is required. Occasionally a blunt hook is used for effecting extraction. It is carried down in the same manner as the gullet forceps, if possible, beneath the foreign body, which is then seized and drawn up. Pieces of coin, pins, and bits of bone are sometimes readily removed in this way. A very singular case, in which an operation of this kind proved fatal, occurred many years ago in Cincinnati. A female having, as she supposed, swallowed a pin, a practitioner endea- vored to extract it by means of a com- mon dress-hook, secured to the end of a piece of whalebone. In his attempt to withdraw it, the hook became fas- tened in the oesophagus, the walls of which were severely lacerated. Violent inflammation ensued, followed in a few days by the death of the patient. The late Professor Cobb, who used to have the preparation in his private cabinet, made the dissection, and discovered the rent, which was upwards of an inch and a quarter in length, just below the larynx. No pin was found, and the probability was that none had ever been swallowed 1 An excellent instrument for extract- ing foreign bodies from the oesophagus is represented in fig. 380. It was con- structed for me, at my suggestion, by Mr. Kolbe, and consists of a steel rod, about fifteen inches long, inclosing a stilette, surmounted by four wing-like processes, which may be shut or ex- panded at pleasure, simply by turning the handle. Another convenient coo- trivance, constructed with bristles, and acting upon similar principles, is exhibited in fig. 381. Pins, needles, aod Instruments for extracting foreign bodies from the oesophagus. 03S0PHAG0T0MY. 587 other slender substances, may sometimes be entangled in the loops formed by tying a number of horsehairs to the extremity of a piece of whalebone. When the substance is of a digestible nature, as a crust of bread, a piece of potato, or a mass of beef, and cannot be readily extracted, it should be pushed down into the stomach by means of a probang, an instrument con- sisting of a stout whalebone rod, surmounted by a suitable piece of sponge. The operation, which should be performed with great gentleness, the patient sitting on a chair, with the head inclined backwards, is not always so easy as might be imagined. Many years ago, I attended a man, in the inferior part of whose oesophagus a large piece of veal had lodged, where it produced excessive irritation and so much spasmodic action as to render it extremely difficult to force it on into the stomach. For several hours his embarrass- ment of breathing and thoracic distress were most intense. A fish-hook along with a piece of its line is occasionally swallowed. An instance of this description, and the first of the kind of which I have any knowledge, occurred in 1814, in the practice of Dr. Bright, of New Castle, Kentucky. Having ascertained that the foreign body was quite small, this gentleman supposed that if a ball, pierced at the centre, were passed over the line, and allowed to fall forcibly against the hook, it would be likely to detach it from the coats of the oesophagus, in which there was reason to believe that it had been arrested. The experiment was accordingly tried, and the success was complete. The hook having lost its hold, applied itself against the lower surface of the ball, which thus, in the withdrawal of the line, prevented its barb from injuring the passage. When a foreign substance, especially if it be rough, sharp, or angular, is retained for any length of time in the gullet, it may occasion serious inflam- mation, followed by abscess, gangrene, or ulceration, and in this way it may even destroy life. Dorsey has related an instance in which a youth of seven- teen suddenly perished from a copious hemorrhage, induced by the long- continued lodgment in the oesophagus of an English farthing. Needles, pins, and bits of bone, after having sojourned for a while in the oesophagus or pharynx, often descend into the stomach, and are ultimately voided by the bowels; or, instead of this, they perforate the coats of these tubes, and travel over different parts of the body, being, perhaps, at length eliminated through the skin; or, finally, they enter the thoracic cavity, and produce destructive inflammation of its contents. In the second volume of the Dublin Hospital Reports, a case is narrated by Mr. Kirby, of a woman who bled to death from injury sustained by the right subclavian artery, from a piece of bone which had perforated the oesophagus, behind which the vessel lay in its anomalous course from the arch of the aorta towards the right side of the trunk. 10. (Esophagotomy.—I have never performed cesophagotomy, and such an operation will, I presume, rarely, if ever, be required, if a proper direction be given to our attempts at extrusion. It is only when the foreign body is immovably fixed in its position that the question should be at all enter- tained. Should the operation be decided on, it may be executed in the fol- lowing manner: The neck being stretched, the head retracted, and the foreign substance made to project as far as possible on the left side of the windpipe, an incision, several inches in length, is made directly over the swelling through the skin and platysma myoid muscle. The tube being thus exP°sed, and any vessels and nerves that may be in the way held aside, its wall is divided to the requisite extent, and the substance, whatever it may be, is extracted with the finger or forceps, as may be found most convenient. As soon as clearance has been effected, and the bleeding arrested, the edges . no esophageal wound are neatly approximated by several points of the interrupted suture, made with very fine, but strong silk, the ends being cut 588 DISEASES OF THE MOUTH AND THROAT. off close to the knots, to afford the ligatures an opportunity of dropping ulti. raately into the interior of the passage. The cutaneous wound being dressed in the usual manner, the case is managed upon general principles, the patient being supported during the first week with broths, conveyed, if necessary, by means of a tube, or, what will be better, introduced into the rectum. Mr. Cock has given a record of seven cases, including one by himself, in which this tube has been opened for the removal of a foreign body. Of these, five were successful and two fatal, one of the patients dying at the end of fifty-six hours from pneumonia, which existed at the time of the operation, and the other in two days from stomatitis and gangrene of the pharynx. For a very instructive and learned paper on organic obstruction of the oesophagus, giving the particulars of a case in which Dr. John Watson, of New York, opened both this tube and the trachea for the relief of the patient, who, however, perished several months afterwards, the reader is referred to the American Journal of the Medical Sciences for October, 1844. 11. Passage of Tubes along the Oesophagus.—The practitioner is some- times obliged to insert tubes into the stomach for washing out its contents, as in poisoning, or for injecting food into the organ with a view of sustaining life, as in disease of the pharynx and oesophagus. In the former case, the addition of a pump is necessary; in the latter, a gum-elastic bottle. Tubes for either of these purposes should be at least eighteen inches in length, and from four to six lines in diameter. The patient being seated upon a chair, with his head reclining against the breast of an assistant, the instrument, carefully oiled, is cautiously conducted down into the pharynx, and thence along the oesophagus into the stomach. If poison be present, tepid water is now injected, and immediately after withdrawn with the pump, though not the whole of it, lest the mucous membrane of the stomach be sucked into the holes of the tube, and so torn into shreds. The operation is repeated until thorough clearance has been effected, or until the fluid returns colorless, the quantity thrown in at each time varying from a pint to a quart, accord- ing to the age of the patient and the circumstances of the case. When the tube is inserted for the purpose of injecting nutriment, the liquid should be introduced very slowly, so as not to occasion sudden and painful distension. It seems to me that none but the veriest bungler could pass such an in- strument into the windpipe instead of into the oesophagus, and yet, judging from the cautious manner in which writers lay down their instructions for its introduction, we are forced to conclude that such an occurrence is not only possible, but occasionally quite probable. The accident would, it may be presumed, be most likely to happen when the patient is in a state of deep coma or partial asphyxia, thus preventing him from perceiving the contact of the instrument. It has been proposed, in such an event, to hold a lighted taper before the tube, on the assumption that, if it be extinguished, it is to be regarded as an evidence that the instrument is in the windpipe, and con- versely. But such a procedure is altogether unsatisfactory, and the only safe plan, at last, for the surgeon, is to rely upon his knowledge of anatomy, and his manual dexterity. The very facility with which the tube glides along may be taken as an evidence that it is descending the oesophagus. HERNIA—GENERAL OBSERVATIONS. 589 CHAPTER XIV. HERNIA. SECT. I.—GENERAL OBSERVATIONS. By the term hernia, as used at the present day, is understood a protrusion of any of the abdominal viscera through a natural or accidental aperture in the abdominal walls, accompanied by a process of the peritoneum, and in- vested by the common integuments. The parts most liable to this occur- rence are the intestines, especially the small, and the omentum. Of the small bowels, the portions most generally concerned in the descent are the ileum and the inferior third of the jejunum. The duodenum is too fixed in its situation to admit of such an accident. The arch and sigmoid flexure of the colon occasionally pass out of the abdomen, and the same fate is sometimes, though rarely, experienced by the caecum and vermiform appendix. Now and then an instance occurs in which a portion of the stomach, the liver, spleen, or urinary bladder, forms a constituent of the hernia. Cases have also been witnessed where the ovaries, the Fallopian tubes, and even the uterus were protruded. The rectum has occasionally been found included in an ischiatic hernia. Various terms are employed to designate such a tumor, derived either from the nature of its contents, the particular condition of the included structures, or the region of the body in which it occurs. Thus, when the protrusion consists of intestine alone, it is called an enterocele ; epiplocele, when it is composed merely of omentum; and entero-epiplocele, when it consists both of intestine and omentum. A hernia is said to be reducible when its con- tents can readily be returned into the peritoneal cavity; irreducible, when they remain permanently fixed in their abnormal situation ; and strangulated, when they are confined by a stricture, or compressed by the edges of the aperture at which they emerged. The term incarcerated is used to denote the temporary sojourn of the parts in their extra-mural situation, without any obstruction to the passage of the feces, and the existence of inflammatory symptoms. The words inguinal, scrotal, femoral, umbilical, ischiatic, obtu- rator, and labial, have reference to the particular regions in which the descent takes place. Finally, hernia sometimes occurs at birth, and it is then said to be congenital. The frequency of hernia cannot be correctly estimated, nor is this a matter of any particular practical moment. It doubtless differs in different coun- tries, in different occupations, and in different classes of society; the poor being much more obnoxious to it than the rich. The affection occurs at all periods of life, from the cradle to the grave. An idea of the influence of age upon the production of hernia may be tormedfrom the following table, founded upon 77,997 cases reported by the London Truss Society:_ 590 HERNIA. YEARS. CASES. I YEARS. CASES. From 1 to 10 . . . 7,229 " 10 " 20 . . . 4,551 " 20 " 30 . . . 8,715 " 30 " 40 . . . 13,614 " 40 " 50 . . . 15,627 From 50 to 60 . . . 14,169 " 60 " 70 . . . 9,761 " 70 " 80 . . . 3,866 " 80 " 90 . . . 442 " 90 " 100 .. . 23 Both sexes are subject to hernia, but men in a much greater degree than women, in the proportion probably of about four and a half to one. Thus, out of 83,584 patients relieved by the London Truss Society, 67,798 were males, and 15,786 were females. Men suffer most frequently from inguinal hernia; women, from femoral and umbilical; the differences depending either upon anatomical causes, or physi- cal conformation. Causes.—The causes of hernia are usually divided into predisposing and exciting. Among the former the principal are, inordinate size of the normal outlets of the abdomen, and the existence of preternatural apertures, from defective development of the walls of this cavity. Under the same head may be included unusual laxity of the muscles and tendons of the abdomen. Distension of the abdomen by pregnancy, ascites, obesity, and different kinds of tumors also favor the formation of hernia. The same is true of tight lacing, mechanical obstruction to the evacuation of the urine, chronic disease of the lower bowel, and general debility, whether natural or acquired. The most common exciting cause of the disease is inordinate contraction of the diaphragm, pushing the abdominal viscera forcibly against their walls, at the same time that these walls themselves are in a state of excessive ten- sion. The contained and containing structures being thus made to act and react upon each other, the floating parts of the former are often readily thrust across the resisting parts of the latter. Hence hernia is most generally pro- duced in straining at stool, in difficult parturition, lifting heavy weights, playing on wind instruments, jumping, running, vomiting, and coughing. Occasionally the occurrence is the immediate result of external violence, as a blow or wound, separating or severing some of the component structures of the walls of the abdomen. Wounds of the walls of the abdomen are a frequent cause of hernia. The culpable manner in which these lesions are generally treated can hardly fail to be followed by protrusion of the abdominal viscera. The puncture made in the operation of tapping has occasionally given rise to hernia. Many years ago a remarkable case of this kind occurred in this city, in a lady who was tapped by an eminent practitioner, under the supposition that she had ascites. It turned out, however, that she was merely in an advanced stage of pregnancy. The operation brought on premature delivery, followed soon after by ventral hernia, which, increasing in volume, became at length quite troublesome, the more so, as it was subject to occasional attacks of strangu- lation, in one of which she lost her life. Anatomy.—Every hernia has a distinct sac, besides a certain number of other coverings, a mouth, a neck, and a body. Each of these parts is of sufficient importance to require separate consideration. The sac forms the immediate investment of the protruded parts, and is of a serious nature, being, in fact, merely a prolongation of the parietal portion of the peritoneum, pushed down during their descent. It varies much in its structure, as well as in its size and shape. In the earlier stages of hernia, it generally retains both its natural transparency and tenuity; but in casesot long standing, and particularly in those of large bulk, it is almost always considerably thickened, opaque, dense, and even fibrous; its free surface is rough, corrugated, discolored, and often incrusted with lymph ; and the sub- jacent cellular substance, which is frequently separable into several layers, is HERNIA—ANATOMY. 591 Fig. 382. commonly indurated, and occasionally loaded with fatty matter. Serum some- times accumulates in considerable quantity in the sac, constituting a species of genuine dropsy. It need hardly be added that these changes are all the direct product of the inflammatory action which the sac experiences during the progress of the disease. The sac also admits of great extension, as is Rhown in certain forms of scrotal hernia, in which the tumor descends nearly as low as the knee. Sometimes the sac, instead of being thickened, is re- markably attenuated, or very thin at one point and thickened at another; occasionally, again, cases are witnessed in which it has given way, either by absorption or laceration. It is also to be remembered that there are certain varieties of hernia in which the protruded parts receive only a partial invest- ment of this kind. This is uniformly the case in hernia of the csecuin and bladder, which are but imperfectly covered by peritoneum, in the natural state. A rupture following upon a wound is always destitute of a proper sac. The size of the sac varies from a pigeon's egg to that of an adult's head. In general, it may be assumed that the younger a rupture is the smaller will be the sac, and conversely. It has already been stated that, in scrotal hernia, the tumor occasionally reaches nearly as low down as the knee. Its shape, which is liable to end- less diversity, may be globular, pyriform, conical, cylindrical, or hemispherical; oc- casionally it has a constricted, hour-glass arrangement, or it consists of alternate dila- tations and contractions. A double sac is sometimes met with. The annexed drawing, fig. 382, from a preparation in my collection, affords a good illustration of the more com- mon shape of the hernial sac. The other investments of the tumor vary in number, as well as in their character, in the several regions in which they are situ- ated, and will be described along with the different varieties of hernia, Meanwhile, it may be remarked that every rupture has an integumentary envelop, consisting of skin and cellular tissue, either in their natural state, or variously altered by the pressure of the protruded parts. Muscular fibres seldom form a distinct tunic in any of the varieties of the affection. The mouth of the hernia is that portion of the tumor which forms the com- munication between the sac above described and the general peritoneal cavity. In its shape it generally resembles an elongated fissure, but in some instances, especially in old and bulky ruptures, it is nearly circular. Its size varies from that of a small aperture to that of an opening capable of admitting a large hst. Two or more sacs have been known to communicate with the abdomen by a common mouth. The neck of the hernia lies just below its mouth, being the narrow, con- stricted portion, embraced by the edges of the natural or accidental orifice at which the descent has taken place. These boundaries are formed either by muscular, tendinous, or aponeurotic fibres, and, from the character which they play in the production of strangulation, deserve to be studied with the greatest care and attention. the Jose of a hernia is its lower extremity, and the body that portion «'hich hes between the base and the neck. Hernial sac, with its mouth, neck, body, and fundus. 592 HERNIA. When the contents of a hernia are prevented from protruding, the neck of the sac has a remarkable disposition to close, so as to destroy, either partly or completely, its communication with the general peritoneal cavity. In time the whole sac may be obliterated, or, as more frequently happens, it remains, and becomes filled with water, forming a tumor similar to a hydrocele of the vaginal tunic of the testicle. By the side of this tumor another protrusion may afterwards occur, the viscera passing through the same orifice, aud push- ing down before them a fresh process of peritoneum. These old sacs are sometimes a source of much embarrassment to the sur- geon in operating for the relief of strangulated hernia, from the fact that they overlap the protruded viscera, and thus serve to mask the parts. The diffi- culty is greatly increased when, as occasionally happens, the contents of the tumor, in consequence of an extension of the inflammation, assume a bloody character. The volume of a hernia, however constituted, is liable to much diversity, and hardly admits of any definite statement. Generally speaking, it may be assumed that the more recent a rupture is the smaller will be its bulk, and conversely; but this law has many exceptions, as is shown, for example, in cases of hernia consequent upon severe muscular exertion and external injury, as a laceration or division of the walls of the abdomen, in which such a pro- trusion often has a large bulk at the very moment of its occurrence. There are also regional differences in regard to the size of these tumors. Thus a femoral hernia is always, other things being equal, much smaller than an inguinal hernia, its size rarely exceeding that of a pigeon's egg, or an almond. The largest tumors of this kind are, generally, old scrotal and umbilical rup- tures. The shape of the tumor is usually intimately connected with that of the proper hernial sac, already described. The most common forms are the globular, ovoidal, cylindrical, and pyriform. In some instances the tumor has a flat, compressed appearance, or the figure of an hour-glass. Much diversity obtains in regard to the quantity of the protruded struc- tures ; in general, however, it is in direct proportion to the size of the tumor. In enterocele the contents of the hernia may consist of nearly the whole of the floating portion of the bowel, of a small loop, or of a part merely of the circumference of the tube; too small, perhaps, to form the slightest appre- ciable swelling upon the external surface. Large quantities of the omentum also sometimes descend, but in most cases the protrusion is small. 1. REDUCIBLE HERNIA. The symptoms of reducible hernia are greatly influenced by the nature of the protruded structures. An enterocele is soft and elastic; smooth, or nearly smooth, on the surface; free from pain and soreness; and of a globular, ovoidal, or conical figure. It imparts a distinct impulse to the finger when the patient coughs ; has a gaseous feel; often emits a clear sound on percus- sion; and disappears during recumbency, but is reproduced immediately on the resumption of the erect posture. The reduction is generally effected suddenly and in mass, with a gurgling, rumbling, or explosive noise. It is worthy of remark, however, that when the bowel contains much solid matter the tumor may be hard, unequal, almost inelastic, and return lazily and almost noiselessly. The size of an enterocele is often considerably influenced by the condition of the alimentary canal; being smaller after fasting and the use of purgatives, and larger when the tube is distended with food, gas, or feca matter. In epiplocele, the tumor is of a more irregular figure, and of a nan ;> doughy consistence, very different from that which characterizes an entero- REDUCIBLE HERNIA—TREATMENT. 593 cele- it emits no sound on percussion ; imparts no impulse on coughing; is free from tension ; does not expand or diminish during the repletion or vacuity of the alimentary tube; and is always reduced with more difficulty than a protruded bowel. Omental, like intestinal hernia, may occur at any period of life, but is more frequent in elderly than in young subjects. A double omental hernia is sometimes met with. I have seen examples of it both in the inguinal and femoral regions. In an eutero-epiplocele the symptoms are of a mixed nature, and hence the diagnosis is often more obscure than in either of the other forms of the pro- trusion. If one part of the tumor feel soft, elastic, and gaseous, and the other doughy, heavy, and nearly incompressible; or if one portion slip up quickly and with a gurgling noise, and the other remain stationary, or is less easily replaced, the presumption will be that it contains both intestine and omentum. Frequently, however, the characteristic symptoms are absent, and the true nature of the swelling can be determined only by the knife. Reducible hernia, unless very large, is rarely attended with any decided derangement of the general health. Very commonly, indeed, all the functions of the body are performed in the most perfect and vigorous manner. When the disease becomes troublesome, the symptoms usually complained of are such as denote disorder of the digestive apparatus, as indigestion, flatulence, eructations, colic, constipation, and painful, dragging sensations in the abdo- men. The patient, in recent cases, is frequently able to move about, and to attend to his business, without any particular suffering or inconvenience, even when he does not wear a truss. I have known persons affected with inguinal hernia live in great comfort for years without any mechanical support whatever. Treatment.—For the reducible hernia, the best remedy is a suitable truss, an instrument designed to answer the purpose of a retentive apparatus. It should be applied as soon as the true nature of the disease has been deter- mined, and be worn uninterruptedly until there is reason to believe that the opening of descent has become effectually and permanently closed. Even when this object cannot be expected to be attained, on account of the great size of the aperture, the long standing of the case, and the advanced age of the patient, the viscera should be constantly maintained in their natural posi- tion, lest, in an unguarded moment, or in consequence of sudden and violent muscular exertion, recurrence of the rupture should take place, and the pro- truded parts become strangulated. When the instrument cannot be worn at night, it should always be replaced in the morning before the patient rises, the surface upon which the principal pressure is applied being previously well washed with soap and water, and then rubbed with alcohol, or some spirituous lotion. Unless these precautions be properly attended to, the skin will be liable to become chapped and covered with boils. There is no period of life, except that of early infancy, in which a truss, if properly constructed and adjusted, may not be worn with advantage, if not with a prospect of ultimate cure. The only objection to the use of such an instrument in very young children is its liability to chafe the skin, aud to become soiled by the excretions, thus imposing a great deal of care and anxiety upon their attendants. The trusses of the present day are, in every respect, very superior to those in use even a quarter of a century ago. The instruments invented by Stag- "er and Hood, of Kentucky, and afterwards improved by Chase, Dodson, and others, are nearly as perfect as it is possible to make such contrivances. They combine great cheapness and finish with extraordinary lightness and efficiency, iare cvery way worthy of the favor which they have received in this country and in Europe. The substitution of the wooden block for the soft pads, for- y H1 vogue, was one of the most valuable additions to the mechanical vol. ii.—38 594 HERNIA. surgery of the present century. With the old instrument, it was not only frequently difficult to maintain the reduction of the hernia, but such a thing as a radical cure was hardly ever even thought of. The American truss, on the contrary, while it most effectually answers the purpose of a retentive ap- paratus, often, by the steady, gentle, and uniform pressure of its block, per- manently cures the disease. The truss of Stagner and Hood, improved by Chase and others, is repre- sented in fig. 383. The block, composed of beech or cedar, is of a semi- ovoidal shape, convex on its abdominal surface, and flat externally; it is placed more or less obliquely, and is, in regard to the spring, so arranged as to admit of being moved, in order to adapt it more accurately to the part and body. Its great advantages are its uniform consistence and smoothness, its Fig. 383. Fig. 3^4. Trass. Truss applied durability, and its inability to imbibe perspiration ; qualities which are nearly- all wanting in the pads of the older instruments, as well as in many of the modern. The spring consists of a light but strong band of steel, capable of encircling about two-thirds of the body, very flexible and elastic, and thoroughly covered to prevent it from chafing the skin. The leather which surrounds the spring terminates in a free extremity, provided with numerous apertures for fastening it at the other end of the instrument, to a screw just beyond the block. To prevent the truss from slipping up, over the hips, a thigh-strap, also well padded, is attached to it. The adjoining cut, fig. 384, represents the instrument as applied to the body. The number of trusses before the profession is immense; a large volume would hardly suffice to describe and delineate them. The principal differences among them relate to the nature, form, and arrangement of the pad, which, consisting of wood, ivory, glass, lead, India-rubber, or wire, may be circular, oval, oblong, triangular, convex, or cup shaped. In Marsh's instrument, the pad is composed of half a dozen small, oblong balls, forming a kind of ring. In the Maidstone truss, which has served as a model for many of these mo- dern contrivances, the pad slides on the spring, so as to allow the instrument to adapt itself to the varying movements of the body. In the truss of Sal- mon and Ody, the pad revolves on a ball and socket. In that of Edwards, it both slides and revolves; and a somewhat similar arrangement exists in the truss of Dr. Sheldon, of New York, which has two pads, both of wood, one semilunar and the other cylindrical, the latter resting partially in the cres- centic margin of the former, thus admitting of more concentrated pressure. Sometimes the pad is filled with air, sand, or hair. The body piece of the instrument also varies a good deal. Thus, the spring occasionally extends entirely round the hips, or, instead of a spring, there is around wire, as in Newson's truss, or a simple belt, as in the Moc Main truss, or an elastic India-rubber band, as in Bourjeaud's. It is hardly possible for a person to obtain a well-fitting truss without direc REDUCIBLE HERNIA — TREATMENT. 595 consultation with the manufacturer. This is a matter which is, unfortunately, too much neglected, the patient too often thinking that he can effect by proxy what he ought always to do himself. When the proper examination cannot be made by the cutler, the measure of the body around the hips should be carefully taken with a piece of annealed wire, with an account of the particu- lar form of the rupture, an inch to an inch and a half being allowed for the padding. Every person having hernia should have two instruments of this kind, so that, in the event of accident, he may not be obliged to be without a truss whfle the broken one is undergoing repair. For want of this precaution, patients have occasionally incurred great risk to life. For very young children, the most suitable retentive apparatus is an India- rubber band and pad, without a spring. Special attention must be paid to cleanliness, and, when the little patient has attained the age of eight, ten, or twelve months, he will generally be able to wear an ordinary truss, provided the spring is not too strong. The chances of a radical cure by the use of the truss are, other things being equal, always greater in proportion to the small size and recent standing of the hernia, the absence of obesity, and the youth of the patient. When the tumor is large, the probability of effecting the obliteration of the abdominal aperture wilbhe comparatively slight, on account of the difficulty of procur- ing an adedprate supply of plastic matter, and hence few such cases ever thoroughly recover. Under opposite circumstances, on the contrary, the opening is often closed in a short time, for then the parts are more easily in- fluenced by adhesive inflammation, which the steady and persistent pressure of the instrument has a tendency to excite. The sooner, therefore, a truss is applied, the better it fits, and the more steadily it is worn, the greater will be the chances of a speedy and permanent cure. Yet the fact that a rupture is old and bulky should not prevent the use of such an expedient, provided the parts are still reducible; for the efforts of the surgeon are occasionally crowned with success in cases apparently the most unpromising. Should no radical cure follow, the patient will lose nothing by the attempt; but, instead of this, he will be a decided gainer, inasmuch as the tumor will not only not increase under such management, but will be effectually guarded against stran- gulation. Some difference in respect to the curability of hernia occurs as this complaint manifests itself in different regions of the abdomen. Thus, an inguinal hernia is always more easily relieved than a femoral, umbilical, or scrotal, for the reason, doubtless, that the structures through which the de- scent takes place are more easily compressed, and, therefore, more easily in- fluenced by exudative inflammation. In young subjects, the probability is that the obliteration of the abdominal aperture is materially promoted by the natural tendency which its margins have to contract. In no instance, per- haps, is there much effusion of plastic lymph; certainly much less than is generally supposed. The importance, therefore, of giving early and efficient support, not only to the parts immediately interested in the protrusion, but to the whole abdomen, must at once be obvious, and should receive due atten- tion in every case where the object is to bring about such a result. The effi- ciency of the truss, in promoting the radical cure of hernia, may be greatly increased, in almost every case, by the use of an abdominal supporter, con- structed upon the principle of the instrument employed by women in dis- placement of the nterus. The weight of the abdominal viscera being thus measurably taken off from the inguinal rings, retention of the bowel is not only much more easily effected, but the edges of the rings are not so likely to »e separated, and the adhesions, consequent upon the wearing of the truss, )ro. p ' UP- Although my experience with this treatment is limited, I am satisfied that its advantages are very great. arious methods, besides the truss, have been suggested for promoting the 596 HERNIA. radical cure of hernia; of these, some date back to a remote period of the profession, and partake largely of the rnde nature which characterized the practice of our forefathers. To this category belong the operations of exci- sion of the sac, the exposure of the sac and the application of the ligature to its neck, and the incision of the sac and the use of irritants for the purpose of inducing its obliteration; all of which resulted not only in much suffer- ing, but in the loss of many lives. What surprises one is, not that these operations should have been practised in ancient times, but that they should have been repeated at a comparatively recent period. In scrotal hernia, the testicles were often extirpated along with the hernial sac; and so common had this practice become in the seventeenth century, that, as Dionis informs us, an itinerant operator was in the habit of feeding his dogs with the organs which he thus removed. Hardly less cruel and unscientific are some of the modern devices for the radical cure of this complaint, especially that of Bel- mas, which consists in exposing the neck of the sac, and introducing little bladders of gold-beater's skin, with a view of exciting adhesive inflammation, Within the last thirty years, chiefly through the influence of Mons. Gerdy, invagination of the common integuments has occasionally been practised for the radical cure of hernia, although with no encouraging success. It is principally adapted to the inguinal form of the complaint, and simply con- sists, as originally executed, in pushing up a fold of skin as far as possible into the neck of the sac, which is then confined there by two points of inter- rupted suture, introduced by means of a stout, curved needle, through the superimposed structures—muscles, fasciae, and skin—and separated about one-third of an inch from each other, the ends being tied over a piece of bougie. The pouch of inverted skin is then denuded of its cuticle with spirits of ammonia, which, causing inflammation in the contiguous surfaces, is thus instrumental in gluing them firmly to each other and to the peritoneum. The operation of Gerdy has fallen into merited neglect, for, independently of the fact that it frequently completely failed, it was not always devoid of danger. Of sixty-two cases of it, collected by Thierry, four are known to have perished, while it is altogether probable that only a few were radically cured. The principles of the operation, however, have been preserved, and have, in a modified form, done good service in the hands of other surgeons. Another plan, at first sight very specious, but also found, upon trial, to be nearly useless, consists in scarifying the neck of the sac, by means of a delicate bistoury, introduced subcutaneously. Pressure is afterwards made with a truss, to approximate the opposed surfaces, in order to facilitate their union by plastic matter. This operation originated with Mons. Guerin, the tenotomist. A third plan for the radical cure of hernia was suggested, in 1836, by Mons. Bonnet, of Lyons. It is called acupuncturation, as it is performed by transfixing the sac with a number of pins, which are permitted to remain until there is ulceration of the skin, compression being exercised in the inter- vals of the little instruments, for the purpose of promoting adhesive action. Of eleven cases thus treated by Bonnet, four were cured, five were unsuccess- ful, and two proved fatal; a result sufficient to condemn the procedure. I may here mention the method of treatment proposed by Professor Pan- coast, and practised by him successfully in thirteen cases. It is essentially similar to the operation for the radical cure of hydrocele by injection, con- sisting in the introduction of some mildly irritating fluid, of which the tincture of iodine is, perhaps, the best. The protruded viscera having been carefully replaced, and firm pressure being made upon the hernial aperture, a drachm of iodine is thrown into the sac, and pressed over its inner surface, so as to bring it in contact with every portion of it. The operation is performed win a delicate trocar, with the point of which the sac is freely scarified before the REDUCIBLE HERNIA—TREATMENT. 597 fluid is forced through the canula. The injection being over, a stout com- press is applied over the hernial opening, and unremittingly supported by the pressure of a well-adjusted truss. The iodine is soon absorbed, and the cure is produced by the agglutination of the contiguous surfaces. The ope- ration, which occasionally requires to be repeated a second, and even a third time, must be performed with the greatest care, lest some of the fluid, passing into the abdominal cavity, should cause fatal peritonitis. The late Dr. Jameson, of Baltimore, many years ago, performed an opera- tion for the radical cure of a femoral hernia, in the case of a young lady, by dissecting up a tongue-like flap of integument, from the neighborhood of Poupart's ligament, and inserting its base, which was fully three-quarters of an inch in width, into the femoral canal. The edges of the wound were then drawn together over the flap, by several sutures. For a few days the patient was restless and annoyed by vomiting; and, although the parts did not all unite by the first intention, yet they soon got well, the transplanted integu- ment contracting into a hard knot over the femoral ring, which was thus completely closed, the recovery being perfect. I am not aware that this operation has ever been repeated. A very eligible method of treatment for the radical cure of hernia, one which has been more frequently employed than any other, was proposed by Professor Wutzer, of Bonn, in 1838. It consists in obliterating the sac of the hernia by invaginating a portion of integument, as originally suggested by Gerdy, by means of an instrument of peculiar construction, consisting essentially of three pieces, a wooden cylinder, a curved needle, and a concave wooden cover, which are retained until the contiguous structures have con- tracted firm adhesions to each other. The wooden cylinder is three inches in length, and from three-eighths to three-quarters of an inch in diameter, according to the size of the hernial canal. It is of a somewhat flattened shape, perfectly smooth, and rounded off at the free extremity, a short distance from which, upon its inner surface, is a small opening for the passage of a long, curved needle, which is con- cealed in its interior, and attached to a movable handle. The cover, also made of wood, is concave on its inner surface, and of the same length and width as the cylinder, to which it is secured by a screw. It also has an opening for the passage of the needle. The accompanying cut, fig. 385, Fig. 385. Wutzer's instrument. conveys a good idea of this apparently complicated, but really very simple and efficient instrument. the protruded parts having been returned, a fold of integument is pushed up as far as possible into the canal of the hernia with the index finger of the "and, its palmar surface being directed forwards and upwards. The cylinder, well oiled, is then carried along the cul-de-sac thus formed, guided Jy the finger, which is gradually withdrawn as the instrument enters. As- suring himself that the extremity of the cylinder is fairly lodged in the internal o» under the external oblique muscle, as he readily may by observing that 59S HERNIA. it is firmly fixed in its place, the surgeon pushes the needle through the sac of the hernia, the canal, and the integument, and screwing the cover mode- rately tight upon the skin, he removes the handle of the needle, leaving the remainder of the apparatus upon the abdomen. The protruding portion of the needle is protected with a piece of cork. The principal precaution necessary, in performing this operation, is to see that the cylinder is tho- roughly secured in the inguinal canal. In hernia of long standing, attended with unusual laxity of the cellular tissue, it is liable to be pushed up beneath the skin of the abdomen; a circumstance, however, which is always easily detected by the fact that the instrument is more movable than when it is in its proper place. The apparatus is retained for a period varying, on an average, from six to eight days, the cover being tightened or relaxed, from time to time, accord- ing to the tolerance of the parts, and the amount of the resulting inflamma- tion. The puncture made by the needle generally begins to suppurate about the end of the fourth day. The patient is kept perfectly at rest in the recum- bent posture, pain is allayed by anodynes, the bowels are not permitted to move, and the diet is perfectly plain and simple. If peritonitis should arise, which, however, is seldom the case, the symptoms must be met by the ordi- nary remedies, and all compression be immediately removed. When the apparatus is taken off, the patient must not get up at once, but remain on his back eight or ten days longer; and when, at length, he begins to exercise, he must be careful to support the parts with a well-adjusted truss, the use of which should be continued for at least six mouths after, lest, the adhesions giving way, the disease should be reproduced. The operation of Wutzer has recently been materially simplified by Dr. Agnew, of this city. The apparatus required for its performance consists: Fig. 386. Agnew's instrument for the radical cure of hernia. first, of a steel instrument, fig. 386, closely resembling a bivalve speculum, the blades, of which one has two longitudinal grooves, being three inches in length and connected by a hinge near the handle, which is itself controlled by a screw; secondly, of a very long, slender needle, fig. 387, mounted upon a wooden handle, knobbed near its needle, and terminating in a curved point, pierced by an orifice ; and, thirdly, of a common stout suture needle, two inches and a half in length. The parts having been well shaved, and a portion of scrotal integument pushed into the external ring, the instrument, with its grooved blade looking towards the abdomen, is employed to carry, by gentle but steady pressure, the invaginated plug to the upper extremity of the inguinal canal. Holding the parts in these relations, the surgeon now inserts the point of the long needle, armed with a silver wire, into one of the canals of the inner blade, widely separated from the other, and, passing it on, perforates the superimposed structures. The needle, being withdrawn, is then carried along the other gutter, and thence, in like manner, across the tissues, the two punctures being CurTed Fig. 3^7. / v-k REDUCIBLE HERNIA—TREATMENT. 599 about half an inch apart, In this way the base of the plug is thoroughly embraced by the loop of the wire, the ends of which are next twisted over a roll of lint upon the surface of the abdomen. The instrument being kept steadily in its position, the sides of the inguinal canal are next approximated by three horizontal sutures, about half an inch apart, the needle, armed with a stout silk thread, being passed between the blades of the cylinder. In this way, all danger of including the spermatic cord and the peritoneum is effectually avoided. The operation being completed, the instrument is removed, and the patient, rigidly confined to bed, is treated antiphlogistically. The horizontal sutures should not be removed for ten, twelve, or fourteen days, or until there is reason to believe that a sufficiency of plastic matter has been poured out to secure the firm union of the plug. The wire thread, if necessary, may be re- tained for an almost indefinite period. Dr. Hachenberg, of Dayton, Ohio, introduces into the cutaneous cul-de-sac a perforated ivory ball, attached to a long, double thread, the upper end of which is brought out at the superior part of the internal ring, where it is Becured to an apparatus designed for the purpose, while the other end is left pendent below. Inflammation soon follows, and when suppuration is estab- lished, the fastening to the abdomen is loosened, and the ball withdrawn by traction upon the lower portion of the ligature. Of three cases treated by this method, two are said to have been entirely successful, and the other materially benefited. Of 140 cases of hernia, operated upon, with slight modifications, according to Wutzer's method, by Professor Rothmund, of Munich, up to 1853, 117 were cured, 4 were ameliorated, 6 were not benefited, and 13 relapsed. Of the latter, some were operated upon a second time, and radically cured. Of the amount of reliance to be placed upon these statistics, it is difficult to form a correct estimate. Rothmund himself states that many of the patients were lost sight of immediately after the operation, while, on the other hand, the cure in a great number of others was ascertained to be perfect at the end of a year and upwards. In this country, the operation of Wutzer has so signally failed that I am myself unwilling to put much confidence in the statistics. Professor Armsby, of Albany, New York, has modified the operation of Wntzer by substituting for the needle a single thread, which is introduced, as a seton, through the hernial sac and inguinal canal, by an appropriate instrument, invagination of the integument having been previously effected, as in the other process. The thread being brought out by one end at the upper part of the internal ring, and by the other at the lower part of the scrotum, is occasionally moved, in order to provoke the requisite amount of inflamma- tion. A truss is applied for a few hours immediately after the operation. Dr. J. W. Riggs, of New York, has likewise suggested the use of the seton for the radical cure of this disease, but on a larger scale than that recommended by Dr. Armsby. In the New York Journal of Medicine and Surgery, for March, 1858, he has described and delineated an ingenious instrument for performing the operation, and has given the results of eight cases, two from ins own practice, and six from that of Professor Carnochan, nearly all being successful, without any bad symptoms having followed. Several of the cases »ere of very long standing. Ihe operation with the seton was devised by Mosner, by whom, according 0 Kotnmund, it has been performed in 34 cases, with 29 cures, 2 ameliora- tes, 1 failure, 1 death, and 1 relapse. to h ?^an(*tne most popular operation for the radical cure of hernia seems fou d A °- M-r" J°hn Wood> of London- The principle upon which it is d consists in the approximation of the tendinous structures of the hernial 600 HERNIA. canal, and in their close conBnement until they are thoroughly united by plastic matter by means of a ligature passed through a puncture in the skin. As I have not performed this operation, I shall content myself with the following account of it taken from the last edition of Mr. Druitt's excellent Manual of Surgery :— "An incision about half an inch in length is made through the skin of the scrotum, over the spermatic cord, an inch and a half below the pubic spine. The skin is then separated, by means of a small tenotomy knife, from the subjacent fascia in a circle around this incision, about two inches in diameter. Next, the finger is introduced into the wound and made to pass into the inguinal canal. The finger then searches for the arched border of the internal oblique muscle, and is carried behind it towards the linea alba. Then a curved needle, represented in the cut, with its point protected by a tube, is Fig. 388. Wood's instrument for radical cure of hernia. carried up along the concavity of the finger, and made to perforate the con- joined tendon close to the internal ring, and to perforate the skin; but the skin, before perforation, is to be drawn upwards and inwards, so that the outward puncture will be, when the skin is restored to its natural situation, lower and more external than the point where the conjoined tendon is per- forated. A thread is now put through the eye of the needle, and the needle withdrawn, leaving one end of the thread projecting. The finger next is made to feel for the external pillar of the ring, and to push the cord down- wards out of the way; and the needle is carried along it, and made to pierce Poupart's ligament; meanwhile the skin is moved downwards, so that the needle-point comes out at the first puncture. A loop of thread is left there and held, whilst the needle is withdrawn. The finger is next made to feel for the internal pillar, and the needle to pierce the conjoined tendon, the internal pillar, and triangular ligament, half an inch above the pubes. The point is brought out at the same aperture as before, the end of thread is pulled out, and the needle withdrawn. The two separate ends of thread which have perforated the internal pillar, and the loop which has perforated Poupart's ligament, are pulled tight, and are passed through a hole in a box- wood pad, and tied over the bar represented above. Thus the inguinal canal is first filled with invaginated fascia and sac; and then its sides are brought together by this subcutaneous suture, so that it is contracted and made to adhere to the invaginated tissues. A pad and bandage are applied, and the ligatures allowed to remain three or four days." The cases best fitted for these various procedures are such as are of com- paratively recent standing, and unaccompanied by any great bulk of the tumor. When the canal is much diminished in length, and increased in dia- meter, as generally occurs in old ruptures, in which the orifices of the canal are on the same line, and immediately above each other, a cure will generally be impracticable by any method whatever. To femoral, umbilical, and ven- tral hernias, these procedures are not adapted, owing to the greater risk o peritonitis and extensive suppuration. IRREDUCIBLE HERNIA. 601 In a case of hernia, consequent upon a wound of the abdomen, in a young man, about thirty years of age, I succeeded in effecting a very excellent cure by cutting down upon the parts, and closing the opening with four inter- rupted sutures, carried through its muscular edges, which had been previously well pared, upon the same principle as in hare-lip. The operation, which was performed in December, 1858, at the Jefferson College Clinic, was unattended by a solitary unpleasant symptom. In a case of large, old scrotal hernia, in a man sixty-two years of age, upon whom I operated in March, 1861, in a similar manner, at the Philadelphia Hospital, the cure was equally perfect, although the parts were seized with erysipelas, which, for a time, was quite alarming. The approximation was effected with three silver wire sutures. In the New Orleans Journal for March, 1859, Professor T. Gr. Richardson has suggested the propriety of treating inguinal hernia by means of the silver wire suture, introduced subcutaneously. The idea is certainly ingenious, and will no doubt receive due attention. It is easy, however, to suppose that the operation must often fail for the want of a sufficiently abundant plasma. Hence, direct incision would probably be preferable. 2. IRREDUCIBLE HERNIA. An irreducible hernia is one in which the protruded parts do not admit of replacement. Various causes may conspire to produce such a result. Some of these causes are altogether of an adventitious character; others relate to changes experienced by the prolapsed structures, in consequence of their long sojourn on the outside of the peritoneal cavity; and others, again, depend npon the condition of the edges of the opening, whether normal or abnormal, at which the hernia has occurred. Finally, the difficulty may exist on the part of the peritoneal cavity. These causes are of great practical import- ance, and, therefore, demand separate consideration. Under the first head of causes, here designated as the adventitious, may be enumerated the adhesions which are so liable to form between the hernial sac and its contents. These adhesions, which are always the direct result of inflammation, are of variable firmness and extent, according to their duration and the amount of plastic effusion. Sometimes all the protruded structures are united, not only to each other, but to the walls of the sac ; but, in gene- ral, certain portions are free, while the remainder are more or less adherent. Occasionally distinct bands are seen stretching from one coil of intestine to another, or from a portion of bowel to a portion of omentum, or, finally, from the prolapsed parts to the surface of the hernial sac. In ancient cases the plastic matter often presents itself in the form of cellular tissue, just as it does, under corresponding circumstances, in the pleura and peritoneum. Secondly, a hernia may be rendered irreducible by the alterations expe- rienced by the protruded structures themselves from interstitial deposits. The omentum is remarkably prone to become hypertrophied from protracted residence on the outside of the abdomen, and similar changes, though not in the same degree, are liable to occur in the bowels. The parts being thus enlarged, perhaps several times beyond their normal volume, are finally ren- dered incapable of being restored to their original situation. Another cause of the irreducibility of a rupture, but one usually of a more transient cha- racter, is the impaction of the bowel with fecal matter, gas, worms, alvine concretions, or some indigestible substance. Sometimes, again, a hernia, originally reducible, may be rendered irreducible by the manner in which the prolapsed parts, especially if consisting of intestine and omentum, are twisted round each other. Thirdly, the cause of the difficulty may exist in the opening in the wall of the abdomen, the margins of which may either contract, and thus prevent 602 HERNIA. the return of the protruded parts; or the orifice may retain its original di- mensions, and yet, in consequence of the changes experienced by the contents of the tumor, the hernia may be rendered irreducible. The whole difficulty, in either case, evidently depends upon a loss in the relative size of the parts concerned in the disease. Finally, the irreducibility of the hernia may depend upon the contraction of the peritoneal cavity, or an unwillingness, so to speak, on the part of this cavity, to reclaim its original possessions. Such an occurrence is very likely to happen in very large and old ruptures, embracing an unusual quantity of bowel and omentum, or of bowel and some solid viscus, as the liver, spleen, or uterus. The parts having resided for a long time in their new situation, are found, when an attempt is made to restore them to their former posi- tion, to be too bulky for the now contracted size of the abdominal cavity. The above causes, excepting the first, are generally tardy in their operation, and hence a considerable period often elapses before the protruded structures become finally irreducible. When inflammation is set up in the sac, or in the prolapsed parts, whether accidentally or otherwise, a hernia may be ren- dered irreducible in a very few days. The varieties of rupture most liable to this occurrence are the scrotal and umbilical. Persons affected with irreducible hernia are subject to habitual derange- ment of the digestive apparatus, especially to flatulence, eructations, acidity, nausea, colicky pains and constipation of the bowels. The size of the tumor varies ; it often remains stationary, or nearly so, for years, but in the end it is sure to increase, and frequently attains an enormous bulk. When a hernia has been long irreducible, it may, especially if unusually bulky, or improperly treated, cause serious irritation both in the sac and in the neighboring parts. Such an effect will be more likely to follow, other things being equal, when the contents of the rupture are composed of omen- tum, than when they consist of intestine, owing to the fact that the former, gradually yielding to the pressure so incessantly exerted upon it, is apt to become not only greatly hypertrophied, but completely metamorphosed in its structure, thus unfitting it for safe companionship. More than one in- stance has been known where such a state of things has caused death by ascites or suppuration, the inflammation extending from the sac and the pro- truded omentum to the peritoneum or to the omentum within the abdomen. Treatment.—In the treatment of irreducible hernia three prominent indi- cations are presented: first, to render the affection, if possible, reducible; secondly, where this cannot be done, to prevent its increase; and, thirdly, to palliate the suffering caused by the confined and compressed condition of the displaced parts. The probability of a successful fulfilment of the first indication will depend materially upon the circumstances of each individual case, aud cannot, there- fore, be stated with any degree of precision. The most important of these circumstances are, the size and age of the hernia, and the condition of the general health. A small tumor will, other things being equal, be more likely to become reducible than a large one, and one of recent standing than one that is old. Indeed, it is questionable, when the tumor is very bulky, whether its contents ought to be returned, supposing that they could be disengaged, on account of the injurious impression which they would create in the ab- dominal cavity, which, in consequence of their long absence and great size, would be little disposed to accommodate itself to their presence, or provide for them a new home. The chances of a fortunate issue will also be greater in a sound than in a sickly person, the function of absorption, upon the vigor- ous execution of which the favorable result essentially depends, being always performed more energetically in the former than in the latter. The measures best calculated for fulfilling this indication, whether the cause of the non- IRREDUCIBLE HERNIA — TREATMENT. 603 redncibility be hypertrophy or adhesion, are, absolute rest in the recumbent posture, low diet, venesection, purgatives, mercurials, and sorbefacient appli- cations. Without repose in the recumbent posture, absolute, steady, and protracted, no course of treatment, however judiciously conducted in other respects, will be likely to prove of the slightest avail. The diet should be non-stimulant, farinaceous, and barely sufficient to support life; it should be low, in the broadest sense of the term. If the patient is young and robust, the treat- ment may be commenced with the abstraction of from sixteen to twenty ounces of blood, the operation being afterwards repeated to one-half, one- third, or one-fourth of that extent every eight, twelve, or fifteen days, until the patient is so far drained of fluids as absolutely to forbid any further de- pletion. In old and enfeebled subjects, the lancet must either be withheld entirely, or used with much caution. Purgatives will be of the greatest benefit throughout the whole course of the treatment, whether short or pro- tracted, or whatever may be the condition of the patient in other respects. They not only unload the bowels, and thus prevent fecal accumulation in the protruded viscus, but they aid in equalizing the circulation, and in promoting absorption. The best articles are compound extract of colocynth, jalap, and blue mass, given in doses sufficiently large to produce one or two efficient motions, and repeated every third, fourth, or fifth night. Their action may be assisted, if necessary, by enemata or saline laxatives. As soon as the system has been properly prepared by diet, venesection, and purgatives, the patient should be subjected to the use of mercurials, such as calomel, blue mass, or corrosive sublimate, with a view to the gradual pro- duction of ptyalism, which should be steadily, but cautiously, continued for many weeks. Such a course is always equally indicated, whether the cause of the irreducibility of the hernia be hypertrophy or adhesion of the pro- truded viscera. The manner in which it proves beneficial need not be pointed out here, as it has been explained elsewhere. Along with the mercurials might be used, more or less freely, the iodide of potassium, and hydrochlorate of ammonia, alternately every other week, in doses varying from ten to thirty grains thrice a day. As it respects the local treatment, the first thing to be done is to suspend the tumor by means of an appropriate apparatus, so that it shall receive no injurious impulse from coughing, straining, or other muscular exertion. This point being attended to, sorbefacient lotions are diligently applied, as solu- tions of acetate of lead, Goulard's extract, or, what is better, of hydrochlorate of ammonia. Various stimulating liniments and unguents may also be used, especially after the case has been some time under treatment. Occasionally steady, systematic compression answers a good purpose; maintained either with adhesive strips, as in the treatment of subacute orchitis, or by means of a truss with a hollow pad, progressively lined with layers of leather, or fur- nished with a gum-elastic air cushion. It is impossible to say how long, in any given case, this mode of treatment should be continued, before its good effects will become apparent, or before we can determine the probability of its inutility. In the few cases in which I have employed it, it was extremely difficult to secure the hearty co-operation of the patient beyond six or eight weeks. This plan of treatment, it will be perceived, is similar to that of Valsalva for the radical cure of aneurism, and was doubtless originally suggested by the circumstance that, during protracted illness, an irreducible hernia has occasionally disappeared spontaneously, the protruded viscera having become disengaged from their sac, or having drawn the sac along with them into the abdominal cavity. V\ hen the case is hopelessly irreducible, all that can be done is to support e Parts 'n such a manner as to prevent their further descent, and, at the 604 HERNIA. same time, protect them from injury. When the tumor is small the best con- trivance is an ordinary spring truss with a hollow pad, made either of metal, gutta-percha, or unoiled sole-leather, its interior being well padded with buck- skin, or some other soft, pliant material, to protect the surface from undue pressure. Such an apparatus will answer nearly equally well for all varieties of irreducible hernia, whether inguinal, femoral, umbilical, or ventral. When, on the contrary, the tumor is very bulky, the gum-elastic suspensory takes the place of the hollow truss, as better adapted to sustain the heavy and pendulous mass. As now manufactured in our larger cities, especially in Philadelphia and New York, it is difficult to imagine anything of the kind more perfect, comfortable, and convenient. It is incomparably superior to the numerous and clumsy contrivances so much in vogue a few years ago. The suspensory, while it may be readily adapted to all the varieties of irre- ducible rupture, is particularly applicable to the scrotal, the descent of which it is well calculated to restrain by the steady and uniform compression which it exercises upon the pendulous tumor. The colicky pains, dragging sensations, and dyspeptic symptoms, so com- mon in persons laboring under irreducible hernia, are best relieved by atten- tion to the diet and bowels, and the avoidance of severe muscular exertion. The food should be plain, simple, and concentrated, comprising the greatest possible amount of nutriment in the smallest possible space; acidity and flatulence should be remedied by the alkalies, especially the bicarbonates, carminatives, and tonics; and the bowels should be maintained in a soluble state by some mild vegetable pill, or the saline cathartics. In short, the patient, while he should consider himself constantly as an invalid, should do everything in his power to keep his health as near as possible to the normal standard; neither starving himself, on the one hand, nor indulging in any excesses, on the other. Inflamed Irreducible Hernia___An irreducible hernia, particularly if it be one of large size, may occasionally be assailed by inflammation, brought about either by external violence, or by the inordinate accumulation of irritating fecal matter in the incarcerated intestine. The symptoms denotive of the occurrence are generally those of an ordinary circumscribed peritonitis; hence, unless the case is carefully investigated, it might very readily be mistaken for one of strangulation. The attack is usually announced by pain and tenderness in the parts, attended with a sense of weight and tension, but without any marked increase in the size of the tumor. The skin soon becomes hot, if not also discolored, and there is occasionally a good deal of oedema. The constitutional involvement is seldom considerable, unless, as sometimes hap- pens, there is a tendency to the formation of a stercoraceous abscess, when it will, of course, be proportionately severe. Vomiting now and then takes place, more especially in the earlier stages of the attack, generally as a consequence of the presence of irritating ingesta, as if nature were desirous of relieving herself in this way, but the matter ejected is never feculent, and this fact, coupled with the circumstance that the patient, although laboring under con- stipation, is still able to pass flatus and fluid feces, is usually sufficient to distinguish the complaint from strangulation. Moreover, in inflamed hernia, the ring is generally free from tension, and the pain is always referred, in the first instance, to the body of the tumor, whereas, in strangulation, it is origi- nally most severe at the site of stricture. The treatment must be conducted upon general antiphlogistic principles; by rest and elevation of the parts, the application of leeches, anodyne and saturnine lotions, laxative injections, and strict abstinence. Purgative medi- cine is carefully avoided, and it may even be necessary to control the action of the bowels with anodynes, in the same manner as in ordinary peritonitis. Obstructed Irreducible Hernia.—Another source of trouble in irreducible STRANGULATED HERNIA. 605 hernia is obstruction from the accumulation and impaction of fecal matter and flatus. The occurrence is most common in large ruptures of old subjects, and may exist independently of inflammation and strangulation, although both may ultimately supervene, especially if the parts be subjected to rough mani- pulation in the employment of the taxis. The immediate cause of the ob- struction is usually some adhesion between the protruded structures and the sac, leading to the formation of an elbow or angle in the incarcerated bowel at variance with the propulsion of its contents, or, what is the same thing, their return into the abdomen. The most prominent symptoms are colicky pains, flatulence, constipation, and irritability of the stomach, with occasional vomiting of ingesta, or ingesta, bile, and mucus. The tumor is generally free, at least for a considerable length of time, from pain and tension, although it may be somewhat tender on pressure. The treatment may be commenced with a stimulating enema, as, for ex- ample, a mixture of turpentine and castor oil, to clear out the lower bowel. The fluid may, if necessary, be introduced with the gum-elastic tube. When this object has been attained, recourse may be had to the taxis, in the hope of being able to empty the obstructed intestine of feces and flatus, the patient being at the time under the influence of chloroform. If the success attend- ing the operation is only partial, a brisk purgative may next be administered, and this, also failing, may be followed by the knife. 3. STRANGULATED HERNIA. Strangulated hernia is that form of the disease in which the protruded parts are firmly, painfully, and injuriously compressed by the edges of the opening at which the descent has taken place, or at the neck of the sac, as seen in fig. 389. Some- Fig- 389. times, however, the constriction occurs at the mouth of the sac, in the interior of the sac, or between the prolapsed structures themselves. Thus, a protruded bowel has occasionally been strangulated by being tightly wrapped up in a piece of omentum, or by being forced through a fissure in its substance. It is not often that a recent rupture is ex- posed to the danger of strangulation; in gene- ral, it is only when the parts have been seriously changed by interstitial deposits, or, in other words, when the hernial canal and rings have become greatly contracted or the protruded structures have disproportionately increased in bulk, that such an event is likely to occur. Out strangulated hernia. of 100 cases of this disease, analyzed by Mr. Wilkinson King, of London, the mean duration of the rupture in 61, prior to the supervention of strangulation, was about twenty years ; whilst out of 98 cases, 94 were in various degrees "old" before this occurrence. Recent ruptures, however, especially if small, are, other things being equal, remarkably prone to be attended with great suffering when strangulation occurs. In such an event, too, the danger both to the part and system is always much greater when the strangulation is not promptly relieved, than in hernias of large size and of long standing, for the reason that the constric- tion is usually more severe in the former than in the latter, and, therefore, wore liable to be followed by mortification. The varieties of hernia in which me strangulation is commonly most violent and dangerous are the femoral and concealed inguinal; both of them usually of small size, and for this rea- son apt, unfortunately, to be overlooked. 606 HERNIA. Strangulation generally takes place suddenly, in consequence of some vio- lent muscular exertion, as in leaping, running, lifting, or coughing. However induced, the person is soon rendered conscious of the occurrence by the tender state of the tumor, and by a sense of general uneasiness in the abdomen. Gradually, perhaps rapidly, the suffering increases; the parts become exqui- sitely painful, both at the site of the swelling and for some distance around; the slightest touch even of the finger is frequently intolerable; a feeling of constriction, as if a cord were stretched tightly round the belly, is often com- plained of; the patient lies upon his back, with the knees retracted and the shoulders elevated, in order to relieve the parts as much as possible of their tension ; there is more or less restlessness, and even jactitation ; the pulse is frequent, hard, and wiry; the mouth is dry, the thirst is urgent, the surface hot, the countenance flushed, and the head oppressed with pain. By and by nausea and vomiting occur, at first of ingesta, then, perhaps, of bile and mucus, and finally of stercoraceous matter; hiccup now sets in, and twitching of the tendons soon becomes a prominent symptom. The mind wanders, sometimes even at an early stage, and not unfrequently there is low, muttering delirium. The bowels are usually obstinately constipated from the first, or, if there be any alvine discharge, it is derived entirely from the part of the bowel below the seat of the mischief. If, when the case has reached this crisis, prompt relief be not afforded, another series of changes occurs, still more striking and portentous. The countenance now assumes that peculiar shrunken aspect, so well described by Hippocrates, and hence usually called by his name; the tongue is dry, tremulous, and unable to pro- trude itself; the gums and teeth are incrusted with sordes; the surface is covered with clammy perspiration ; the extremities are icy cold; the tumor crackles under pressure, and is of a livid color, and the patient is in a state of the utmost exhaustion, unable to answer any questions, or to maintain himself upon his pillow. The pain, previously complained of, has suddenly ceased, and the poor sufferer, if not wholly unconscious of his condition, per- haps flatters himself that he will soon be well, when, in fact, he is in the very jaws of death. Mortification of the protruded parts has taken place, and his only hope of safety is in the formation of an artificial anus. The period at which death occurs varies, on an average, from three to five days, being generally earlier in strangulation of small and recent hernias than in that consequent upon large and old ones. The symptoms of strangulation, especially in its earlier stages, are not always as urgent as they have been here represented. Sometimes, indeed, they are exceedingly mild, even for several days, when, perhaps, all of a sud- den, they become greatly aggravated, and denotive of the worst consequences. It is worthy of remark, too, that they are usually more severe in strangulation of the bowel than in strangulation of the omentum, though not as much so as is commonly supposed. The diagnosis of strangulated hernia may usually be readily determined by the history of the case, a thorough examination of the abdomen, especially of those regions which are most liable to visceral protrusions, and a careful consideration of the constitutional and local phenomena. There is always a partial, and, when the stricture is very tight, a complete interruption between the sac and the general peritoneal cavity; and hence, if the patient be re- quested to cough, while the fingers are pressed upon the tumor, no impulse will be imparted to them. Moreover, if the tumor be grasped firmly with one hand, and alternately squeezed and relaxed, while the index finger of the other hand is placed upon the neck of the hernia, opposite the seat of the stricture, the impulse produced by the compression will cease abruptly at the seat of the obstruction, owing to the fact that the contents of the sac cannot be forced farther on, as happens when the communication remains free. Ihe STRANGULATED HERNIA — TREATMENT. 607 chief difficulty in regard to the diagnosis of strangulated hernia arises from the circumstance that there is occasionally no external tumor whatever, or, if a tumor be present, that it is impossible to determine whether it is hernial in its character, or the result of an incipient abscess, or of an inflamed lym- phatic ganglion. Besides, it should not be forgotten, as will be shown by and by, that all the symptoms of strangulated rupture are sometimes most painfully simulated by various internal affections, as intussusception of the bowel, or strangulation of the bowel and omentum by bands of false mem- brane. The mere mention of these facts should be sufficient to impress upon the mind of the surgeon the importance of increased vigilance in his exami- nations of all doubtful cases of this kind, as everything may depend upon a correct diagnosis. Dissection of the body after death from hernia reveals, in general, nothing but the ordinary evidences of peritonitis. The protruded parts are in a state of the most profound vascular engorgement, livid, purple, or claret in color, and incrusted with plastic matter. If gangrenous spots exist, they are easily recognized by their greenish or blackish hue, and by their soft consistence. At the seat of the stricture the bowel is usually ulcerated, or pierced with apertures, so small, commonly, as hardly to admit even of the escape of gas, much less of mucus and feces. Occasionally the only morbid change there is a ring-like groove in the walls of the intestine. The sac, participating in the morbid action, generally exhibits strong traces of inflammation. On laying it open there is almost always an escape of serous fluid, varying much in quantity and color in different cases, and under different circumstances. While it is seldom entirely absent, in any instance, it rarely exceeds half an ounce or six drachms, the average ranging from a drachm and a half to two drachms. Its color is at first like that of water, but as the strangulation advances it is rendered red, dark, or purple, from the admixture of hematosin. Occasionally the sac contains pure blood, but this is unusual. The external investments of the tumor are more or less congested, discolored, and, when the mortification has extended also to them, emphysematous, from the extri- cation of gas. The general peritoneal surface also exhibits traces of the effects of the strangulation, being always most distinct at and immediately around the seat of the constriction. The affected parts are variously discolored, incrusted with lymph, and here and there adherent. Occasionally the cavity of the serous membrane contains a small quantity of altered serosity. Such, in few words, are the usual and most prominent morbid changes observed after death from strangulated hernia. If the patient survive the effects of the mortification, the superincumbent structures of the hernia slough away, and the dislocated bowel being also opened, an artificial anus is established, admitting thus of the discharge of fecal matter along the upper portion of the tube; while that which intervenes between the accidental and natural outlets, gradually unburdening itself of its contents, sinks into a state of collapse. Treatment.—For the relief of strangulation, various means are at our com- mand, all resolving themselves into the one great and important element of an early and effectual reduction ; for it must be evident that there can be no safety, either for the parts or the patient, so long as the protruded viscera «re permitted to remain in their constricted condition. The sooner, there- •ore, an attempt is made to restore them to their natural situation, the greater will be the chance of preventing inflammation, which is so much to be dreaded "J all cases of this kind, because it constitutes the chief source of danger. c Period at which inflammation supervenes after the occurrence of the strangulation varies from a few hours to several days, depending mainly upon nature of the protrusion, the character of the stricture, and the state of 608 HERNIA. the system. As a general rule, it raay be assumed that the occurrence will be early in direct ratio to the small size and recent standing of the hernia, the firmness of the parts opposing restoration, and the robustness of the patient. Once begun, the inflammation may proceed with great rapidity, involving not only the whole of the protruded viscera, but extending, as we have already seen, on the one hand, to the general peritoneal cavity, and, on the other, to the various coverings of the tumor. This being the case, no one can doubt the propriety of early restorative interference. The means which are employed for effecting the reduction of the strangu- lated parts constitute what is called the taxis, a Greek term, signifying to set in order, or to restore what has been deranged. It has reference merely to certain manual efforts at replacement, which should always be tried before we resort to the knife. The only exception to this rule is where the strangula- tion has existed so long, and the symptoms, local and constitutional, are so urgent, as to render it probable that, if practised, the protruded structures would suffer serious detriment. In such a case, the best taxis is the knife. In order to impart all possible efficiency to the taxis, it is necessary, first, to evacuate the bladder, and also the rectum, provided it be much distended; secondly, to relax the abdominal muscles; and thirdly, to use certain adju- vants, as chloroform, venesection, and external applications. The first of these objects is attained by the patient's own efforts, or, if necessary, by the catheter, and by a slightly stimulating enema; and the second, by placing the patient upon his back, and elevating the head and shoulders, the thighs being bent nearly at a right angle with the trunk, and held close together by an assistant, with the toes somewhat inverted. In most cases, if, indeed, not in all, great advantage will be derived from putting a pillow under the but- tocks, so as to lift up the pelvis. In this manner, the poiuts of attachment of the abdominal muscles being made to approximate each other, the greatest possible degree of relaxation will be secured; a circumstance of paramount importance in all such proceedings. The third indication is fulfilled by the administration of chloroform, carried to the extent of complete obliviousness. The part and system being thus thoroughly relaxed, the surgeon, standing, sitting, or kneeling, as may be most convenient, close to the right side of the patient, as he lies upon the edge of the bed, the sofa, or the floor, grasps the tumor with, the right hand, and draws it carefully downwards towards him- self, to disengage the protruded parts from the neck of the sac, and at the same time give them the proper direction in relation to the outlet of the open- ing or canal through which they have descended. This being done, he exerts gentle, uniform, and steady pressure upon it, to force out its contents, the left thumb and index finger being applied to the upper part of the tumor for the purpose of fixing it at that point, and thus promoting the reduction. If the hernia is very large, the manipulation is performed with both hands, with a degree of caution the greater as the force will now be likely to be more considerable. In a few minutes—perhaps only a few seconds—after the pres- sure has been applied, the operator will generally be conscious of a slight noise, as well as of a slight diminution of the tumor, caused by an escape of gas, and, perhaps, also of fecal matter. Steadily continuing his efforts, he finds that one portion after another of the protruded parts goes up, the last usually with a distinct gurgling sound, until the sac is completely emptied of its contents. Sometimes the most trifling pressure is sufficient for the re- placement, while at other times a large amount is necessary. When the hernia consists both of bowel and omentum, the former generally ascends before the latter, though in this respect there is not a little diversity in d«- ferent cases. The length of time during which the taxis should be continued must vary according to circumstances ; in general, an old hernia will, when strangulate , STRANGULATED HERNIA—TREATMENT, 609 bear pressure much better, and also for a longer time, than a recent one, and a large than a small one. Much will likewise depend upon the amount of inflammation that may be present in the protruded viscera, the parts being always most tolerant of manipulation when this is slight, or when it exists only in a moderate degree. Then, again, a good deal will depend upon the peculiarity of each individual, one person enduring pain much better than another, although the bowel and omentum raay be equally severely compressed in both. When the symptoms are urgent, it is a good rule not to continue the efforts at the taxis beyond ten, twelve, or, at most, fifteen minutes, but to proceed at once to an operation, or, what is preferable, to administer a full anodyne, and cover the tumor with some refrigerant lotion. At the end of some hours, the manipulations may be renewed, and now, perhaps, with a better prospect of success, seeing that the parts have had time to become soothed and relaxed. These attempts, however, also failing, the operation should be commenced without delay. The taxis may be aided, in addition to chloroform, by venesection, the warm bath, anodynes, and various external applications. Venesection, carried to the extent of partial syncope, has generally been viewed as one of the most valuable auxiliaries of the taxis. The blood should be drawn in a full stream, while the patient is in the erect or semi-erect pos- ture, the object of the operation not being spoliative, but exhaustive. Thus performed, it seldom fails to relax the abdominal muscles, to reduce the tumor, and to prevent or relieve inflammation. Bleeding, however, is not to be re- Borted to indiscriminately; for, while it is exceedingly important in small and recent hernias, occurring in young, robust, subjects, with a strong, hard, and frequent pulse, and great tenderness of the abdomen, it is altogether inad- missible in protracted strangulation, or in aged and debilitated persons. A small, rapid, and wiry pulse, so characteristic of peritonitis, does not contra- indicate venesection, unless there is other evidence of prostration, as cold- ness of the extremities, profuse perspiration, and collapse of the features. In my own practice, a resort to bleeding, as an auxiliary of the taxis, has been exceedingly uncommon, chloroform having afforded me all the aid I could desire. When the parts are much inflamed, blood may sometimes be advan- tageously taken from the tumor by leeches. The warm bath is used nearly with the same view as venesection, namely, to depress the system, and induce relaxation of the abdominal muscles. The temperature, at the moment of the immersion, should be about 90° of Fahren- heit, from which it should be gradually raised to 110°. As soon as a dis- position to faintness is felt, the taxis is renewed, and is often successful, especially if aided by anassthesia. Owing to the inconveniences attending its use, the warm bath is rarely employed in private practice, and perhaps this is well, for there is certainly not much sense in parboiling a man when he can be so easily relieved with the aid of chloroform. Among the adjuvants of the taxis, anodynes hold deservedly a high rank. They sometimes succeed when everything else fails. They relieve vomiting, diminish the morbid sensibility of the tumor, tranquillize the system, and induce sleep, during which the reduction of the hernia is occasionally effected as if by magic. They should be given in full doses, either in the form of morphia, opium, or laudanum, according to the judgment of the practitioner. »hen they cannot be taken by the mouth, they should be administered by the rectum, which, indeed, is sometimes the preferable mode. In this way, 1 have repeatedly succeeded in effecting the reduction of a strangulated hernia, with the greatest facility. A 'good rule is, when the symptoms are not urgent, and especially when the patient is averse to the use of chloroform, t0 give four grains of opium, and, if the parts do not return of their own accord during the resulting sleep, to employ the taxis within from four to six vol. n___39 610 HERNIA. hours afterwards, or before the effects of the medicine have begun to pass off, It has happened, more than once, that a strangulated hernia, upon which the taxis had been tried in vain, has spontaneously disappeared during a natural sleep, much to the discomfort of the ever-ready knife's-man. Xo educated surgeon at the present day would think of employing tobacco and tartar-emetic, as auxiliaries of the taxis. Fortunately this practice, which numbers many victims, has either become obsolete, or is rapidly tend- ing that way. Prior to the discovery of chloroform, as an anassthetic agent, there was some excuse for the use of these potent remedies; but certainly none exists at the present day. The employment of purgatives, too, cannot be too pointedly condemned, inasmuch as they are liable to cause vomiting and griping, and, by propelling the contents of the bowel against the strangulated portion of the tube, dis- tension and inflammation of the canal above the seat of the stricture. In omental rupture they cannot exert the slightest agency in extricating the protruded mass. Some benefit may be expected, especially in large and old hernias, from stimulating injections, as castor oil and turpentine, or senna and salts, used copiously by means of a gum-elastic tube carried high up the rectum. The peristaltic action thereby induced unloads the large intestine, and occasionally draws the strangulated portion of the canal into the ab- dominal cavity. Applications made directly to the tumor and the parts immediately around are sometimes beneficial, both in effecting relaxation and relieving inflamma- tion. With this view two classes of remedies, very opposite in their character, may be used, namely, cold and warm. Respecting their relative merits, it is impossible, in the existing state of the science, to form any accurate opinion. It is certain that they are not both equally applicable in all cases and in all circumstances. The best plan, undoubtedly, is to be governed, at least in some degree, in their employment, by the feelings of the patient, or the tole- rance of the part and system. As a general rule, it will be found that cold applications will be borne best by the young and robust, and in cases of recent standing, whereas warm will be most agreeable when the patient is delicate and nervous, or old and feeble. In my own practice I have derived most advantage from cold, applied by means of a small bladder partially filled with pounded ice, or a refrigerant lotion, composed of equal parts of alcohol and water, or a strong solution of nitrate' of potassa and hydrochlorate of ammonia. When a sudden and powerful impression is desired, the tumor may be covered with a thin sponge, saturated with ether, or it may be irrigated with cold water, poured from a pitcher, or thrown upon it with a large syringe. Injections of ice-water might also be tried with a prospect of success. The external application of cold must not be too prolonged, as it has sometimes been followed by gan- grene, especially in the aged and infirm. However employed, it seems to do good by diminishing the congestion in the vessels of the tumor, allaying morbid sensibility, moderating the tendency to inflammation in the protruded parts, relaxing the stricture, aud, perhaps, also condensing any gas that may exist in the constricted bowel. Warm applications are particularly soothing and useful when there is inor- dinate sensibility in the tumor and abdomen, along with an irritable state of the system and a disposition to nausea and vomiting. They may consist simply of water, or, what is better, of water and laudanum, kept constantly upon the parts by means of a large, thick flannel cloth, covered wjth oil-silk, and renewed at least every half hour, care being taken always to have afresn cloth ready the moment the previous one is removed. Warm applications relieve soreness and pain, and, if properly employed, relax both the'■ VaT* and system, often inducing tranquil sleep and copious perspiration, during STRANGULATED HERNIA—TREATMENT. 611 which the bowel has been known to return spontaneously into the abdominal cavity. Although I am in favor of these applications in the milder forms of stran- gulated hernia, I should be very loth to employ them when there is the least urgency, or when the symptoms are such as to render the further postpone- ment of the knife a matter of doubt. It should be remembered that they are at best merely adjuvants, and that by continuing them too long most valuable time may be lost. If, therefore, very decided amelioration do not promptly follow their employment, and, above all, if it be found, after they have been diligently applied for some hours, that the renewed efforts at the taxis are as unavailing as the previous ones, an operation should be performed with the least possible delay. That such a measure, however, is often necessary I am altogether unwilling to believe. On the contrary, I am satisfied from personal experience that, with the aid of anassthesia, proper attention to the patient's posture, and a thorough knowledge of the anatomy of hernia, almost every case will be promptly relieved by the taxis. For years past I have not been obliged to use the knife in a solitary instance, even where the strangulation had existed for three, four, and five days, and where I had been requested by the attendant to bring my instruments for the purpose of ope- rating. In most of these cases I have astonished the patient by the facility and promptness of the reduction, the absence of future suffering or incon- venience, and the rapidity of his recovery. It has long been the custom with some surgeons to operate in every instance of hernia after the slightest trial with the taxis, and in some of the foreign hospitals the employment of the knife seems to have become the rule, and the taxis the exception, recourse being had to it within five or six hours after the commencement of the stran- gulation. Such a procedure as this is certainly not justifiable when carried to such an extent, any more than too great a procrastination with the taxis. The plan which I pursue, when called to a case of strangulated hernia, is perfectly easy and simple. In the first place, the patient is put thoroughly under the influence of chloroform, not ether, because this is apt to cause vomiting; secondly, the abdominal muscles are completely relaxed ; thirdly, the tumor is fairly grasped with the hand, and then gently and steadily com- pressed, not pushed, kneaded, or squeezed by fits and starts. By the adoption of this simple method, patiently continued, I am certain that almost every her- nia, however severely strangulated, may be safely and expeditiously reduced. No opportunity has been afforded me of giving a fair trial to the method of reducing strangulated hernia, suggested by Baron Seutin, of Brussels, and which, he declares, he has practised so successfully for the last twenty years that he has rarely had occasion to employ the knife. It consists in forcibly dilating the stricture by means of the tip of the index finger, carefully insin- uated into the constricting orifice, and then used as a hook, its palmar sur- face presenting towards the protruding parts, while the skin of the tumor is pushed gently upwards so as not to embarrass the proceeding. The patient lies upon his back, with the pelvis raised much higher than the shoulders, and the operation is persevered in until the ring is sensibly dilated, either by simple stretching or actual laceration of the resisting tissues; an effect which 's generally indicated by a characteristic crack, perceptible by the finger, if not also by the ear. A patient has sometimes succeeded in effecting the reduction of his own hernia, after every effort with the taxis had failed in the hands of his attendant. ouch an expedient is always proper if the person is intelligent, especially if He has been in the habit of relieving himself on previous occasions. It is well known, too, that our success with the taxis is sometimes more piompt and efficient if the abdominal muscles are rendered somewhat tense "n when they are completely relaxed, as advised in a previous paragraph. 612 HERNIA. Indeed, some practitioners, acting upon this knowledge, adopt this procedure in all cases. Lastly, I have often seen good effects follow the inordinate elevation of the pelvis, caused by suspending the patient, as he lies in bed, partially by his feet, and doubling up his body, thus producing the greatest possible degree of relaxation of the abdominal muscles, and also a certain degree of traction of the alimentary tube above the seat of the constriction. In his effort at the taxis, the surgeon, instead of restoring the protruded viscera to the abdomen, may push them upwards into a sort of artificial pouch in the cellular substance, between the transverse fascia and the transverse muscle, thus leaving them unrelieved; or, it may be, that the stricture is within the sac, instead of on the outside, and that, although replacement may have been effected, the strangulation continues as violently as before. Such cases are well calculated to embarrass the practitioner, but they admit of no delay. The proper plan, in the first case, is, to request the patient to use every possible exertion, by coughing and other muscular efforts, to reproduce the hernia, and, if he succeed in this, to proceed at once to the use of the knife. This failing, the surgeon, guided by his previous knowledge of the situation of the tumor, and the direction of the replacement, cuts down upon the parts, dividing layer after layer until he comes in contact with the dis- affected viscera, which are then disengaged, and restored to their natural position. A similar procedure is adopted when the stricture exists within the hernial sac, and the protruded structures have been returned without relief of the strangulation. Finally, it is impossible for the surgeon to be too wary in the employment of these manipulations; they must, as already stated, be made gently, not roughly, nor must they be continued too long at a time, or be too frequently repeated. The want of proper precaution may be productive of great suf- fering and mischief, if not actual loss of life, from peritonitis and inflammation of the walls of the abdomen, followed, if the patient survive, by large abscesses and excessive constitutional irritation. Supposing that the taxis has succeeded, the patient must not be permitted at once to rise, and go about his business, particularly if the strangulation has been at all severe. In such a case recumbency is enjoined along with light diet and a full anodyne, uutil all danger of inflammation is over, when, resuming the use of his truss, he may get up and walk about. Operation.—When an Fig. 390. operation becomes neces- sary, the patient is placed upon his back, very much as during the taxis. The bladder having been emp- tied, the hair shaved off the part, and an anaesthetic administered, an incision, linear, crucial, Y or V-like, T" I V or thus, is made through the skin and superficial fascia, over the most prominent portion of the tumor, commencing at its upper extremity, and terminating near its base, its length varying from two to three inches, according to the size of the hernia. The integument may be divided either subcutaneously, by pinching up a fold Mode of operating in strangulated hernia STRANGULATED HERNIA — OPERATION. 613 of skin, as is shown in fig. 390, or by a direct incision, which, in fact, I usually prefer. However this may be, the rule is always to have a large external wound, but a small internal one, pretty much as in the operation of lithotomy. Thus, layer after layer is divided until the surgeon reaches the proper hernial sac, free use being made of the grooved director, fig. 391, Fig. 391. Grooved hernia director. in exposing the deeper-seated structures. The presence of the sac will usually declare itself by its bluish, vesicular appearance; but, to dispel all doubt, Fig. 392. Fig. 394. Fig. 395. 614 " HERNIA. divided to the requisite extent, followed, of course, by the escape of its con- tents. It should be recollected that the quantity of fluid is always small in recent strangulation, and that cases occur where it is entirely absent, lest in our endeavors to find it the dissection should be carried too far. The left forefinger, fig. 392, introduced into the bottom of the wound, now seeks for the seat of the obstruction at its upper extremity, and, having found it, a probe-pointed bistoury is carried flatwise along its palmar aspect underneath the stricture, which is immediately divided by bringing the edge of the instru- ment, as seen in fig. 393, to bear against it. A little incision, not more than a line and a half in length, will generally answer the purpose. The dislocated viscera are now drawn away from the seat of the obstruction, and being found in a condition to be restored, are next carefully replaced into the abdominal cavity, the part that protruded last being reduced first, and the bowel before the omentum. The edges of the wound being approximated by several points of the interrupted suture carried through the muscular layers, the dressing is completed by adhesive strips, a compress, and a bandage. The division of the stricture may be safely effected either with the hernia knife of Sir Astley Cooper, fig. 394, or with a common probe-pointed bis- toury, represented in fig. 395. It would almost be superfluous to say that the patient should be most care- fully watched after so serious an operation as that just now described. The treatment must be strictly antiphlogistic, and the probability of the occurrence of peritonitis must not be lost sight of for a moment. Much may be done in the way of prevention in most cases by the administration of a full opiate im- mediately after the patient has been put to bed, and by close attention to the diet and bowels, which should not be permitted to be moved for several days, but should be kept in the most tranquil condition possible. Should perito- nitis arise, as indicated by the excessive tenderness of the abdomen, the re- tracted limbs, the shrunken features, and the small, wiry, and contracted pulse, the proper treatment will be venesection, leeching, anodyne fomenta- tions, and large doses of opium. When the patient has recovered, he must wear a truss until the parts have become completely consolidated, otherwise relapse will be inevitable. Examination and Treatment of the protruded Intestine.—In the operation as now performed, it is supposed that the protruded parts are in a fit condi- tion to be restored to their natural situation ; but cases arise where the sur- geon may entertain doubts in regard to the propriety of this procedure, or where such a course would be altogether improper. Much judgment and ex- perience are frequently required to enable him to decide the question correctly, and to act with the promptness and certainty which should characterize his efforts for his patient's relief. On the one hand, he may return parts actually in a state of gangrene, and thus inevitably kindle the flames of a fatal inflam- mation ; or, on the other, he may, for want of proper knowledge, cut into the bowel and excise the omentum when they are in a condition to be safely replaced. Actual inspection is, in general, the only reliable source of infor- mation on such occasions, but valuable aid is occasionally furnished by ex- traneous circumstances, as the history of the case, the small size of the swell- ing, the duration of the strangulation, and the condition of the system. Thus, when the hernia is small and recent, the danger of mortification is always greater than when it is large, or large and old ; it is also greater when the strangulation has been protracted than when it is recent, and the probability of its existence is almost converted into certainty when, after the ordinary phenomena of strangulation, there is a Ilippocratic appearance of the coun- tenance, a feeble, tremulous pulse, hjccough, and a crackling state of the tumor, with a sudden cessation of pain and excessive prostration of the vital powers. OPERATION—PROTRUDED INTESTINE. 615 The hernial sac having been exposed, and the stricture divided, the parts are gently drawn down, preparatory to a thorough examination of their con- dition. In all cases, whatever may have been the duration of the strangula- tion, there will be more or less injection of the vessels of the protruded structures, rendering the former unnaturally conspicuous, and heightening the color of the latter. The vascularity of the bowel is always, in the milder forms of the accident, arborescent, that is, the vessels are spread out over the surface of the tube in dendritic lines, and the accompanying discoloration is so slight as to be scarcely distinguishable from the normal appearance ; but when the constriction has been severe or long-continued, the vessels assume acapilliform arrangement, and the peritoneal lining of the intestine exhibits a claret, purple, or blackish hue, with, perhaps, here and there a slight ecchy- mosis. The discoloration, in either case, raay be diffused or circumscribed, uniform or diversified; generally the latter. When the discoloration is slight in degree, although it may be extensively diffused, it may be assumed that the bowel is in a condition to be returned, especially if, after having been emptied of its blood, the vessels are speedily refilled. If, on the other hand, the bowel is very dark, purple, or almost black, the presumption will be strong that there has been great derangement of the circulation, if not actual stagnation of the blood, and replacement should not be attempted unless there is reason to believe that the part will be able to recover from the effects of its compression. To determine this question, one of the most serious that can arise during an operation, the intestine, after having been thoroughly liberated, should be fomented with a sponge or cloth wrung out of warm water, and steadily maintained in contact with it for ten, twelve, or fifteen minutes ; if it be found at the end of this time that there is no change in the appearance of the protruded knuckle, denotive of a return of its circulation, it will be proper to puncture some of its vessels, or even to scarify the bowel very slightly at a few points. If no blood issue, the pro- bability is that the tube is mortified, and this probability is converted into positive certainty, if, superadded to this, there is a softened condition of the parts, an absence of all sensibility, and a total loss of temperature. Much stress has been laid by surgeons upon the greenish or ash-colored appearance presented by the bowel in strangulation, but my conviction is that its import- ance has been greatly magnified, and that, unless it be combined with other changes, especially changes of consistence, it should not be considered as an evidence of mortification. When mortification has actually taken place, then, of course, the bowel is not returned, but freely opened to afford an outlet to its contents, the stric- ture having been previously relieved in the ordinary way. It has been ob- jected to this procedure that it has a tendency to break up the adhesions which the intestine has formed to the edges of the hernial aperture, but such a conjecture is altogether hypothetical, and the practice founded upon it should, therefore, be disregarded. During the progress of the inflammation which precedes the mortification, the bowel is always firmly glued to the ad- jacent parts, and hence the incision necessary to liberate it never permits the extravasation of fecal matter into the peritoneal cavity. To leave the stricture undivided would be to afford only partial relief, not only as respects the symptoms of the strangulation, but also the evacuation of the tube, and might thus lead to the necessity of another operation, at a period, perhaps, when such a procedure might seriously disturb both the part and system. The wound is afterwards left open, and covered with warm water-dressing, fetor being allayed by the use of the chlorides. ao surgeon, nowadays, thinks of excising the mortified portion of bowel, and uniting the tube by the interrupted suture. Such a procedure would e attended with great risk, and has, therefore, very properly fallen into 616 HERNIA. desuetude. Xor is it necessary, as it was once deemed to be, to secure the bowel to the external wound by a stitch through the mesentery, since, as has been already seen, the adhesion between it and the edges in the hernial aperture is always sufficiently firm to prevent its separation, and, consequently, the occurrence of fecal extravasation into the peritoneal cavity. It has been proposed, when the mortification is very limited, to replace the bowel instead of opening it, as when the mischief is more extensive, on the supposition that, before the slough can separate, the parts immediately around the seat of the disease will have contracted firm adhesions to the neighboring viscera, thus protecting the peritoneal cavity against fecal effu- sion. The propriety of such a measure may well be doubted, and I should, therefore, discountenance its adoption, knowing as we do that a dead tissue, if brought in contact with a living one, must always act as a foreign substance, and that, although it might induce a deposition of lymph on the surface in its vicinity, yet the adhesions thus formed might not be strong enough to resist either the peristaltic movements of the bowel, the efforts of the abdominal muscles, or the pressure of the abdominal viscera. Instances occur in which the bowel is ulcerated, in consequence of the compression exerted upon it by the stricture. Only one opening may exist, or the part may be pierced at a number of points, not larger, perhaps, than so many pin-heads, and separated by more or less healthy tissue. In the former case, the aperture, if not more than two lines or two lines and a half in diameter, may be included in a delicate ligature tied firmly around a tena- culum, the ends being afterwards cut off close to the knot, to enable it to dis- charge itself into the bowel, and pass off with its contents; otherwise the part must be treated as if it were mortified. A similar practice is adopted when the intestine has a riddled, cribriform appearance ; because here it would not be possible to tie up each aperture, and yet not safe to return the viscus without such a precaution. Sometimes, again, the bowel is circularly indented by the stricture, as if it had been compressed by a tightly-drawn cord. In this way its circulation may be much embarrassed, if not completely suspended, followed by ulcera- tion and even gangrene. The serous coat, possessing greater resisting power than the others, usually retains its integrity longest, and the rule, therefore, is to return the viscus if its appearance is such as to justify the belief that it will become promptly adherent to the neighboring organs; otherwise to treat it as if it were sphacelated. Finally, the bowel may have contracted adhesions to the inner surface of the sac, thus rendering its restoration difficult, if not impracticable. The mode of procedure varies according to the nature of the union, as to whether it is recent or old ; in the former case, it will be easily broken up with the finger or handle of the scalpel, when the viscus, if otherwise in a proper con- dition, is at once replaced ; in the latter, the liberation may be effected by a careful dissection, provided the adhesions are not very extensive, in which case the bowel, after having been freed by the division of the stricture, should be left in its extra-abdominal situation. When the adhesions are very firm, but limited, it has been suggested to dissect up the corresponding portion of the sac, and to return it along with the bowel; but in performing such an operation the greatest caution is necessary, otherwise the part may act lrn- tatingly, and thus cause serious mischief. Sometimes there is a firm and intimate adhesion between the bowel and the stricture extending round their entire circumference, and seriously inter- fering with the latter's division. The practice under such circumstances has been to incise both bowel and stricture ; but this need surely never be done if proper care and patience be exercised, for by a little management the sur- geon will always either find, or, at all events, will be able to make, a little OPERATION—PROTRUDED OMENTUM. 617 opening between the parts for the insertion of his director or probe-pointed bistoury. It is only when the adhesions are very old and firm that any real difficulty can arise, and even that raay always be comparatively easily over- come by a little dissection. Examination and Treatment of the Protruded Omentum.—Yarious circum- stances may arise to render it improper to reduce a strangulated omentum, among which the principal are inflammation, mortification, hypertrophy, and morbid adhesions. It is well known that this body is much less capable of resisting the effects of inflammation than the intestine; hence it is, not unfre- quently, in a condition not to be replaced when the other is, especially when it is loaded with fat, as it nearly always is in corpulent subjects, and when the slightest compression almost is sufficient to deprive it of vitality. The discoloration of an inflamed omentum is always less than that of an inflamed bowel, and its vessels, instead of exhibiting an arborescent arrangement so conspicuous in the latter, usually present themselves in straggling, perpen- dicular lines. Conjoined with these changes, there is always, particularly in the more violent and protracted forms of strangulation, well marked loss of consistence in the protruded part, so that the slightest pressure of the finger is sufficient to convert it into a pulpy mass. The tests for ascertaining the vitality of a strangulated omentum are simi- lar to those which we have described for judging of the vitality of a strangu- lated intestine; but it should be borne in mind, as was before stated, that a highly inflamed omentum is much more liable to die after it has been replaced than a correspondingly inflamed bowel; and hence, if its vessels are not speedily refilled after their contents have been pressed out, or the circulation do not afford evidence, of returning vigor under the use of fomentations, no attempt should be made at restoration, lest the strangulated mass, acting as a foreign substance, should induce fatal peritonitis. Instead of this, the whole of the affected membrane is excised, and each artery is included in a separate liga- ture, one end of which is cut off close to the knot, and the other brought out at the wound, where it is secured by an adhesive strip. Before so important an operation is performed, the omentum should be carefully unrolled, for it has occasionally happened that it has contained a loop of intestine, which might thus be opened by the knife, much to the detriment of the patient and the dismay of the surgeon. To prevent it from being drawn up into the ab- domen before its vessels are secured, it should be firmly held by an assistant, either with the fingers or by means of a temporary ligature. Retrenchment will also be required when the omentum is much enlarged by interstitial deposits, rendering it impossible to replace it; or when, if restored, it would be likely, on account of its inordinate bulk and tubercu- lated surface, to cause violent peritonitis. Such a procedure is far preferable to that of leaving the protruded part in the hernial sac, in the hope of pre- venting thereby a recurrence of the rupture; a circumstance which, although possible, is not at all probable, and which, even if it did occur, would hardly compensate the patient for the severe dragging sensations to which he would ever after be exposed in consequence. An adherent omentum is treated upon the same principles as an adherent bowel, only that greater liberty may be taken with it when the adhesions are old, in which case it may not only be extensively dissected away from the sac, ^t, if necessary, cut off, in the same manner as in mortification and hyper- trophy, already described. A strangulated hernia sometimes becomes the seat of an abscess, the in- QamQiation occasioned by the constriction terminating in suppuration. Such a" event is most common in hernia of long stauding, attended with the for- mation of a large sac, and the adhesion of the protruded structures to its inner surface. The immediate cause of the deposition of matter may be the 618 HERNIA. constriction itself, the compression of the sac by the imprisoned viscera, or, finally, some external injury, as a blow, or twist, or rough manipulation, inflicted during an attempt at reduction. The matter, which occasionally forms very rapidly, is of a sero-purulent character, and is sometimes quite profuse, amounting to many ounces. If the patient survive for eight or ten days, the fluid gravitates towards the most dependent portion of the tumor, where it may readily be detected by the distinct sense of fluctuation which it imparts to the fingers, by the exquisite pain and tenderness it produces on pressure, and by the red, cedematous coudition of the integuments. In some cases, the matter breaks through its confinement, and finds its way by ulceration to the nearest surface. I have known an abscess to form when the protruded part consisted exclusively of bowel, but the occurrence is by far most com- mon when the hernia is omental, or omental and intestinal. The termination of such an abscess is variable. The matter may be evacu- ated, and the patient make a good recovery, the parts being resolved imme- diately after the fluid has been drawn off, or the pus may escape into the peritoneal cavity, and cause fatal inflammation ; or an opening may form externally, admitting of the discharge both of matter and of feces, as when the bowel has been invaded by gangrene; or, finally, the abscess may be emptied by puncture, but, the constriction remaining unrelieved, the patient may perish under symptoms of strangulation. In any event, a hernial abscess must be considered as a serious complica- tion, both as it respects the fate of the patient and the nature of the diagnosis, which is often extremely difficult and perplexing. The proper treatment, of course, is to lay the sac freely open, to evacuate the purulent fluid, to relieve strangulation, and to restore the protruded structures to their natural position. Division of the Stricture External to the Sac.—This procedure, devised upwards of a century ago, by J. L. Petit, has many advocates, especially in England, where it has received much attention within the last fifteen years, chiefly through the influence and writings of some of the London surgeons. In this country it has probably not attracted as much notice as it deserves. The great advantage of it is that, as it does not interfere with the proper hernial sac, it is much less liable to be followed by peritonitis, which consti- tutes the great source of danger in the ordinary operation. Added to this, it is generally more easy of execution, and attended likewise with less risk of injury to the intestine. On the other hand, the stricture may exist within the sac itself, and hence the parts might be returned without being relieved; a result, the effects of which would only be too certainly fatal. The cases to which the method is more particularly applicable are, first, where there is reason to believe, from the character and duration of the symptoms, that the strangulation cannot be dependent upon the presence of plastic adhesions, but that it is caused by the edges of the hernial aperture; and, secondly, where the tumor is old and has been long irreducible, and where, conse- quently, if the stricture be internal, relief may be afforded by a subsequent operation. The relative safety of the ordinary operation and the operation of Petit, or the division and non-division of the sac, has been placed iu a very strong light by the statistics of Mr. Gay, of London. Thus, out of 125 cases, treated according to the former method, 52 perished, whereas oat of 73 cases m which the sac was not opened only 13 succumbed. Accidents.—The principal accidents that are liable to happen during this operation are wounding of the intestine and hemorrhage. Formerly these accidents were not infrequent, but they certainly are at the present day, owing, no doubt, to our improved knowledge of the anatomy of the different varieties of hernia, and of the relative position of the bloodvessels. Wounding of the intestine is generally the result of sheer carelessness, but hemorrhage MORTALITY. 619 may occur in the hands of the raost skilful operator, and may, therefore, be considered as, in some degree, unavoidable, whatever raay be the precautions exercised in making our incisions and in dividing the stricture. A wound of the bowel will be denoted by the escape of gas, feces, mucus, or ingesta, and, unless extensive, will not add materially to the danger of the operation. If it be very small, as, for instance, not more than a line and a half in length, it may be hooked up with the tenaculum, and embraced by a fine ligature, the ends of which are cut off close to the knot. If the incision be more extensive, the interrupted, Lerabert's, or the glover's suture, must be used, as in ordinary wounds of the bowel. The tube is then replaced, and the case treated upon general antiphlogistic principles. The hemorrhage may proceed from injury of the epigastric, obturator, or spermatic artery, and is sometimes alarmingly profuse. In operating for strangulated femoral hernia, the femoral or saphenous vein has occasionally been wounded, but such an occurrence implies great carelessness, and never happens to a skilful surgeon. When the bleeding is external, the vessel from which it proceeds may occasionally be exposed simply by everting the edges of the wound, or drawing down the neck of the hernial sac; this failing, it is sought for with the knife. The same plan is pursued when the hemorrhage is internal, the wound being enlarged, more or less freely, with the probe- pointed bistoury. Sometimes the flow of blood is readily arrested by syste- matic compression, made with the compress and bandage, or by means of the finger of a relay of assistants. Lastly, the protruded parts, instead of being restored to the abdominal cavity, may be engaged in the cellular tissue between the transverse fascia and transverse muscle, where, the strangulation continuing, they may become a source of fatal mischief. To prevent this occurrence, the finger should always, if possible, be carried into the belly, and gently moved about, to ascertain that the viscera are in their proper situation. Should this be found not to be the case, every effort should be made to liberate them ; with the finger, if practicable, with the knife, if not. To leave them in their new position, would be almost certain death. Mortality.—The mortality after herniotomy must necessarily vary with many circumstances, as the mode of operating, the duration of the strangula- tion, the presence or absence of other maladies, the age of the patient, the nature of the rupture, and the effects of previous treatment. 1st. It has already been seen that the operation of Petit is, as a general rule, attended with much less hazard to life than that in which there is a division of the hernial sac. Of 774 cases treated according to the latter method, and collected by Mr. Gay from various sources, private as well as public, 334 died. Such a mortality is truly appalling; but, while it probably affords a fair average proportion in a given number of cases, it cannot be re- garded as a just representation of the results of individual experience. Her- niotomy shares, in this respect, the same fate as lithotomy, amputations, resec- tions, ovariotomy, trephining, and other capital operations, some surgeons being much more fortunate than others, either because they possess greater skill, or because they are more careful in the selection of their cases. 2dly. The duration of the strangulation must necessarily greatly influence the issue, recovery being more likely to take place when the operation is per- formed early than when it is postponed to a late period, when the patient is, perhaps, already nearly dead from shock, or shock and inflammation. All writers concur in the conviction that delay beyond the second day is ex- tremely hazardous. The annexed table of Mr. Gay, slightly modified, places this subject in a very clear light:— 620 HERNIA. DAT. CASES. RECOVERIES. DEATHS 1st . . 40 43 6 2d . 41 30 11 3d 9 3 6 4th . 5 2 3 5th . 4 0 4 6th . 7 3 4 10th . 3 0 3 118 81 37 3dly. Recovery after operation is often materially affected by the previous state of the patients health. The existence of organic lesion of the heart, large vessels, lungs, pleura, and kidneys, especially if attended with anemia, is particularly unfavorable to success, such a condition predisposing to rapid exhaustion, and to the development of a bad form of peritonitis. 4thly. Young persons are less liable, other things being equal, to die from the effects of the operation than the old and decrepit, who are very apt to sink under its effects, especially when there has been unusual delay. 5thly. The mortality of strangulated femoral and umbilical ruptures is, on an average, considerably greater after operation than that of inguinal hernia, but in what ratio has not been determined. Finally, it must not be forgotteu that the results of herniotomy are often materially influenced by the effects of the previous treatment. Rude and pro- tracted manipulation cannot fail to be prejudicial, from its tendency to pro- voke peritonitis, and there is no doubt that many a patient has been killed by tobacco injections, the hot bath, and excessive venesection, although the operation itself may have been well performed. Causes of death.—The principal causes of death after herniotomy are shock, hemorrhage, peritonitis, erysipelas, and pyemia. 1st. Fatal shock after this operation is uncommon. It is most frequently witnessed in old, dilapidated subjects, exhausted by the long continuance or severity of the strangulation, and occasionally occurs where there is not the slightest evidence of constriction of the bowel, pressure upon the omentum alone being capable of producing it. 2dly. Loss of life from hemorrhage after herniotomy is infrequent; for the surgeon, as already stated, seldom divides any important artery in his attempts to uncover and liberate the protruded parts; and, when the accident occurs, he is generally able to secure the vessel before the patient has sustained any serious detriment. 3dly. The most common cause of the fatality after this operation is un- doubtedly peritonitis. This disease, in fact, generally exists, to a greater or less extent, in all cases of strangulated hernia prior to the operation, and it is. therefore, not surprising that it should often be materially aggravated by the use of the knife and finger, especially when the sac is laid open, by the contact of inflamed with healthy peritoneum after the reduction of the parts, or by the escape of fecal matter, as sometimes happens in ulceration of the bowel. When death arises from peritonitis, however induced, it usually takes place within the first three or four days after the operation. 4thly. A bad form of erysipelas not unfrequently comes on after this ope- ration, generally during the first thirty-six hours, being most common in per- sons of broken constitution and intemperate habits, and in such as are laboring under organic disease of the heart and kidneys. The attack manifests itself by a reddish or livid appearance of the parts, soon followed by gangrene and sloughing, or, at all events, by a foul, unhealthy condition of the wound, aim by great irritability and depression of the system. The period at which it proves fatal varies, on an average, from three to five days. 5thly. Pyemia, as a cause of death after herniotomy, is of rare occurrence. INGUINAL HERNIA. 621 It is most liable to arise in persons who have suffered severely from the shock of strangulation, or from shock and hemorrhage, and usually comes on within the first three days after the operation. Finally, death is occasionally produced by the rude employment of the taxis, in consequence of the imperfect division of the stricture, or the adhesions of the protruded parts to each other and to the hernial sac. An accidental wound or rupture of the intestine may be cited as another cause of fatality. SECT. II.—HERNIA OF PARTICULAR REGIONS. The principal varieties of hernia are the inguinal, scrotal, femoral, and umbilical, to which may be added the rarer forms of obturator, sciatic, peri- neal, pudendal, vaginal, and diaphragmatic. INGUINAL HERNIA. When the contents of the abdomen pass out at the groin, the complaint constitutes what is called an inguinal hernia, or a rupture of the groin. Of this affection there are two distinct varieties, fig. 396, namely, inguinal Fig. 3P6. hernia by the oblique descent, and inguinal hernia by the direct de- scent, each of which demands sepa- rate consideration. Oblique Inguinal Hernia—Ob- lique inguinal hernia derives its name from the fact that it pursues the course of the spermatic cord in the male, and of the round ligament in the female. It is of more fre- quent occurrence than all the other varieties of the complaint put toge- ther; is met with chiefly in men, and is more common on the right side than on the left. The reason why this form of hernia is so much more frequent in men than in wo- men, is the greater relative size of the inguinal rings and canal in the former than in the latter, thus constituting a powerful predisposition to the disorder. Another reason, aonbtless, is that men are much more exposed to all kinds of hardships, involving inordinate muscular exertion. The situation of the liver has usually been assigned as the cause of the greater frequency of hernia on the right side than on the left, the pressure which it exerts upon the alimentary tube, and through it upon the inguinal region, being much greater than that exerted by the spleen. As another cause of the difference, though probably not a T.ery efficient one, may be mentioned the circumstance that most persons are "ght-handed, thereby keeping the right abdominal walls more constantly in a state of tension, especially in the working classes, among whom inguinal jenna ls so common Occurring at all periods of life, it is produced by the ame causes as ruptures in other situations, and may be complete or incom- Pete, according as the parts protrude or not at the external ring. rin " C°^plete 0Dlique inguinal hernia the viscera enter the internal inguinal g. and, descending along the inguinal canal, emerge at the external ring, Inguinal hernia ; on the right side oblique, on the left direct, a. The hernial sac. b. The epigastric artery. 622 HERNIA. forming thus a tumor in the groin, immediately over Poupart's ligament, and just outside the spine of the pubes. Varying in volume from that of a pigeon's egg to that of the fist, it is usually of a globular form, and of a soft consist- ence, receiving a distinct impulse on coughing, and receding during recum- bency, but reappearing in the erect posture. There is a peculiar form of inguinal hernia, accompanied by an undescended testicle, in which the tumor extends uncommonly far outwards and upwards towards the crest of the ilium. In a case recently under my charge, in a man, aged thirty-five, an inmate of the Philadelphia Hospital, the tumor was of extraordinary volume, measuring twenty-two inches at its attachment to the abdomen, by nine in length, and ten in width. It was of a globular form, and hung down over Poupart's ligament on the right side, as far nearly as the upper third of the thigh, reaching, on the one hand, over to the pubic sym- physis, and, on the other, to the anterior superior spinous process of the ilium. It was soft, elastic, and easily reducible, the parts returning with a gurgling noise. The opening through which the bowel had descended appeared to b? upwards of an inch in diameter, and to correspond with the internal rings The testicle lay at the outside of the tumor, between the inner ring and thp anterior superior spinous process of the ilium, and was remarkably sensitive to the touch, but of the usual size. The left testicle was also retained in the] groin, occupying the site of the internal ring. The scrotum existed in a' rudimentary state. The hernia had come on five years previously, in conse-.' quence of a strain, and had of late greatly increased in bulk. The tumor, exhibited altogether a very remarkable appearance. s There is no doubt that the protruded viscera in the above case would have passed into the scrotum, if their progress had not been impeded by the undescended testes, which had the effect of pushing them upwards and out- wards. Diagnosis.—The diagnosis of this variety of hernia may be obscured by various affections liable to occur in this situation, among which the most com- mon are hydrocele of the spermatic cord, imperfect descent of the testicle, diseased lymphatic ganglions, and psoas abscess. An oblique inguinal hernia, so long as it remains in a reducible state, can, in general, easily be distin- guished from other affections; but the case is very different when it becomes irreducible or strangulated. Then the most experienced surgeon cannot always determine, without the greatest care, the precise nature of the com- plaint. An encysted hydrocele of the spermatic cord is generally small, not exceed- ing the volume of a pigeon's egg, round or ovoidal, tense and elastic, uniform in its consistence, fixed in its situation, and distinctly translucent when viewed against the light. These characters, together with its history, are sufficient to distinguish it from hernia, provided it is below the external ring, but when it is above this point, under cover of the tendon of the external abdominal muscle, some difficulty may be experienced. When this is the case, a small exploring needle will generally furnish the requisite information. An imperfectly descended testis might be mistaken for an oblique inguinal hernia, especially if it were to lie, as it sometimes does, partly within and partly outside the external ring. Its ovoidal form, however, its constant, unvarying volume, its firm consistence, and the peculiar sickening sensation produced by compressing it, together with the history of the case, and the absence of all disturbance of the intestinal tube, will hardly admit of the pos- sibility of confounding the two complaints with each other. An inguinal hernia is sometimes closely simulated by an inflamed lymph'*1* ganglion, and the diagnosis may be still further embarrassed by the co-exis■ ence of the two diseases. Enlargement of the absorbent glands of the groin may result from various causes, of which, however, the most common are INGUINAL HERNIA — DIAGNOSIS. 623 391; gonorrhoea and chancre, leading often to a great deal of tenderness, pain, and swelling, followed, in time, by suppuration and abscess. In the early stage, the affection might be mistaken, especially by an incautious observer, for an inguinal rupture. In general, the enlargement is easily recognized by its situation, which is oftener below than above Poupart's ligament, by its defined, circumscribed character, by its mobility, and by our being able, when the tumor is grasped, to lift it away, as it were, from the subjacent parts ; circumstances which, joined to the history of the case, will usually serve to show that the tumor is not a hernia. Another source of doubt in this affection is psoas abscess, which, as it progresses, often points just above Poupart's ligament, generally, however, nearer to the anterior superior spinous process of the ilium than to the pubic symphysis, which is not the case in complete inguinal hernia, whether by the oblique or direct descent. In psoas abscess, moreover, the patient is always some- what lame on the corresponding side, and there is more or less derangement of the general health prior to the occurrence of the doubt in the diagnosis. Besides, in strangulation the tumor is fixed, whereas in psoas ab- scess it is movable, receding under pressure, and disap- pearing measurably or completely during recumbency. In the female the diagnosis of inguinal hernia is occasionally obscured by the existence of a serous cyst, formed apparently in connection with the canal of Nuck, a process of peritoneum, extended over the round liga- ment. The tumor, which is sometimes prolonged into the labium, is free from pain, slow in development, semi-pellucid, globular, ovoidal or pyriform, elastic, fluc- tuating, and filled with a thin, watery fluid, similar to that of hydrocele. Its volume ranges between that of an egg and a large fist. In a case mentioned by Scarpa, the cyst, attached by a narrow pedicle, was fourteen inches in circumference, and contained forty-three ounces of fluid. In oblique inguinal hernia the spermatic cord is situ- ated behind the tumor, as exhibited in fig. 39*7, the epi- gastric artery lying on its inner side, close to its neck. As it proceeds downwards to its place of destination in the groin, it clothes itself, in addition to its proper sac, with the infundibuliform process of the transverse fascia, the fibres of the cremaster muscle, the spermatic fascia, superficial fascia, and skin. Hence, every such hernia may be said to have six coverings, which, in cases of long standing, are generally quite thick and closely matted together, hut often very thin and indistinct in those of recent formation. I recollect operating, some years ago, upon a strangulated inguinal hernia, where the coverings of the tumor consisted only of the skin and the merest film of cellu- lar tissue. In old ruptures, on the contrary, especially in those of large bulk, a tedious dissection is often necessary before we can reach the proper hernial sac, skin, fascia, muscular and aponeurotic fibres being all in a state of thick- e,11|ig, induration, and condensation from interstitial deposits. In recent oblique inguinal hernia, the internal ring occupies its accustomed s' uation, that is.it is midway between the anterior superior spine of the IU|u and the pubic symphysis, and this, therefore, is the point where the pad Hernial sac, showing its usual situation in front of the spermatic cord. 624 HERNIA. is to rest in the reducible form of the affection ; but in cases of long stand- ing and of great bulk, the opening undergoes important changes in its relative position, being dragged down just behind the external ring, the in- tervening canal itself being effaced. The ring, moreover, under these cir- cumstances, is generally very much enlarged, and of an annular form, so as to admit very readily the extremity of a big finger. A knowledge of these changes is of the greatest importance both in relation to the taxis and the operation for strangulated hernia. The contents of this variety of hernia usually consist of a knuckle of the ileum, either alone, or in union with a portion of omentum; sometimes of the arch of the colon, and occasionally of the cascum, the sigmoid flexure of the colon, and of the urinary bladder. The disorder may co-exist with inguinal hernia by the direct descent, femoral hernia, or umbilical hernia. In one case an inguinal and a femoral hernia were found on each side of the same person. Treatment.—For the reducible oblique inguinal hernia a well constructed truss is used, the pad being of an ovoidal shape, arranged obliquely in refer- ence to its spring, and applied in such a manner as to compress the internal ring. The precise point upon which, in recent cases, the pad should rest is about four lines above Poupart's ligament, equidistant between the pubio symphysis and the anterior superior spinous process of the ilium. In cases, however, of long standing, where the two openings are on the same plane, the pressure must obviously be made Fig- 398. lower down, as well as farther in towards the median line, or, to speak more de- finitely, directly in the situation of the outer ring. The block, too, should be somewhat larger, in order that its influ- ence may be more widely diffused. In Double truss. the double form of hernia a double truss will be required, and one of the best for this purpose is that delineated in fig. 398, with two pads in front and two behind, to equalize the pressure both upon the part and trunk. The irreducible oblique inguinal hernia is treated upon the general prin- ciples laid down in the previous section, care being taken to give due support to the parts by means of a suspensory bag, or a hollow truss, worn day and night. In this way the hernia is prevented from increasing, at the same time that it is measurably protected from harm. In the event of strangulation occurring in this variety of hernia, the taxis is to be employed in strict conformity with the direction of the descent. Thus, in recent cases, where the rings retain their natural position, the parts are pushed obliquely upwards and outwards, in the course of the inguinal canal; whereas, under opposite circumstances, the pressure is made directly upwards, or upwards with a slight inclination outwards. Unless the strictest attention be given to these rules, the surgeon may find it extremely difficult, if not impossible, to attain his object. In regard to the position of the patient, it should be in strict accordance with the instructions laid down under the general observations upon this subject. Should the taxis fail, and an operation become necessary, the stricture will generally be found at one of three situations ; at the internal ring, within the canal at the edge of the transverse and internal oblique muscles, or at the ex- ternal ring. In old and large hernias, the obstruction is usually at the latter point, whereas, in the small and recent, it is commonly at one or the other of the former. However this may be, the finger will always readily detect it as soon as the proper hernial sac has been sufficiently exposed to receive it. In dividing the stricture where no doubt exists as to the precise nature of the descent, INCOMPLETE OBLIQUE INGUINAL HERNIA. 625 the direction in which the knife should be carried is obvious enough, being in the one case obliquely upwards and outwards, and in the other directly upwards; but when it is uncertain whether the hernia was originally one by the oblique or straight descent, the safest rule, as it respects the epigastric artery, is to cut directly upwards, inclining the knife neither to one side nor to the other. For, should the hernia be one by the direct descent, and the surgeon carry his instrument upwards and outwards under the idea that the hernia was oblique, he would almost inevitably injure the vessel in question, and thus lead to a very embarrassing, if not a fatal, hemorrhage. The rule here described, then, should be most scrupulously observed in all cases of doubt. The direction of the external incision must vary according to the nature of the descent, and raay be simply a linear one, as when the tumor is very small, or T-like, or crucial, if it be large. The dressings and after-treatment are in every respect the same as under ordinary circumstances. Incomplete Oblique Inguinal Hernia.—The incomplete inguinal hernia has received different names, expressive either of its situation or of its obscure character, as interstitial, interparietal, and concealed. The term incomplete is, perhaps, as proper as any other, and may, therefore, be employed to their exclusion, the more especially as we shall thus remove one source of confusion. In this variety of hernia, which is merely a subdivision of that just de- scribed, the abdominal viscera pursue the same course, only that they do not pass out at the external ring; indeed, very frequently they do not even de- scend nearly so low down. I have seen several instances where the hernia consisted of less than half the circumference of the bowel, which projected scarcely half an inch into the inguinal canal, and which, consequently, did npt form the slightest appreciable tumor in the groin. Such an occurrence is always peculiarly dangerous, from its great liability to be overlooked when it becomes strangulated. In the cases adverted to all the patients perished, because the true nature of the complaint was overlooked on account of the absence of anything like an external tumor. Dissection revealed the presence of severe peritonitis and the existence of a stricture just within the inguinal canal. In one of the cases it seemed to have been formed by the edges of the internal ring pinching the inclosed bowel. In general, however, the protrusion is more voluminous, and often consists both of bowel and omentum, passing down some distance into the canal, and forming a well-marked prominence externally; liable to be mistaken for en- cysted hydrocele of the spermatic cord, psoas abscess, or an imperfectly de- scended testicle; and, when strangulated, tender under pressure, painful, resisting the taxis, and attended with great constitutional distress. The mode of determining the diagnosis is similar to that of ordinary oblique in- guinal hernia, but additional solicitude should be felt when, if strongly-marked symptoms of strangulation exist, there is no tumor in the inguinal region, or m any of the usual sites of rupture. In such a case the most thorough scrutiny should be instituted, and it would be good practice, where there is no ootward evidence of the affection, to put the patient in the proper position ■or the taxis, and to use the same means for effecting reduction as if we were positively assured of the presence of hernia. I should, in such an event, place no little reliance upon any tenderness that might be discovered at or "ear the internal ring, as a guide to the course to be pursued for the relief of my patient. Even if it were only slight, but circumscribed, a judicious surgeon would hardly hesitate, especially when everything else is clearly de- notive of the existence of strangulation, to use the knife, well knowing that "ogreat harm could result from it, even if the operation proved a failure; Whereas, if a hernia really existed, it would be the only proper procedure after 1 fw trial of the taxis. VOL. II —40 626 HERNIA. The coverings of this variety of hernia are, examining the parts from with- out inwards, the skin and superficial fascia, the tendon of the external oblique thecremaster muscle, and the infundibuliform process of the transverse fascia together with the proper sac. The stricture is usually formed by the edze, remained reducible at the end of forty years. The most common causes of this occurrence are plastic adhesions between the protruded parts, or between these and the inner surface of the sac; but it happens also not unfrequently from a kind of sarcomatous en- ■argement of the omentum, interfering with its return through the inguinal ri,,gR- A hypertrophied state of the bowel itself is another circumstance 628 HERNIA. that may render a hernia originally reducible in time irreducible. However this may be, the patient generally experiences dragging sensations and colicky pains in the abdomen, and the bowels are almost always habitually consti- pated. The tumor is firm, but somewhat elastic to the touch, and quite tolerant of manipulation, except when inflamed or irritated by exercise. A large irreducible omental hernia occasionally produces such an' amount of pressure as to cause enlargement of the testicle and spermatic cord, effusion of serum into the vaginal tunic, or suppuration of this membrane, followed, now and then, by an extension of the inflammation to the peritoneum, and the death of the patient. The coverings of an old scrotal hernia are often very thick, dense, and firm, and not easily distinguishable from each other in case of an operation. The proper sac lies in immediate contact with the testicle, and, to reach it, it is necessary to divide, in addition to the skin, the dartos, which answers here to the superficial fascia, the spermatic fascia, the creraaster muscle, and the infundibuliform process of the transverse fascia. No vessel of any im< portance is involved in its anatomy ; in old and large scrotal hernias, however; the external pudic artery is often much enlarged, and consequently capable1 of furnishing a considerable hemorrhage. ' Diagnosis.—Scrotal hernia is liable to be confounded with other affections' particularly with hydrocele, varicocele, and sarcocele, chiefly, however, in its, earlier stages ; for, when the complaint is well established, it is almost impos-, sible to mistake its real character, except by the raost superficial examination.i From hydrocele it may generally be easily distinguished by the following circumstances. Hernia always begins above, showing itself, in the first in-' stance, as a tumor in the groin, from which it gradually descends into the' scrotum. In hydrocele the reverse is the case, the swelling commencing' below, and gradually extending Fig. 401. upwards. In hernia the tumor is, irregular in shape, generally more, or less flattened in front and be-> hind ; whereas in hydrocele it is1 usually pyriform, being larger' below than above. In hernia the1 testicle is at the bottom of the| tumor, while in hydrocele it is at, its posterior surface, commonly, above the junction of the inferior, with the two superior thirds,' though this arrangement is by no1 means constant; for in many cases| of hydrocele the organ lies at the| base of the swelling. In herniai the tumor is doughy, or gaseous,, not elastic and fluctuating as in, hydrocele; opaque, and not translucent; in the former the patient usually, experiences disagreeable dragging sensations and colicky pains, especially when the protrusion is very large ; while in the latter he suffers no inconve-| nience save what results from the volume and weight of the swelling. Iu reducible hernia the contents of the tumor are easily replaced when the patient is recumbent, but redescend the moment he resumes the erect posture; while, in hydrocele no such changes can possibly occur, whatever raay be the pos-, ture. When we add to these symptoms the fact that the spermatic cord is, always behind the protruded parts in hernia, and, consequently, much Ie»S| distinct in its outline than in hydrocele, in which it can almost always be feh> as a firm, rounded body at the upper extremity of the tumor, and the circum- A scrotal hernia; showing the usual relation of the sac to the vaginal tunic. SCROTAL HERNIA—TREATMENT. 629 stance that the opening through which the rupture has taken place can always be satisfactorily traced with the finger, while in hydrocele the inguinal rings retain their natural form ; we shall have no difficulty, at least in the majority of instances, in arriving at a correct decision. Much valuable information may also be derived from the history of the case, and from the use of the ex- ploring needle, which, whenever there is any doubt about the matter, will not fail to afford the requisite light. Scrotal hernia and hydrocele not unfrequently coexist, constituting a com- bination which it may be extremely difficult to distinguish. The best guides, in such an event, are the history of the case, and the phenomena which ordi- narily characterize the two affections when occurring separately. When the diagnosis is very obscure, valuable information will be furnished by the use of the exploring needle. In most of these cases the hydrocele is formed first, and consequently occu- pies the lower part of the scrotum, being separated from the hernial sac by a kind of hour-glass constriction. Sometimes, however, the two tumors are insensibly blended together; and instances are observed—perhaps more fre- quently than is generally supposed—in which the hydrocele is situated directly in front of the rupture ; so that, if an operation should be required, it would be necessary, in order to reach the seat of the stricture, to carry the knife across three distinct layers of serous membrane, the most deep-seated being the proper hernial sac. Scrotal hernia can always be readily distinguished from varicocele by the peculiar feel which the enlarged veins in this disease impart to the finger, which is similar to that of a bundle of earth-worms, or of the intestines of a squirrel; by the bluish appearance of the tumor; and by the circumstance that the swelling, after being effaced, is always promptly reproduced when the patient is placed erect, and pressure is applied to the external abdominal ring. In reducible hernia, on the contrary, such a procedure necessarily prevents the reproduction of the tumor. In hernia, moreover, the swelling receives a distinct impulse under coughing and other muscular exertion; while in varicocele the parts are perfectly passive. In sarcocele the best guides are the history of the case, the uniform hard- ness of the swelling, the normal state of the abdominal rings, the inability of the surgeon to affect the volume of the tumor by manipulations, and the in- durated and distended condition of the scrotum. When the disease is asso- ciated with hydrocele, a part of the tumor will be likely to be translucent, soft, and fluctuating; thus strikingly contrasting with the remainder. Solid tumors—fibrous, adipose, sebaceous, cystic, and encephaloid—de- veloped in the scrotum, testicle, or vaginal tunic, are, in general, easily dis- tinguished by their progress, by their forra and consistence, by the nature of the local distress, and by the presence or absence of constitutional involve- ment. Treatment.—Scrotal hernia, whether reducible, irreducible, or strangulated, is treated upon the same general principles as hernia of the groin, of which, as was stated before, it is merely a continuation. A suitable truss is the proper remedy for the reducible variety, and the prospect of a permanent cure under its influence will be in proportion, all other things being equal, to the recency and small size of the tumor. The pad is, of course, placed over the internal ring, or, in cases of long standing, just above the external, the relative position of the two apertures under such circumstances not being forgotten. When the hernia is irreducible, it should be supported, both day and night, by a suspensory bandage, provided with shoulder-straps, otherwise 't will answer the purpose but indifferently. By means of such an apparatus, ' ie patient will be relieved of much of his inconvenience, at the same time that the tumor will be protected from further increase. Great attention should 630 HERNIA. also be paid to the bowels, which should be constantly maintained in a soluble condition. The diet should be plain and simple, easy of digestion, and com- prised in the smallest possible bulk, lest the alimentary tube should suffer from flatulence and fecal distension. All violent bodily exertion, fatiguing walks, and exercise on horseback must be avoided. The taxis, in case of strangulation, is conducted in the usual way; and in dividing the stricture, which will generally be found in the external ring, the knife is carried directly upwards. Congenital Scrotal Hernia.—The formation of congenital scrotal hernia will readily be understood if it be remembered that the testicle is originally situated upon the psoas muscle, just below the kidney, and that, as it descends to the place which it is destined finally to occupy, it carries with it a process of the peritoneum, constituting what is called the vaginal tunic of this organ. Ordi- narily, the portion of membrane lying in the inguinal canal is closed before birth, thereby cutting off all communication between the scrotum and the general abdominal cavity ; but at times the reverse is the case, and then an opportunity is afforded for the protrusion of the abdominal viscera and the formation of the variety of hernia in question. Occasionally, the testicle, as it descends towards the internal ring, becomes adherent to a coil of intestine which it thus carries along with it. Congenital scrotal hernia is of frequent occurrence, and is capable, if neg- lected, of acquiring a large bulk. In a case recently under my observation, in a child only two years old, the tumor was fully as large as a foetal head, and extended two-thirds down the thigh. In general, however, it is quite small, and easily reducible; the testicle lies at the bottom of the tumor, and the vaginal tunic, which always forms the proper hernial sac, usually contains a small quantity of water. The external coverings of the tumor are the same as in scrotal hernia of the adult. The contents usually consist of bowel alone, generally of a fold of the ileum; in some cases, of both bowel and omentum; and occasionally, though very rarely, exclusively of omentum. A reducible congenital scrotal hernia requires the same management as an ordinary inguinal one ; but it will be well not to begin the treatment with the truss, inasmuch as it is generally impossible for the little patient to bear the pressure of such an instrument without severe suffering. Instead of this, the parts should be supported with a compress and roller, or, what is better, with a gum-elastic girdle, provided with a broad, elastic pad. In this way, an in- crease of the tumor may be pretty effectually pre- vented until the child has reached the age of eight, ten, or twelve months, when it will commonly be able to wear a truss, which may then advantageously re- place the earlier and less perfect contrivance. What- ever apparatus be employed, great attention must be paid to cleanliness and to the prevention of undue irritation of the skin. If worn persistently, a radical cure may often be effected in a very short time, as the parts at that period of life always manifest a strong disposition to close after the descent of the testicle. It is not often that a congenital scrotal hernia becomes irreducible, and it is still more rare to see it strangulated. Such an event, which has occasion- ally been witnessed within a few days after birth, is characterized by the ordinary phenomena, and mav, in general, be promptly relieved by the taxis. illustrating the state of the Should this fail, the knife must be used, but with pans in infantile hernia. the utmost caution, on account of the great tninnwB Fig. 402. FEMORAL HERNIA. 631 o'the external covering of the rapture, and the liability of peri::r.::r? from tkecivisitn of the vaginal tunic of the testicle, which, c> before stated, fcrms kere the proper berniai sao. /nT,:-ituc Hemi-.:.—A very rare form of scrotal rupture is occasionally met with, generally descriheii under the vague name of infantile hernia, f r. 4'i2. »Bdre_ardci as a s\h: division of the congenital, although it has been found several tide? in adults who V..id been ertlre'p free from a., complaints of this kicd in early life. Its peculiarity consists in lav1;-.^ the vaccinal tunic of the teskie in front of the proper hernial sac. s? that, if a aissettion be made of the pans, the protruded viscera will be seen to be invested by three distinct *r> ;s layers, lesiaes the ordinary external coverings In other ana more explicit terms, the communication between the vacrinai tnnic and the abdom- iaal cavity is completely shut up. bar the former membrane, instead of ■erely incising the testicle, as in the natural state, extends hi_:h up around th* s -ennatic cord, forming thus a s:rt of pouch, behind which the viscera iesfend, in company with a prolongation of the peritoneom, which thas eeu- stitu.fs. as in ordinarv of rapture, the prober hernia, sac. FEMORAL HERNIA. It w;ald be well if the term crural could be nlttrether dispensed with in •eit: ^ of hernia of the thi^h, and the word femoral alone be used. It would certainly serve materially to slur lifv the ?u:;;eo:. and to relieve it of ■nch ■::" the com as hm which has hitherto attended its staay. Under this conviction, I shall limit myself in the remarks which I am ib.at to orTer ■pon this form of rupture, exclusively to the employment of the latter desig- nation. In femoral hernia, the abdominal Tiscera descend beneath Poupart's ihra- ■JKBt, al::..: what is called the femoral canal, the tumor, when fuby developed, •::~i: r itsri: at the upper and inner surface of the thich. as repre-er.tr a in fcn 4'.»3. In order to comprehend the precise relations of !he protruded parts Tiz. 4-' OrdiaarT site and ipp-rararc-r of femcnt ierrii. t,J the surrounding structures, it will be necessary to recall a few of the aua- 'o««cal elements implicated in its formation. In the first place, then, it may °* observed that the passages alot .: which the bowel ccurses. bear a very T*1^? resemblance to those which are concerned in the formation of an ■Jnintl hernia by the oblique d-scent, consisting. like them, of a canal and ■oope-i-.j-s, as seen in §_'. 404. one denominated the interna", ri:._-. and the 632 HERNIA. Femoral hernia, a The sac. b. The femoral vein, c The artery, d. The abdominal ring. e Section of the psoas and iliac muscles. /. The acetabulum. other the external. To render the similitude more pointed, I shall desig- nate the openings as the femoral rings, and the intervening track as the femo- ral canal; in the same manner as there 404. are two inguinal rings and an inguinal canal. The internal femoral ring is some- what of a triangular figure, being bounded anteriorly by Poupart's liga- ment, behind by the pubic bone, ex- ternally by the femoral vein, and on the inside by Gimbernat's ligament, or the third attachment of Poupart's. This opening is considerably larger in the female than in the male, and this is one, if not the principal, reason why this variety of rupture is so much more frequent in the former than in the lat- ter. It is naturally closed by a lym- phatic ganglion and a small quantity of cellulo-fatty matter, which thus ge- nerally offer not a little resistance to the descent of the abdominal viscera. The external femoral ring, usually call- ed the saphenous opening, because it is here that the saphenous vein empties into the great femoral, is of an ovoidal shape, very spacious, and bounded by the crescentic edge which is formed here by the femoral aponeurosis. It is occupied by a number of lymphatic glands, as well as by a large mass of dense, cellulo-adipose substance, form- ing what is termed the cribriform fascia, a structure playing an important part in the anatomy of femoral hernia. The canal between the two openings now described is very short, especially in front, its wall here being formed solely by the upper lunated border of the external ring, known as Hey's liga- ment. The posterior wall, on the contrary, is much longer, and is represented by the pubic portion of the femoral aponeurosis. Thus constituted, the pas- sage is lined by a prolongation of the transverse fascia in front, and the iliac behind, and also by a thin layer of cellulo-adipose tissue, which, lying imme- diately beneath the former fascia, is continuous above with the cellulo-fatty matter which aids in filling up the internal ring, and below with the cribri- form fascia. This substance, it may now be remarked, forms what is called the proper fascia of femoral hernia. The abdominal viscera, passing down the thigh, through the openings here described, clothe themselves with a portion of peritoneum, which thus, asm the other varieties of the complaint, constitutes the proper hernial sac. If. therefore, a dissection be made of the coverings of the tumor, extending from without inwards, they will be found to present themselves in the following order : skin, superficial fascia, cribriform fascia, the funnel-shaped process ot the transverse fascia, the proper fascia, and, lastly, the peritoneum. The position of the epigastric artery and the spermatic cord is deserving of par- ticular notice in relation to this variety of rupture. The former always lies on the outside of the tumor, close to its neck, while the latter lies above and internally. The obturator artery, when given off by a trunk common to it and the epigastric, as it is supposed to be in one case out of every four, arranges itself along the anterior and upper part of the tumor. _ The contents of a femoral hernia usually consist exclusively of small intes- tine, generally a portion of the ileum, especially in cases of recent standing) F FEMORAL HERNIA—DIAGNOSIS. 633 but under opposite circumstances, and, in particular, when the tumor is bulky, both bowel and omentum frequently enter into its composition. Instances in which omentum alone protrudes are by no means uncommon ; and I have a preparation, taken from an old lady of upwards of seventy, who had long labored under double femoral rupture, in which the contents are exclusively of this character. Examples are met with, although rarely, in which the tumor is composed of an ovary and Fallopian tube, of the uterus, or of the uterus, the Fallopian tube, ovary, and vagina. A case has been recorded in which the urinary bladder was the part protruded. Femoral hernia occasionally co-exists with inguinal. The tumor in femoral hernia is always small compared with that of inguinal hernia, seldom exceeding the size of an almond, and occasionally hardly attaining that of a nutmeg. Sometimes, however, its bulk is quite extra- ordinary, equalling that of a fist, or even that of a fcetal head. In the latter case, the tumor is commonly of a globular shape, whereas, under ordinary circumstances, it is of an elongated ovoidal figure, longer in the transverse diameter than in the vertical. The hernia may be complete or incomplete, just as in the inguinal varieties of the complaint. In the former case, the viscera escape at the external ring, and form a tumor which lies.on the upper and inner surface of the thigh, immediately below Poupart's ligament, and a little external to the spine of the pubes. In order to reach this point, the parts are obliged, upon arriving at the external ring, to change their direc- tion, passing upwards towards the groin instead of downwards towards the knee, and in doing this the two portious are doubled upon each other. The reason of this change of direction, a knowledge of which is so important in relation to the proper employment of the taxis, is the manner in which the saphenous vein enters the femoral, and the peculiar connection of the cel- lular tissue, at the lower margin of the external ring, with the femoral aponeurosis. The barrier thus formed, however, is sometimes broken down, and then the hernia not only descends along the thigh, but often acquires a large bulk in consequence of the restraint being thus taken off. In the incom- plete form of the disorder, the tumor is always very small; and hence the true nature of the case is very liable to be overlooked, the intercepted portion of bowel occasionally not exceeding one-third, one-half, or two-thirds of the diameter of the tube. It is, in fact, a most dangerous form of hernia, similar, in every respect, to concealed, interstitial, or interparietal hernia of the groin, described in a previous page. Diagnosis.—Femoral hernia is liable to be mistaken for other affections, from which it is of the greatest consequence that it should be distinguished. Of these the most important are inguinal hernia, psoas abscess, varix of the saphenous vein, and enlargement of the lymphatic glands. In regard to the distinction between femoral and inguinal hernia, little difficulty can arise if it be borne in mind that, in the former, the neck of the tumor is below Poupart's ligament, while in the latter it is above. A good plan, therefore, in cases of doubt, is to trace the course of this ligament along its inner half with the finger, when, if it be found to be overlapped by t'le swelling, it may be assumed that the hernia is inguinal, it being well , known that a femoral hernia rarely, if ever, ascends so high up. Besides, "uportant information may be gained by a careful examination of the inguinal and femoral rings, the former of which, in particular, will always readily admit tue tip of the finger when it is not occupied by the abdominal viscera. The ?,Ze an(l shape of the tumor are not to be disregarded. In femoral hernia it >ssmall and transversely elongated; in inguinal, on the contrary, it is com- paratively large, and of an irregular, hemispherical form. In the former, the imor h fixed, and, when strangulated, soon becomes very tender; in the 634 HERNIA. latter, it is movable, and does not suffer so early, nor are the constitutional symptoms usually so urgent. Psoas abscess occasionally points beneath Poupart's ligament, forming a tumor of variable size and shape, at the upper and inner part of the thigh, which may be mistaken for femoral hernia. The error will be most likely to occur when the swelling is small and recent; but even then a little care will generally suffice to establish the diagnosis. The best guides are the history of the case, the flexed condition of the thigh, with a certain degree of lame- ness, and the fact that the swelling always readily disappears under pressure during recumbency. Yarix of the saphenous vein at its entrance into the femoral, or of both vessels at this point, is sometimes met with, and several cases are known where it was treated as a femoral rupture. !Such nn error implies the most culpable carelessness, for it could certainly not be committed by anyone who has the slightest tact or experience in examining patients. The diagnosis will always be easy when it is recollected that a varix is much softer than a femoral hernia; that it has a peculiar knotty feel; that it always co-exists with varicose enlargement of the saphenous vein below, and that, after having been effaced by manipulation, it speedily reappears under pressure applied to the femoral vein just above the external ring, when the patient stands up, no such effect following if the tumor be hernial. The lymphatic glands, at the upper and inner part of the thigh, are liable to enlargement, both acute and chronic, and numerous cases have occurred of errors of diagnosis between this disease and femoral hernia, a rupture hav- ing been laid open for a supposed abscess, and an inflamed ganglion treated as a rupture. It is, perhaps, not always easy to discriminate between these two affections; but it is hardly possible to conceive of a case where a careful examination of the part and a proper inquiry into the previous symptoms would not promptly dispel all doubt in relation to its real character. When symptoms of strangulation exist, along with a tumor of a suspicious nature, and one which does not promptly yield to antiphlogistic measures, the rule is to operate, both in this and in the other varieties of hernia. What com- plicates these cases occasionally, and embarrasses the diagnosis, is the co- existence of glandular enlargement and femoral hernia, the latter of which is then apt to be very small, being coucealed by the former. Treatment.—Reducible femoral hernia must be treated with a well-adjusted truss, constructed upon the same principles as that used for inguinal hernia. It should rest over the hips midway between the crest of the ilium and the great trochanter, and should be provided with a small, slender block, very convex on the surface, and fastened to its spring nearly at a right angle. The object should be to concentrate the pressure as much as possible, which cannot be done when the pad is broad and flat, on account of the constant motion of the pectineal muscle. Care must be taken not to permit the block to exert any injurious compression upon the femoral vein, which, by embar- rassing the return of the blood, might thus occasion serious mischief in the limb below, as anasarca, and even active inflammation. The precise spot where the pressure is to be made is just below Poupart's ligament, and a little external to the spine of the pubes, directly in the line of the femoral canal > and the upper portion of the external ring, it being impossible, by any con- trivance yet devised, to concentrate the pressure upon the internal ring. It is for this reason, in part, that a femoral hernia is so seldom radically relieved, the other causes of failure being found in the peculiar nature of the bounda- ries of the internal ring, these being partly osseous and partly ligamentous, and, therefore, in great measure, insusceptible of adhesive action. A truss, then, in this variety of rupture, should be worn rather as a retentive appa- ratus than one designed to bring about a permanent cure. Owing to tne FEMORAL HERNIA — TREATMENT. 635 circumstance, however, just alluded to, it is questionable whether a small por- tion of the hernia does not generally remain above the block of the instru- ment, within the mouth of the internal ring. The irreducible hernia of the thigh is best supported by a truss with a hollow pad, so arranged as to receive and accommodate the protruded mass, and thus protect it from further increase, as well as from external injury. A piece of tin, silver, or gutta-percha, adapted to the shape of the tumor, well padded, and provided with a narrow margin, would answer a good purpose in such a case. The neck of the pad, or the part which intervenes between the pad and the spring of the truss, might be composed of some elastic sub- stance, to enable these two portions to move upon each other in the various attitudes of the thigh and body. A proper support of this form of rupture is particularly important, since, if it be permitted to increase, it may acquire a large bulk, and thus greatly interfere with the patient's occupation, to say nothing of other inconvenience, and of the risk of strangulation. For the relief of strangulated femoral hernia the taxis is employed ; early, if possible, to obviate the necessity of an operation, and gently, in order that no harm may befall the compressed and entangled structures. It is of the greatest practical moment to remember that the symptoms bene are always, other things being equal, much more urgent than in strangulated inguinal rupture, and that mortification occasionally takes place within less than twenty- four hours after the occurrence of the accident. Time, then, is a matter of immense consequence in nearly all cases of this description. With a view of affording the taxis the best chance of success, particular attention should be paid to the attitude of the patient, the head, shoulders, and pelvis being thoroughly elevated, the legs flexed upon the thighs, and the thighs upon the pelvis, and both limbs, but especially the affected one, strongly rotated in- wards. The object of the latter procedure is to relax, as completely as possi- ble, the lunated margin of the external ring, which, particularly in the more perfectly developed forms of the affection, always exerts a very powerful constricting influence. For want of this precaution, the practitioner, unac- quainted with the anatomy of this region, often signally fails in accomplishing his object, whereas, if he pursued a proper course, he would, perhaps, experi- ence little, if any, difficulty. The effect which this structure exerts upon the reduction pf the protruded parts is well exemplified upon the dead subject, when the limb is alternately everted and inverted after a coil of intestine has been carried through the femoral canal and brought out at the external ring. It will then be seen that the former movement invariably pinches and com- presses the bowel, while the latter relaxes it, and thus places it in a better condition for prompt and safe replacement. The important rule now described being complied with, and the patient being brought under the influence of anassthesia, the next step is to draw the tumor downwards and slightly inwards, to efface the elbow which it forms with the femoral canal, and to bring it opposite the external ring. The parts are now pushed directly backwards, so as to get them fairly out of the reach of the lunated edge of the ring, when, the pressure being next made in an upward direction, the reduction is, in general, easily accomplished. It is seldom that the bowel ascends with a gurgling noise, unless the protrusion is large, when the sound may be as distinct as in ordinary inguinal hernia. rhe length of time during which the taxis should be persisted in must, of c°urse, be influenced by the circumstances of each particular case; but it may be stated, as a general rule, that it should be considerably less than in hernia of the groin : the efforts, too, should, if possible, be conducted with more gentleness, and no auxiliary measures, save anaesthesia and blood-letting, S1°uld be called into requisition in ordinary cases. If the symptoms are not Ulgent, or such as are denotive of inflammation of the part and peritoneum, 636 HERNIA. trial raay be raade, after the first failure of the taxis, of anodynes and topical applications, either cold or warm, care being taken, in the meanwhile, to maintain the body and limbs in a position favorable to spontaneous reduction. If, after a certain period, the protruded parts do not return, or if, after a second effort, the taxis again fail, the symptoms gradually, but steadily, ad- vancing, no time should be lost in having recourse to the knife. To wait longer might, and probably would, endanger both the part and system. An operation being determined upon, the patient is placed in the same position as in the operation for inguinal hernia, when an incision is made over the upper portion of the tumor, parallel with Poupart's ligament, and intersected by another carried down perpendicularly towards its base; or, instead of this, a T-shaped incision is made ; or, if the hernia be very diminu- tive, a single vertical cut may suffice. The skin and cellular tissue being thus divided, the greatest caution will be required in executing the remaining steps of the operation. Layer after layer is now elevated, and divided upon the grooved director, any lymphatic glands that may come in the way of the knife being pushed aside beyond the reach of harm. The cribriform fascia is often of considerable thickness, especially in corpulent subjects, and, along with the glands involved in its substance, forms a confused mass, difficult to unravel. This having been penetrated, the next structure that presents itself is the anterior layer of the sheath of the femoral vessels, below which, and in immediate contact with the hernial sac, is a thin stratum of cellular tissue, intermixed with a few granules of fat. Dividing this, if possible, with in- creased caution, the operator next searches for the seat of the stricture, which will usually be found at the lunated edge of the external ring, especially at its outer and upper part, at Gimbernat's ligament, or at Poupart's ligament. This examination may be made with the grooved director, or, what is prefer- able, with the finger, which is followed immediately with the probe-pointed bistoury, or hernia-knife, with which the resisting structure is slightly notched, the smallest incision being generally sufficient for the purpose. The protruded parts are next gently compressed with a view of unloading the bowel of its contents, and the omentum of its blood, after which they are carefully re- turned into the abdomen, the sac being left intact. But it may happen that the stricture is seated within the sac, particularly if the hernia be large and old, and, when this is the case, the sac must, of course, be laid opgn, its divi- sion being effected in the same manner as in inguinal hernia. Finally, it may be stated that in femoral hernia, consequent upon wounds, the external coverings are sometimes so extremely thin as to permit the peristaltic motions of the bowel to be seen. In dividing the stricture in femoral hernia, it is of the greatest consequence to remember the relations which the tumor bears to the femoral vein, the epigastric and obturator arteries, and the spermatic cord, lest these important structures should be interfered with, and a copious, if not fatal, hemorrhage be the result. To accomplish this object, the safest rule is to carry the knife upwards with a very slight inclination inwards, and to keep it as much as possible behind Poupart's ligament. If the instrument were to be directed outwards, the femoral vein might be punctured, as has happened in more than one instance ; if inwards, the spermatic cord might be endangered ; and if too far forwards, the obturator artery, should it lie in front of the tumor, as it does when it is given off by the epigastric, might be wounded. Seeing how closely the tumor is embraced by these important structures, the surgeon should be most cautious in his movements, taking care, above all things, to make as little use of the knife as possible in dividing the stricture. It would * be well, indeed, if the edge of the instrument were quite blunt, and if the necessary division were effected with a kind of sawing motion, as such a pro- cedure would afford the vessels in question a better opportunity of escapiuj, ANOMALOUS FORMS OF FEMORAL HERNIA. 637 injury. Should hemorrhage, however, arise, despite the utmost precaution, it must at once be arrested by the ligature; or, when this is impracticable, on account of the inaccessible situation of the vessel, by means of pressure, either with the finger of a relay of assistants, or an appropriate compress and bandage, retained until all danger of bleeding is over. The after-treatment is the same as in inguinal hernia; arid similar precau- tions are necessary in regard to the use of the truss when the patient begins »to walk about. Anomalous forms of Femoral Hernia.—In addition to the varieties of femo- ral rupture above described, there are several others, which, although extremely rare, deserve brief notice in a work of this kind. These anomalies, for so they should be considered, refer chiefly to the passage of the protruded parts and the relation which they bear to the neighboring vessels, and to the shape, size, and contents of the tumor. Hesselbach mentions an instance in which the sac of the rupture had descended behind Poupart's ligament, betweeu the femoral vessels and the anterior superior spinous process of the ilium. It lay under cover of the iliac portion of the femoral aponeurosis, its neck being crossed by the internal circumflex iliac artery. Air. Stanley met with one in which the sac, about the size of a walnut, lay directly in front of the vessels ; and in another case, mentioned by the same author, it passed out of the abdomen external to these vessels, but close to them. Cloquet also describes a case in which the parts had descended in front of the vessels of the thigh. The same anatomist states that he saw an instance in which the tumor had passed through an opening in the posterior part of the sheath, so that it lay immediately upon the pectineal muscle, and conse- quently behind the artery and vein, separated from them only by the deep- seated portion of the fascia. In nearly all of these anomalous cases the epigastric artery, or this vessel and the obturator, is intimately connected with the sac of the hernia, either crossing it in front, or running closely along its inner surface. Hence, if the point of the knife be used in the division of the stricture or the deep-seated coverings of the tumor, a troublesome, if not a fatal, hemorrhage will be almost inevitable. The surface of the femoral hernia, instead of being smooth and uniform, as it generally is, is sometimes remarkably constricted, having a kind of hour- glass appearance, caused either by the passage of a vessel of considerable size, or by the unequal compression of the overlying fascia. Occasionally, again, the sac is multilocular, or divided into several com- partments. In a case mentioned by Monro there were not less than four such cavities, of which three communicated with each other. Ordinarily the femoral rupture is very diminutive, its volume not exceeding that of a small almond or a pigeon's egg. Now and then, however, an in- stance occurs in which the tumor descends half way down the thigh, or fills up almost completely the space between the anterior superior spinous process of the ilium and the pubic symphysis. A unique case of a large femoral hernia, the walls of which were so thin as to permit the peristaltic motion of the bowel to be perceived, has been recorded by Thompson. Although the femoral hernia is generally composed exclusively of intestine, an instance occasionally occurs where the contents are exclusively omental. I recollect a case of double femoral rupture in an old lady, whose body I examined after death, in which each tumor contained merely a process of omentum, one of which had become much enlarged and indurated from its protracted imprisonment. 638 HERNIA. UMBILICAL HERNIA. Umbilical hernia derives its name from the fact that the abdominal viscera are protruded at the umbilical ring, or what is vulgarly called the navel. The occurrence of this'form of the complaint is not infrequent, and it presents some variety according as it shows itself in the foetus, in the infant, and the adult. a. In the Foetus.—Umbilical hernia of the foetus is always dependent upon defective development of the walls of the abdomen, and is frequently associ- ated with malformation of other parts of the body, as hare-lip, bifid spine, club-foot, or extrophy of the bladder. Its contents usually consist of a coil of the small intestine, or of this portion of the bowel and of the colon, some- times of the liver, occasionally of the spleen, and now and then, but very rarely, of the stomach. The affection has been noticed at a very early period of foetal existence, though it is most common during the latter stages of pregnancy. The tumor varies in volume, according to the extent of the de- ficiency in the parietes of the abdomen, from that of a thimble to that of a fist. It has a proper hernial sac, but no cutaneous covering, its external investment consisting of the transparent envelop of the umbilical cord, united to the peritoneum by a thin layer of cellular tissue. The umbilical vessels are sometimes separated by the protruded viscera, and the cord is generally situated at the inferior margin of the tumor, or a little to one side of it. When the umbilical tumor is large, death usually takes place within a few days after birth, from the effects apparently of peritoneal irritation. If the child survive, an attempt may be made to bring about a permanent cure by transfixing the edges of the umbilical ring with several delicate pins, and winding around each, in an elliptical form, a well-waxed ligature, as in the common hare-lip suture. In performing the operation cafre is taken not to interfere in the slightest degree with the peritoneum ; the pins should be re- tained the better part of a week, and the abdomen should be well supported in the interval, as well as for some time after, by broad strips of adhesive plaster. b. In the Child.—Umbilical hernia in the child generally comes on within the first two or three months after birth, and cases occur where it is congeni- ta], or where it shows itself soon after the first severe paroxysm of crying. "Whatever maybe the period of its evolution, the immediate cause of the disease is a succession of violent muscular efforts, by which the abdominal viscera are forcibly impelled againt the umbilical aperture, before it has had time to become completely obliterated. The tumor, which rarely exceeds a common marble in bulk, is either hemispherical or conical, soft and gaseous in its consistence, and sensibly impressed by crying, laughing, coughing, or sneezing; retiring under pressure, and reappearing immediately when the pressure is removed. If, after the reduction has been effected, the finger be inserted into the opening, it will be found to be of a circular shape, with sharp and well-defined edges. The coverings of the tumor are the skin, cellular tissue, and peritoneum, its ordinary contents being small intestine; very rarely omentum, or omentum and intestine. An umbilical hernia in the child must be treated by the same means, or, at all events, according to the same principles, as a rupture of the same kind in the adult. If the disorder receive early attention, a radical cure may often be effected in a very short time, as there is always, at this period, a great tendency to contraction of the umbilical ring. Sometimes, indeed, the hernia disappears spontaneously, even after it has made considerable progress, especially when the general health is good, when there is not much obesity, and, above all, when care is taken to avoid the exciting causes of the com- plaint. Such a fortunate event, however, is very uncommon; hence toe UMBILICAL HERNIA—IN THE ADULT. 639 best plan always is not to wait for it, but to treat the case at once with a retentive apparatus, adapted to the age and comfort of the little sufferer. The contrivance from which most benefit is to be expected is a leather, wooden, ivory, or metallic pad, of a circular shape, perfectly flat, and large enough to overlap the edges of the ring, and confined by a broad strip of adhesive plaster, carried completely around the body. Over this, a broad gum-elastic band should be worn, in order to give due support to the whole abdomen. If the child h'as attained the age of two or three years, a proper truss should be worn, such as that used in this variety of hernia in the adult. c. In the Adult.—In umbilical hernia in the adult the tumor is usually globular, or pyriform, and from not being larger originally than the end of the finger, it may, as it increases in age, acquire an enormous volume, ex- tending, perhaps, as low down as the pubes. In corpulent persons it often manifests a disposition to insinuate itself beneath the skin, within the adipose matter, and the consequence is that it sometimes forms hardly any perceptible enlargement, as it does when the subject is emaciated. A hernia in such a state is peculiarly dangerous if it happen to become strangulated, from its liability te be overlooked, and, therefore, mismanaged. An instance of a fatal mistake of this kind occurred, some years ago, in the hands of a medical friend, a man of great intelligence, who never suspected the true nature of the disease until it was revealed by dissection after death. The patient was a married woman, whose abdomen was loaded with an enormous quantity of fat, beneath which a large, strangulated umbilical hernia existed. An umbilical hernia in the adult generally contains omentum, or omentum and a portion of the colon; sometimes small intestine, but very rarely alone. Many years ago I dissected the body of a German woman, the mother of three children, in whom the hernia was composed exclusively of the gravid uterus, near the full period of gestation. The centre of the tumor bore dis- tinct evidence of the remains of the umbilicus. An instance of a double umbilical hernia occasionally occurs. The coverings of the tumor consist of the skin, superficial fascia, and peritoneum, the latter of which, especially in cases of long standing, is sometimes very thin, or thin at one point and thick- ened at another. The umbilical ring is generally towards the upper part of the tumor. The most common cause of this form of rupture is laborious parturition, pregnancy, and habitual straining at stool. Females are much more subject to it than males, and fat persons than lean ; it is rarely met with before the age of twenty-five or thirty, or until after the abdomen has become enlarged and pendulous from incessant distension of its walls. Constipation of the bowels, flatulence, colicky pains, nausea, and other evidence of digestive dis- order are common attendants upon this variety of hernia. The means best calculated for the retention of a small umbilical rupture in the adult is a truss with a wooden block, at least two inches in diameter, slightly convex upon its abdominal surface, and secured to an elastic springy ong enough to encircle the body. The ends of the spring should be fastene'd behind to a broad, oblong pad, six inches in length, and arched transversely, to adapt it the more accurately to the spine. When there is much obesity, or great volume of tumor, the block should be proportionately larger, and the operation of the instrument should be aided by a gum-elastic supporter, which, by taking off the weight of the abdominal viscera, will thus serve to diffuse and equalize their pressure against the abdominal parietes. a\To truss that does not combine these qualities can be considered, under such circum- stances, as of much value ; for, although a radical cure can seldom be effected •a any case, there is hardly a tumor, however large, inconvenient or painful, ftt cannot be materially relieved by these means. As to the blocks and pads with a central prominence, until lately so much used in this country, it 640 HERNIA. would be difficult to conceive how they could produce any other than an in- jurious effect, as their action must inevitably be to separate still farther the edges of the umbilical ring into which the knob projects. One of the peculiarities of the umbilical hernia in the adult is that, if neg- lected or mismanaged, it soon becomes irreducible, either from the enlarge- ment of its contents, or from their jidhesion to each other and to the inner surface of the sac. Hence, every possible endeavor should be used to pre- vent this occurrence, or, if this be impracticable, to restrict it within the smallest possible limits by suitable antiphlogistic and retentive means. The existence of tenderness and pain in the tumor, constipation of the bowels, nausea, and general uneasiness in the abdomen, should be attentively watched, and regarded with suspicion. Should the symptoms increase instead of diminishing, blood should be abstracted by the lancet and by leeches, the rectum stimulated by injections, and the belly well fomented with water and laudanum. To aid in the removal of plastic matter, small doses of mercury may be used for some time after, and sorbefacients applied to the tumor. If, notwithstanding these precautions, the hernia remains irreducible, or if it was so before the surgeon was consulted, timely measures must be employed for the prevention of its further increase, as well as for its protection against external injury. The most efficient and convenient apparatus for this pur- pose is a hollow truss, cup-shaped, well padded, and retained in place by a scapulary, or the addition of a gum-elastic supporter. To obviate griping, flatulence, and dyspepsia, a concentrated and easily digestible diet and a soluble state of the bowels should be enjoined. If strangulation ensue, no time should be lost in employing the taxis, the patient being anaesthetized, and placed in the same posture pretty much as under similar circumstances in the other varieties of hernia. If the tumor is at all bulky, its contents, after having been drawn away from the umbilical ring, must be pressed directly upwards, or upwards and backwards, in a direction opposite to that of the displacement, it being remembered that in all cases of this kind the tendency of the protruded parts is to descend to- wards the pubes. Should the taxis fail, and the symptoms not be urgent, the effects of a full anodyne and of cold or warm applications may be tried, and often with a prospect of success. When we consider how disastrous have been most of the operations that have hitherto been performed for the relief of strangulated umbilical hernia, we can scarcely lay too much stress upon the protracted and judicious employment of the taxis. There is a period, of course, when we must desist, or when further efforts of the kind would be improper, but it is not always easy to specify it, and hence much must be left, in every case, to the judgment of the practitioner. In performing the operation, an inverted JL*snaPe(^ incision will generally be proper, the vertical limb being carried nearly an inch above the upper extremity of the tumor, directly in the course of the linea alba. Bearing in mind the thinness of the external coverings, particularly in recent cases, the k'nife is passed, upon a grooved director, successively through the skin and cellulo-fatty matter, down to the hernial sac, which is, if possible, left intact, experience having shown that its division is fraught with the greatest danger from its liability to be followed by fatal peritonitis. Seeking now for the seat of the stricture, which will usually be found to be at the upper margin of the ring, the knife is conducted upwards upon the finger, and the resisting structure divided to the requisite extent. The protruded parts being drawn somewhat downwards, to liberate them from their confinement, are next gently replaced into the abdomen, first bowel and then omentum, in the usual man- ner. Should the constriction, however, be ascertained to be within the sac, then the sac must be opened, care being taken, for the reason already men- tioned, to make the incision as small as possible. When the hernia is irre- VENTRAL, PELVIC, AND DIAPHRAGMATIC HERNIA. 641 ducible, the protruded structures are left, after the division of the stricture, in their extra-abdominal situation. VENTRAL, PELVIC, AND DIAPHRAGMATIC HERNIA. Hernia may occur at other points than those where the natural openings of the abdomen exist, the names by which it is designated having reference to the particular situation of the protruded viscera, as ventral, obturator, and ischiatic. a. Ventral hernia is so called from the fact that it involves the parietes of the belly, which are rendered defective in consequence of a wound, or the accidental separation of some of the muscular and tendinous fibres. It may occur in any part of the walls of the abdomen, but is most common in the middle line, above the umbilicus and in the inferior half of the semilunar line. The tumor, though generally diminutive, is capable of acquiring a large bulk, and has seldom more than three coverings, namely, the skin, superficial fascia, and proper sac. The symptoms and treatment involve nothing peculiar; nor does the operation when strangulation takes place, except that special care should be taken not to injure the epigastric artery, as might happen if the stricture were divided in any other direction than the perpendicular. The sac ought also generally to be left intact for fear of violent peritonitis. b. In obturator hernia, the viscera follow the course of the obturator ves- sels, forming a tumor at the upper and inner part of the thigh, under cover of the pectineal and adductor muscles, generally so small as not to be cogni- zable by the finger, much less by the sight. It usually consists of a portion of small bowel; is supposed to be more common in females than in males; and, owing to its deep situation, is rarely detected during life. A few cases of double obturator hernia have been observed. In the event of its becoming strangulated, reduction might possibly be effected by thoroughly relaxing the muscles of the thigh, and pushing the finger directly upwards in the course of the obturator foramen. If the taxis should fail, an operation might be required, but it would be difficult of execution, and not without danger on account of the close proximity of the femoral vessels to the line of incision. A modification of the ordinary femoral truss might answer for the retention of such a hernia when it forms a distinct external tumor. c The ischiatic hernia, which protrudes at the ischiatic notch, is extremely rare, and has probably never been recognized in the living subject. In the few cases in which it has been dissected after death, it has been found to contain small intestine ; in one instance the ovary was protruded. d. Perineal hernia descends by the side of the rectum and anus, or imme- diately in front of these parts, its contents generally consisting either of the small intestine or of the urinary bladder. The protruded parts do not always appear externally in the perineal region, but occasionally they form a tumor of the volume of a pullet's egg. In a case which came under my observation, some years ago, in a middle-aged lady, the mother of six children, the tumor, which lay between the vagina and rectum, and was of a very soft consistence, was about the size'of an ordinary marble, and easily reducible by the slightest pressure. The most remarkable feature about it was its transparency, which was so great that the bowel could almost be seen through it. It had existed For many years, but had not been productive of any physical inconvenience. «. Labial hernia is a very rare form of this complaint, in which the parts descend between the vagina and the branch of the ischium. The tumor, which is soft and elastic, varies in size from a small marble to a pullet's egg, Readily recedes under pressure, and is usually situated in the inferior half of 'he great lip, beneath the mucous membrane. It is nearly always composed a portion of bladder, the cases in which it contains intestine being ex- VOL. 11.-41 642 HERNIA. tremely rare. In a woman examined by Mr. A. Burns, a hernia, occupied by the bladder, existed in each labium. The affection is distinguished from inguinal hernia by the natural state of the external ring, and by the fact that the tumor can be traced with the finger into the pelvic cavity. When the rupture becomes troublesome, it may be restrained by a pessary, or a gum- elastic bandage, the constant use of which has occasionally produced a radical cure. Strangulation is, in general, easily relieved by steady and persistent pressure; this failing, the sac is exposed, and the stricture divided in the direction of the vagina. /. Vaginal hernia is merely a variety of the labial; it presents itself under two varieties of form, the anterior and posterior, the first usually containing bladder, and the other intestine. It varies in size in different cases, being sometimes not larger than a thimble, while, at other times, it is so voluminous as to block up the whole vagina ; it is of an irregular, globular shape, elastic, free from pain, influenced by coughing, and easily reduced by pressure. The treatment consists of rest in the recumbent posture, astringent injections, a hollow pessary, and an abdominal supporter, aided, when the tumor is cystic, by the occasional use of the catheter. g. Occasionally the abdominal viscera project into the chest, thereby con- stituting diaphragmatic hernia. The left side is more frequently involved than the right, and the protruding parts usually consist of the stomach, colon, omentum, or small intestine, the order of frequency being as here stated. The liver, spleen, and even the pancreas sometimes enter into the hernia. The affection may be produced by external violence, as a fall, blow, or wound, or by severe straining in vomiting; but, in the majority of instances, it is the result of congenital malconstruction, attended with a separation of the mus- cular or tendinous fibres of the diaphragm. In the only two cases of the accident that have come under my observation, the cause, in one, was a stab in the side, through the sixth intercostal space, and, in the other, a fall from the third-story window of a house upon the brick pavement below. The wound, in both instances, was on the left side, and was large enough to admit nearly the whole of the stomach into the thoracic cavity. One of the persons died in a few hours, the other on the second day. An interesting case has been recorded by Mr. Guthrie, in which the greater part of the stomach and duodenum had passed into the chest through an opening in the diaphragm caused by a Minie ball. Occasionally the protrusion takes place through a pouch by the side of the oesophagus, the aorta, or the vena cava. A proper hernial sac exists only when the accident is caused by a gradual separation of the fibres of the diaphragm ; in the congenital form, the peritoneum and pleura are directly continuous with each other; and in that following upon wounds and lacera- tions, the serous membrane is always divided along with the other structures of this musculo-aponeurotic septum. Congenital diaphragmatic hernia may co-exist with bifid spine, hare-lip, or club-foot, and proves fatal in nearly half the cases that occur at the moment of birth; a few cases survive several months, or a few years, and now and then a person attains to adult age. In diaphragmatic hernia from accident, death may take place instantly, or not for several days, weeks, months, or even years, though the latter event is ex- tremely rare. The diagnosis of the disease is uncertain, and hence little is to be expected from treatment. Much valuable information respecting this form of hernia will be found in a learned paper upon the subject by Dr. H. I. Bowditch, of Boston, in the Buffalo Medical and Surgical Journal for 1853. STRANGULATION OF THE BOWEL—ARTIFICIAL ANUS. 643 SECT. III.—INTERNAL STRANGULATION OF THE BOWEL. Fig. 405. Internal strangulation of the intestines may take place in different ways, and under a great variety of circumstances. A knowledge of this fact sug- gests the propriety of arranging it under the following heads : 1. Strangula- tion from the development of a membranous band, from the attachraent of one portion of the bowel to another or to an adjoining organ, or frora unna- tural adhesions of the free extremity of the vermiform appendage, omentum, or Fallopian tube. 2. From the rotation of the canal on its own axis, or round an axis formed by the mesentery. 3. From one portion of the bowel compressing another. 4. From the intestine slipping into an abnormal aperture in the omentum, mesentery, or mesocolon. 5. From the pressure exerted on the canal by a tumor, an enlarged ovary, or a diseased uterus. 6. From one piece of bowel falling within another, consti- tuting what is called intussusception, as seen in fig. 405, from a preparation in my cabinet. This classification comprises all the forms of internal strangulation of which I have any knowledge. However induced, the symptoms are similar to those which characterize strangulation in hernia, and need not, therefore, detain us here. The diagnosis is generally exceedingly embarrassing, and often entirely impracti- cable, both as it respects its character and situation. The most reliable circumstances are the absence of everything like a tumor in the abdominal and pelvic regions, whether at the usual site of hernia or anywhere else, and the excessive obstinacy of the constipation and gastric distress. But these symptoms, prominent as they usually are, are altogether unreliable as signs of the disease, inasmuch as they are precisely like those which occur in incomplete inguinal and femoral rupture, unattended by external swelling. Owing to the fact just mentioned, internal strangulation is generally a fatal disease, its very obscurity forbidding interference. But even when the surgeon is bold enough to undertake an operation, it is extremely rare that he succeeds in affording relief, either because the procedure is attempted as a dernier resort, or because it excites fatal peritonitis. In two cases of the kind, where, after mature consultation with eminent physicians, interference was deemed pro- per, I signally failed to confer any benefit, one patient dying at the end of four hours, and the other in less than thirty-six hours. Intussusception of the bowel. SECT. IV.—ARTIFICIAL ANUS. Artificial anus is usually the result of gangrene of the bowel from the pres- sure exerted upon it by the stricture in strangulated hernia. It may also low uPon a wound of the bowel, and upon stercoraceous abscess. How- ever Pro hat should be the conduct of the surgeon in wounds of the bowel without protrusion? This occurrence is far more frequent than wounds with protru- sion, and it becomes, therefore, a matter of paramount importance to deter- mine, if possible, the proper mode of practice adapted to such an emergency. lo my mind, the course to be pursued is perfectly clear. It has been seen that all wounds, however small, should be secured with suture, as the only guarantee against fecal effusion. Now, if this be true of small wounds, how 702 WOUNDS OF THE ABDOMINAL ORGANS. much more iraportant is it in regard to large wounds, which must inevitably be followed by an escape of the contents of the tube, and, as a necessary re- sult, by fatal peritonitis ? The discharge raust be prevented, or, if it have already taken place, the most prompt and decisive measures must be adopted for its successful removal. How, then, is this to be accomplished ? By the surgeon folding his arms, and looking upon the scene as an idle and disin- terested spectator? If he do, his patient will perish from peritonitis just as certainly as if his skull had been severely fractured, and a large portion of his brain let out, or as if he had swallowed an overdose of hydrocyanic acid, arsenic, or any other deadly poison. The proper mode of treatment, then, resolves itself into this, to dilate the external wound, if it be not already suf- ficiently large, to close the orifice in the bowel, and to clear away the effused matter. By this procedure, promptly and efficiently executed, the patient is placed in no worse condition, to say the least, than a female who has under- gone the Caesarean section, or a person whose abdoraen has been ripped open in the first instance; recovery from which is, as is well known, by no means infrequent. The truth is, the fatality of penetrating wounds of the abdomen has been greatly exaggerated. Injuries of this kind have been a sort of bug- bear with practitioners, not so much on account of what they themselves have witnessed, as on account of what they have heard from others; and hence a prejudice has arisen against this practice so deeply rooted as to render it almost impossible to surmount it by any course of argument, however well-founded. But this practice of dilating the external wound, and searching for the bowels, is not universally applicable. If, for example, the orifice in the in- testine is very diminutive, as it may be supposed to be when it has been made by a small knife, such a step would be highly improper, as tending seriously to complicate an injury, which, if left to itself, might heal without the risk of fecal extravasation. Equally improper, in my judgment, would it be to pursue such a course when, from the history of the case, there is reason to believe that the bowel has been wounded in different places, as when the injury has been caused by a ball. An instance has already been detailed where a pro- jectile of this nature perforated the tube at four separate points, involving the ileum, jejunum, duodenum, and colon. Such cases are necessarily fatal, and it is not proper, therefore, to aggravate the patient's suffering by making an extensive incision into the wall of the abdomen, with a view of sewing up the internal wound. When the protruded parts are covered with dirt, feces, and blood, or other extraneous substances, they should be carefully cleansed before they are re- duced. The necessity of this procedure is self-evident. The best article for the purpose is tepid water, squeezed frora a sponge held at some distance. The stream thus produced is well calculated to detach the foreign matter, whatever it may be, without the induction of additional irritation. In no case should the parts be sponged or wiped. If the matter adhere very firmly, it may be picked off with the finger or the forceps. A similar course is pur- sued when the bowels are besmeared with blood, feces, and other substances, without any lesion of their tunics. When blood is extravasated in considerable quantity into the peritoneal sac, as is evinced by the soft and tremulous state of the pulse, the pallor of the countenance, the coldness of the extremities, and the constant disposition to swooning, the patient must immediately be placed in the recumbent pos- ture, and made to take large and frequently-repeated doses of acetate of lead in union with opium. Sinapisms are applied to the hands and feet, and the abdomen is covered with cloths wrung out of cold water, or, what is better, with a large bladder partially filled with pounded ice, or some refrigerating mixture. The abdomen is, at the same time, encircled with a broad bandage, to afford equable support to the viscera, and thus assist in promoting the WOUNDS OF THE INTESTINES — TREATMENT. 703 coagulation of the blood. When there is reason to suspect that a large artery has been opened, the most effectual practice will be to cut down upon the parts, and apply the ligature. Such a procedure, desperate as it may seem, would certainly be preferable, when the wounded artery is within reach, to letting the patient perish from hemorrhage. The bowel having been replaced, the first and most important object is to guard against the occurrence of peritonitis, the great danger after every injury of this kind. Perfect quietude in the recumbent posture, the early and copi- ous abstraction of blood, especially if the patient be plethoric, or the wound extensive, and the most rigid observance of the antiphlogistic regimen, are the means upon which our reliance is mainly to be placed in the first instance. As to purgatives, their use is not to be thought of, even for a moment. On the contrary, the bowels must be locked up as speedily as possible, and be bo maintained for many days by the frequent exhibition of anodynes. The object should be to prevent all muscular contraction in the tube until the wound is tolerably well cicatrized, and all danger of peritonitis is passed. To insure this result, two grains of opium, or its equivalent of morphia, should be administered at regular intervals, at least every eight, ten, or twelve hours. The action of the medicine must be sustained, not wavering. Even the mildest enemata should be avoided, unless they are found to be absolutely indispensable to the comfort of the patient, by promoting the dis- charge of flatus. When, at length, it is determined to use purgatives, none but the most simple should be given, as Epsom salts, Seidlitz powder, or citrate of magnesia. These articles not only, in general, agree well with the stomach, but they also liquefy the feces, thus rendering them less liable to be arrested at the affected part, to derange the sutures, and to disturb the heal- ing process. I am satisfied that practitioners are not sufficiently aware of the importance of this mode of treatment, and that, as a necessary consequence, much mischief is produced by its neglect. They forget that whatever tends to excite peristaltic action must necessarily interfere with the reparative pro- cess, and that fecal matter is, in itself, usually exceedingly harmless, even when long retained in the intestinal canal, as is exemplified in the treatment of peritonitis, and after operations for the relief of vesico-vaginal fistule and laceration of the perineum. The pulse is attentively watched, and any tendency to undue reaction is promptly met with the lancet, or the application of leeches to the abdoraen. The amount of blood abstracted must vary according to the indications of the case, particularly the age and constitution of the individual, the return, continuance, or increase of local pain, the force and frequency of the pulse, and the extent of the injury. The first bleeding should, in general, be toler- ably copious, but after this, six, eight, or ten ounces will be sufficient at each repetition. In this manner we prevent inflammatory action, or moderate it materially, if it has already taken place, without inducing too much prostra- tion. It must be recollected that the pulse in peritonitis is hard, wiry, and contracted; a circumstance calculated to throw the practitioner off his guard, and lead him into the error of omitting the abstraction of blood at a period when it is loudly called for, and when, in truth, it can only be of any service in arresting the progress of the disease. The detraction of blood, however, is not always admissible. The shock sustained by the system may be unusu- ally severe; the reaction raay be tardy and imperfect; and the patient may »e, perhaps for several days, in a dozing state, with a small, tremulous pulse, a pallid countenance, and cold extremities; demanding imperatively the em- ployment of stimulants instead of depletory remedies. The abdomen is toraented with cloths wrung out of a hot solution of opium ; sinapisms are applied to the extremities ; and free use is raade of brandy and carbonate of ammonia. The urine is drawn off, if necessary, with the catheter; and, if 704 WOUNDS OF THE ABDOMINAL ORGANS. cough be present, it is combated by the usual means, its progress being arrested as speedily as possible, lest the concussion thus induced should prove detrimental by interfering with the reparative process. Should tenesmus be present, relief is attempted by anodyne injections or opiate suppositories. If the abdomen be very tender and tympanitic, it should be covered with a large blister, sprinkled with morphia, and retained until thorough vesication is produced. The diet must be of the most simple nature. For the first few weeks it should consist chiefly of animal broths and amylaceous articles, as arrowroot tapioca, or sago; afterwards it maybe more nutritious, though still fluid. Solid, stimulating, or flatulent food is not to be used for several months. Cold water, flaxseed tea, or gum Arabic water, simple or acidulated, form the best drinks. When irritability of the stomach exists, the use of ice will be grateful and beneficial. In a word, the patient should be half starved, and depleted as much as may be consistent with the restorative process. The treatment raust be prompt and energetic. The great error generally is that blood is not abstracted sufficiently early, or before the peritoneal inflammation has made such inroads upon the system as to render it impossible to save the patient. The external wound, in favorable cases, will require none but the most simple dressings, as it will generally unite by the first intention ; but when this does not take place, or when an artificial anus follows, the utmost atten- tion should be paid to cleanliness. As the opening contracts, means are employed to prevent the escape of fecal matter, and induce it to resume its natural channel. When the patient is able to sit up, or walk about, the weakened parts are supported with a suitable truss, which should be worn day and night, to guard against the separation of the edges of the wound, and the consequent protrusion of the abdominal viscera. After convalescence is fairly established, as well as for some time subse- quently, great attention should be bestowed upon the bowels, which must constantly be kept in a soluble condition, that no undue accumulation of feces raay take place in the injured portion of the tube. The diet must also be very light, and the food carefully masticated before it is swallowed. All rough exercise, as riding on horseback, jumping, runniug, and even rapid walking, must be prohibited. SECT. III.—WOUNDS OF THE LIVER, GALL-BLADDER, AND SPLEEN. Wounds of the liver are infrequent in civil practice, but common enough in military. Varying in their nature, site, and extent, they are generally attended with considerable hemorrhage, and are always to be regarded as serious accidents. The symptoms are often extremely obscure. The most reliable, perhaps, in a diagnostic sense, are, a fixed pain, and a feeling of weight in the region of the affected organ, and a discharge from the wound of bilious matter, of a yellowish or greenish color, very thin, and of a viscid consistence. Along with these symptoms there is generally gastric irritabi- lity, with frequent vomiting, great thirst, constant jactitation, and excessive prostration, occasionally amounting to complete collapse. If the PatieDj survive a short time, the eyes, skin, and urine become jaundiced, attended with violent headache, and indescribable languor. Sometimes the nature ot the accident is revealed by an escape at the wound of hepatic tissue, in most cases important information may be obtained, in regard to the probate character of the injury, by observing the situation and direction of the exter- nal wound, or the course pursued by the vulnerating body. When two open- ings exist in the hepatic region, at opposite points of the body, and there 1 WOUNDS OF THE LIVER. 705 at the same time a discharge of bilious matter, there can hardly be any doubt respecting the diagnosis. In wounds of the gall-bladder there would pro- bably be a flow of pure bile. It is easy to understand why wounds of the liver are so frequently attended with severe hemorrhage. The organ is extremely vascular, having three dis- tinct sets of vessels, the hepatic artery, the portal vein, and the hepatic veins; and hence it is impossible for any weapon, however small, to penetrate the parenchymatous substance without dividing some of their branches. If the wound involve a large vascular trunk, the hemorrhage may prove fatal in a few minutes, or, at farthest, in a few hours. An Irishman, aged 28 years, in an affray, in November, 1855, received a cut in the epigastric region, three inches long, and transverse in its direction. It penetrated the peritoneal cavity, wounding the left lobe of the liver, which projected through the external opening. He lived thirty-six hours, looking very pallid, and having a small, feeble pulse. He bled considerably at the wound. On dissection, performed by Dr. Gilpin, the medical attendant, we found the cut in the liver to be an inch and a half in length by three-quarters of an inch in depth; the parts around were incrusted with coagula, and nearly three quarts of fluid blood were contained in the abdominal cavity. There was hardly any trace of peritonitis. A little wound, not three lines in length, existed in the omentum. The man had evidently died from loss of blood, chiefly from the liver. The subjoined case shows that recovery from a wound of the liver is not impossible, even under apparently the most desperate circumstances. Harvey, a colored boy, aged eight years, was accidentally shot with a pistol, July 30th, 1845, the ball entering on the right side, between the eleventh and twelfth ribs, nearly midway between the linea alba and the spine, and emerging on the opposite side of the spine, not quite half an inch from the median groove, both openings being situated on the same horizontal plane. Considerable hemorrhage followed, which, together with the shock of the injury, produced an alarming degree of prostration, lasting upwards of forty-eight hours. At my first visit, at the expiration of this period, he was literally in a state of collapse; his pulse could scarcely be felt, the ex- tremities were cold, the respiration was almost imperceptible, and, in short, everything clearly indicated that he had received a most severe, if not a fatal wound. He had taken neither food, drink, nor medicine since the accident, and lay in a profound stupor, from which it was impossible to rouse him. Under the influence of injections of brandy and hartshorn, and sinapisms to the extremities, chest and spine, the boy began to revive, and at the end of twenty-four hours the reaction seemed to be complete. A probe, intro- duced at the anterior wound, passed readily in the direction of the liver, but did not issue behind. In a few days free suppuration occurred, espe- cially at the posterior orifice, attended by the discharge of a slightly greenish, viscid fluid, having every appearance of bilious matter. This continued for about ten days, when it gradually ceased, both wounds closing in less than.a month. The treatment, after the establishment of reaction, was extremely simple, consisting of an occasional laxative, and of light, but nutritious, food, with a liberal use of brandy. The recovery was complete, the boy being now, fourteen years after the accident, alive and well. In 1851, when I last examined him, the anterior scar was four inches below the axilla, as the arm hung by the side, and six inches frora the posterior one. The liver is sometimes severely lacerated frora falls, blows, or kicks upon the side, or by the compression caused by the body being forcibly jammed in between two hard, resisting objects, as a post and the wheel of a carriage. the number, extent, situation, and direction of the fissures vary so much in vol. n.—45 TOG WOUNDS OF THE ABDOMINAL ORGANS. different instances as to render anything like a definite statement impossible. The following case will serve as an example of such an accident. John Shidaker, a stout, athletic German boatman, aged twenty-three, was admitted under Dr. Pyles, into the Louisville JNIarine Hospital, June 29th 1844, on account of remittent fever. A few days after, in a fit of delirium' he jumped off the portico upon the pavement below, a distance of fifteen feet, bruising and otherwise injuring several parts of the body. Death occurred in an hour after the accident. The liver, somewhat enlarged, softened, and of a dark bluish color, was found to be lacerated in thirteen places. The rents run in different directions, and, with the exception of two, were per- fectly distinct from each other. They varied in length from a few lines to four inches, and in depth from two and a haff to six lines, none extending completely through the substance of the organ. The spleen was ruptured on its convex surface, the right kidney ecchymosed, and the small intestine extensively contused. The abdominal cavity contained upwards of eight pounds of fluid blood. None of the large vessels were injured. In the treatment of wounds of the liver the great object is to limit inflam- mation, by the most perfect quietude, gentle laxatives, and a careful restric- tion of the diet. If the patient be young and robust, he may require the use of the lancet; but, in general, it is better to content ourselves with leeches, fomentations, and blisters. When suppuration is threatened, mer- cury, to the extent of ptyalism, is administered, to modify the inflammatory action and favor resolution. Pain is relieved by the liberal use of anodynes. Wounds of the gall-bladder are always fatal, as the escape of bile into the abdominal cavity is inevitably followed by destructive peritonitis. Division of its duct, as well as of the hepatic and choledoch ducts, is productive of similar consequences. Wounds of the spleen are still more rare than wounds of the liver, which they strictly resemble in their character and in the mode of their production, The prognosis is usually unfavorable, rather on account, however, of the con- sequent hemorrhage than the severity of the resulting inflammation. When there is a large opening in the side or abdomen, a portion of the spleen may protrude, thus affording an opportunity of ascertaining the true nature of the lesion by direct inspection; but, in general, the only phenomena which the practitioner has to guide him in the formation of his opinion of the case are, the site of the external wound, the fixed nature of the pain, and the extreme pallor of the countenance, indicative of the great hemorrhage which is so liable to follow such accidents. The absence of symptoms of intestinal, gastric, and other lesions affords important negative evidence. The treatment of wounds of the spleen is to be conducted upon general antiphlogistic principles, of which rest and light diet are among the most important. If there is copious hemorrhage, acetate of lead and opium should be administered in large and sustained doses, aided by the internal and local use of ice. Stimulants are employed warily, lest the reaction be great and sudden, reinviting hemorrhage, or hastening inflammatory development. If the wounded organ protrude, or lie within the edges of the outer opening, prompt replacement is effected; not, however, if, upon examination, it appear that the wound is large, and disposed to bleed much, for, in such a case, it will be much better to let the part remain in its impacted situation than to restore it to the abdominal cavity, thereby favoring profuse effusion from the divided and now unsupported vessels. I am inclined to believe that most ot the recoveries after lesions of this kind are due to the partial escape of the organ from the abdomen, and the compression of the wounded structures bj the edges of the external orifice. Hence, the circumstance is to be regarded, at least sometimes, rather as a favorable than as an untoward occurrence. FOREIGN BODIES IN THE STOMACH AND BOWELS. 707 the splenic artery be pierced or severed, the ligature must be employed, even at the risk of greatly enlarging the external wound. Instances occur in which the spleen protrudes some distance beyond the external wound, in a state of severe inflammation, several days having, per- haps, elapsed since the infliction of the injury. The proper treatment, in such an event, I conceive, is not to attempt the restoration of the projecting por- tion, lest it should mortify, or lead to dangerous hemorrhage, but to excise it on a level with the surrounding surface. The propriety of this practice is sanctioned by the report of numerous cases in which it was adopted. Rupture of the spleen is much more common than wounds of this viscus, being sometimes produced by the raost trifling accidents, especially if there be considerable softening of its substance, as so frequently happens during the progress of intermittent fever. Under such circumstances, the organ has been known to give way spontaneously, or under the slightest violence, as a blow upon the abdomen, a sudden twist of the body, or straining at stool. The accident is usually fatal in a few hours from the loss of blood, which is often effused in immense quantities, and which no remedies can control. SECT. IV.—FOREIGN BODIES IN THE STOMACH AND BOWELS. Foreign bodies, varying much in their character, occasionally descend into the stomach, and, becoming arrested there, cause great distress, and sometimes even death. Jugglers in the exercise of their profession and persons intent on self-destruction, are, perhaps, the most common subjects of such accidents. A few years ago a man in Iowa, in performing some tricks at legerdemain, allowed a bar of lead, ten inches long, upwards of six lines in diameter, and weighing one pound, to fall into the stomach. The usual symptoms are, violent pain in the epigastrium, extending about in different directions, a sense of weight and obstruction in the stomach, nausea, and constipation of the bowels. The patient is generally able to walk about, and even to attend to business, especially during the first few days after the introduction of the extraneous body. The manner in which these substances are disposed of varies. Pieces of bone, cartilage, pins, needles, and coins, often pass into the bowels, and are finally discharged along with the feces. When the body lodges, and is pro- ductive of pain and danger, extrusion must be effected with the knife, the place of incision being regulated by the site of the intruder, which can often be distinctly felt through the walls of the abdomen. In the case above alluded to, Dr. Bell, of Wapello, removed the bar of lead by making an incision, four inches in length, from the umbilicus to the false ribs, some distance beyond the median line. The opening made in the stomach was just large enough to admit of the passage of the bar, and required no sutures, as it became immediately closed by the contraction of the muscular fibres of the organ. The external wound was stitched in the usual manner. No untoward symp- toms occurred, and the man recovered in less than a fortnight. Gastrotomy, first performed by Shoval, in 1635, has recently attracted a good deal of attention as a means of prolonging life in organic stricture of the oesophagus, threatening death by starvation. The principal operators have been Sedillot, Fenger, Forster, and S. Jones, but the results have not been of such a nature as to encourage repetition, all the patients having died ft'ithin a short time after the undertaking, either from exhaustion or perito- n'tis. But even supposing that life was not put in immediate jeopardy by t'ie operation, what ultimate good, it may be asked, could reasonably be expected from it? None whatever ; for, the disease of the oesophagus being malignant, death will soon be inevitable, and, hence, the adoption of such a 70S WOUNDS OF THE ABDOMINAL ORGANS. measure would only be a species of refined cruelty, reflecting no credit upon the surgeon. The only case in which, in my judgraent, gastrotomy would be justifiable, apart from the presence of a foreign body in the stomach, is where the stricture is the result of a scald or burn, or of the contact of some caustic substance, as nitric acid, lye, or potassa, completely destroying the power of deglutition. Should the operation be deemed advisable, it raay be executed, according to the method of Sedillot, by making, on the left side of the middle line of the abdomen, about two fingers' breadth from the costal cartilages, and a short distance below the ensiforra portion of the sternum, a crucial incision three inches in length, first through the skin, then through the muscles, and lastly through the peritoneum. Inserting the index finger into the wound, the surgeon feels for the left border of the liver, which he takes as a guide to the stomach. The organ is then drawn forward, examined, and carefully stitched, by its anterior surface, to each limb of the cutaneous flap by silver wire, after which an opening is made into it, about midway between its two extremities, and a little above its lower margin. When the consolidation is sufficiently firm, as it will be in three or four days, to prevent the possibility of separation, nutritive injections are introduced from time to time to sustain life. The wound gradually becomes fistulous, and thus affords ready access, should the patient survive, to the stomach. When the orifice has become fairly fistulous, a silver tube, provided with two rings, and resembling in shape a shirt button, may be worn to prevent undue contraction. The operation of enterotomy is sometimes required on account of the pre- sence of a foreign body in the bowels, whether formed within, or introduced from without. In this country, intestinal concretions are exceedingly rare, but in certain parts of Europe, especially in Scotland, they are by no means uncommon, and occasionally call for the use of the knife. In the latter coun- try, they usually consist of the fibres of the beard of the oat, cemented toge- ther by albumen and phosphate of lime, and sometimes acquire a very large bulk, weighing many ounces, and even three or four pounds. When small, they generally move about, changing their place from time to time; but when the reverse is the case, they are liable to become impacted in a kind of pouch, formed by the expanded tube. In general, they are solitary, but now and then they are quite numerous, as many as several dozens being found in the same individual. Their increase is usually tardy. The symptoms denotive of their presence are colicky pains, a sense of weight and soreness at the site of the concretion, dyspeptic derangement, and mechanical obstruction to the evacuation of the feces, with gradual emaciation, and failure of the general health. When the foreign body occupies the rectum or sigmoid flexure of the colon, the patient is tormented with a constant desire to go to stool, tenesmus, and distress in the sacro-lumbar region. When the concretion is large, or the emaciation considerable, it can generally be felt through the walls of the abdomen, and when several are lodged together, they may even be made to strike against each other, so as to cause a distinct noise. These concretions are sometimes ejected by vomiting or stool; when situated in the rectum, they raay occasionally be extracted with the fiuger, .scoop, or forceps. When they are not disposed of in this way, and life is in danger, enterotomy must be performed, and, not unfrequently, the operation proves successful. An incision of adequate length being made through the abdo- men, in the direction of the muscular fibres, and at the site of the foreign body, the bowel is laid open to an extent barely sufficient to seize and extract it, when the opening is immediately closed with the continued or interrupted suture, as may be deemed most advisable. The external wound is treated m the ordinary manner. . Foreign bodies, introduced from without, give rise to the same train ol WOUNDS OF THE WALLS OF THE ABDOMEN. 709 symptoms as those formed within ; but, in general, the effects are more violent, and the treatment requires to be more prompt and decisive. When the ordi- nary remedies have failed, recourse is had to the knife, the two wounds being managed afterwards in the same manner as in the former case. The opera- tion is, unfortunately, not often successful, chiefly for the reason, perhaps, that it is commonly performed too late. In a case under the charge of Dr. Samuel White, of Hudson, New York, early in the present century, a large teaspoon, swallowed in a paroxysm of delirium, was extracted in this way from the ileum, and the man recovered in a few weeks. SECT. V.—WOUNDS OF THE MUSCULAR WALLS OF THE ABDOMEN. Wounds of the muscular walls of the abdomen are, like similar injuries elsewhere, of various kinds, incised, punctured, lacerated, contused, gunshot, and poisoned. In character they may be simple or complicated ; in extent, superficial or deep, small or large ; in direction, horizontal, oblique, or verti- cal. Exhibiting no symptomatological peculiarities worthy of special notice, these different classes of wounds are often of a grave nature, liable to be followed by the worst consequences. Thus, there may be profuse hemor- rhage, extensive laceration of the peritoneum, or violent contusion of some of the abdominal viscera, putting life in jeopardy, either immediately or remotely, by shock, exhaustion, or inflammation. Among the more terrible lesions of this description are buffer accidents, as they are termed, produced by the body being tightly jammed between the buffers of two railway cars. In these accidents the internal viscera, both hollow and solid, are often frightfully contused, lacerated, and even pulpified, without any wound whatever of the muscular walls of the abdomen. The collapse is generally most appalling, and the majority of the patients sink in a few hours, or, at most, in a few days, after the receipt of the injury, without a successful attempt at reaction. The bleeding attendant upon wounds of the abdomen proceeds from various sources, according to the region in which they are situated. In general, it is derived from the epigastric, mammary, circumflex, and lum- bar arteries, or some of their principal branches. Usually small and easily controlled, it is occasionally exceedingly profuse and arrested with great difficulty. If the wound is of a valvular form, a large quantity of blood may accumulate immediately beneath the skin, or in the cellular tissue beneath the muscles; forming, in the one case, a diffused, bluish swelling, and, in the other, a hard, circumscribed tumor. Or, the blood, instead of collecting ex- ternally, may escape into the peritoneal cavity, thus constituting a very dangerous, because a concealed, bleeding. In the latter case, the nature of the hemorrhage will be indicated by a ghastly pallor of the countenance, by cold, clammy sweats, and by great feebleness of the pulse, along with frequent sighing, intense thirst, and excessive restlessness. If the quantity of blood poured out be considerable, it may produce sensible enlargement of the hypo- gastric region, soft at first, and solid afterwards, as the fluid always has a tendency to gravitate to the lower part of the belly. Sometimes the hemor- rhage is strictly internal, proceeding from a wound of one of the visceral arteries, or, it may be, frora one of the large vessels of the abdomen. Such an occurrence is always fraught with danger and perplexity. Incised wounds of the abdomen, other things being equal, bleed less than lacerated and contused wounds. Punctured wounds sometimes bleed pro- fusely, and the same remark applies not less forcibly to gunshot wounds. In the latter, it sometimes comes on secondarily, that is. from the fifth to the eighth day after the infliction of the injury. 710 WOUNDS OF THE ABDOMINAL ORGANS. However the bleeding may be induced, or from whatever source it may emanate, the only way to arrest it is to ligate the affected vessel, unless, as may occasionally happen, it be situated favorably for compression ; in which case the best instrument for the purpose would be an ordinary truss, the pad of which should be placed directly over the divided parts. When the bleed- ing is internal, the outer wound should promptly be enlarged, and the artery secured by ligature. Muscular wounds of the abdomen must always be treated with the inter- rupted suture, carried down to within a very short distance of the peritoneum, but, of course, not into it. A very firm hold should be taken of the edges of the breach, otherwise, as the connective tissue is both soft and scanty, the thread will be sure to tear itself out long before the completion of the con- solidating process. Moreover, the stitches should be placed very closely together. During the subsequent treatment great attention should he paid to position, in order to keep the parts fully relaxed ; and after the patient begins to walk about, the abdomen should be well supported, for many months, with a broad gum-elastic bandage, provided with a flat pad. Unless these precautions be properly attended to, ventral hernia will be inevitable. SECT. VI.—GUNSHOT INJURIES OF THE ABDOMEN. Gunshot wounds of the abdomen offer few peculiarities apart from those of ordinary injuries. When the missile penetrates the muscular walls of this cavity it generally inflicts irreparable mischief, even when it does not enter any important viscus, simply by exciting violent inflammation of the perito- neum. Indeed, fatal disease of this membrane is not unfrequently induced by the contusion merely which it experiences from the blow of a ball or shell, without any actual wound of its substance. Gunshot lesions of the stomach, intestines, spleen, liver, gall-bladder, kidneys and bladder, are nearly always fatal, death being caused either by shock, by shock and hemorrhage, by hemorrhage alone, or by inflamraation usually supervening within a few hours after the accident, and rapidly tending to destruction, despite the best-directed efforts of the surgeon. In order to exhibit the nature and effects of these lesions in a more tangible light, I shall subjoin here, in a modified tabular form, the returns of the wounded, as given in the Medical and Surgical His- tory of the British Army, in the Crimea. Cases. Deaths. Discharged. Invalided. 1. Simple flesh wounds and ( Slight . . .43 contusions . . . \ Severe . . .72 o t> i i- i-u uj ™ f Not accurately known 14 2. Penetrating the abdomen J ~„ . ' . o and lodging, with, lesion 1 ^. *Tri i m 6 6' (Of viscera . . 101 3. Rupture of viscera without external wound . 4 4. Fracture of pelvic bones without penetration of the abdomen.......29 16 5 Total........266 149 86 38 Of the above cases there were 23 in which the missile lodged, with a mor- tality of 21, and 63 in which it did not lodge, with a mortality of 60. Thus, it will be perceived that, in gunshot wounds of the abdomen, with penetration of its cavity, death was the rule, and recovery the rare exception. The cause of death in these cases was usually shock, with or without hemorrhage, and the great majority expired within the first twenty-four hours after the receipt of the injury. A very small proportion of the cases perished from peritonitis. It not unfrequently happened in the above cases that several viscera were 43 18 37 24 13 1 3 95 1 5 4 PARIETAL ABSCESS — HEPATIC ABSCESS. 711 wounded by the same missile. "Thus, in one instance, the liver, spleen, and pancreas were injured by the same bullet; in another the liver and kidneys; in another the pancreas, stomach, and colon ; in many the small intestines and arinary bladder, the men having been shot from above." In a soldier of the 19th regiment, a musket-ball entered near the umbilicus and issued near the sacrum, perforating the small bowel at sixteen points, the man being at the moment in the act of defecation. He survived his wounds nineteen hours. Gunshot lesions of the walls of the abdomen present the same characters as similar injuries in other muscular regions. Erysipelas is a common effect, and they are occasionally followed by tedious abscesses, the matter forming in the track of the missile and producing, if not speedily evacuated, extensive havoc among the surrounding structures. Of the symptoms, diagnosis and treatment of these accidents nothing need be said here, as these topics are fully discussed in some of the preceding sections. SECT. VII.—ABSCESSES WITHIN THE WALLS AND CAVITY OF THE ABDOMEN. Parietal Abscess.—It is not often that abscesses form in the walls of the abdomen. The occurrence is chiefly witnessed as a result of external injury, as a blow or kick, but it is also occasionally noticed as a consequence of in- flammation of the bowel from the presence of impacted feces, or of a foreign body. However induced, the symptoms are usually well marked, being such as attend acute inflammation in other parts of the body, only that there is generally more pain and constitutional disturbance. The matter may collect, first, immediately beneath the skin, in the cellulo-adipose substance; secondly, between the layers of the different muscles ; and, thirdly, between the muscles and the peritoneum. In the latter case, it is usually of a decidedly sterco,- raceous odor, owing to the imbibition of sulphuretted hydrogen from the in- testinal tube, which is very apt, as the disease advances, to become adherent to the posterior wall of the abscess. This event often happens even when the bowel retains its integrity, as, indeed, it generally does, however exten- sive may be the accumulation, its tendency being always to the external sur- face. Owing, however, to the manner in which the pus is bound down by the muscles and aponeuroses it is a long time in coming to a head. The diagnosis of these deep-seated abscesses is sometimes extremely ob- scure, especially in their earlier stages. The most reliable phenomena are, the occurrence of rigors, alternating with flushes of heat, the indurated and circumscribed nature of the swelling, the excessive pain and throbbing, and the existence of an erysipelatous blush of the surface, with marked oedema of the subcutaneous cellular tissue. The fluctuation is always very faint, even when the matter is approaching the surface. If the abscess be situated to- wards the middle line, it may receive an impulse from the aorta, and thus induce a suspicion of the existence of aneurism. Whenever there is any doubt about the diagnosis, recourse is had to the exploring needle. The treatment is, of course, rigidly antiphlogistic ; by venesection, leech- ing, and medicated poultices, along with the frequent application of iodine, and the use of purgatives, nauseants, and anodynes. As soon as fluctuation '8 perceived, or even before, provided there is no doubt respecting the diag- nosis, a free incision is made, patency being afterwards maintained with the tent. If the matter is permitted to remain long pent up, it must necessarily lead to serious structural changes, rendering the cure very tedious. Hepatic Abscess___Abscesses within the abdoraen are usually situated in the hver, their occurrence being quite frequent in warm climates, especially in the 712 WOUNDS OF THE ABDOMINAL ORGANS. East and West Indies. They are also sufficiently common among the boat- men of our Southern rivers. Some years ago, nearly a dozen cases of hepatic abscess, all from Louisiana, were admitted into the Louisville Hospital in less than two months. The matter may discharge itself in different direc- tions ; most generally, perhaps, into the peritoneal cavity, where, of course, it promptly excites fatal inflammation, or into a neighboring coil of intestine, into the lungs, or, externally, through the walls of the abdomen. It is only in the latter event that the disease ever calls for surgical interference, and it is evident that an early and correct diagnosis here is a matter of paramount importance. If the case be neglected, or misunderstood, the abscess giving way may suddenly burst into the peritoneal sac, and thus destroy a patient, who, under other and more favorable auspices, might be saved. Besides, if the fluid be long retained, it may cause irreparable injury to the hepatic tis- sues, so that, although it may ultimately find an external outlet, recovery will be impossible. The most valuable diagnostic characters of hepatic abscess are, a severe, gnawing, aching, or throbbing pain in the hypochondriac and scapular re- gions, marked enlargement of the liver, great embarrassment of breathing, and inability to lie on the left side, accompanied by violent rigors, alternat- ing with flushes of heat, excessive gastric irritability, and a muddy, jaundiced state of the eye and skin. As the matter accumulates and approaches the surface of the organ, it excites inflammation in its peritoneal covering, caus- ing it to adhere to the wall of the abdomen. The morbid action steadily advancing, ulceration is set up in the superincumbent structures, leading, eventually, after weeks of suffering, to an escape of the fluid, its approach being always preceded by an erysipelatous blush, and by a doughy, (edema- tous state of the surface. There are four circumstances in connection with abscess of the liver worthy of special attention. 1st. Care should be taken not to puncture the swelling until there is a well-marked red, purple, or livid spot, with an cedematous state of the skin and cellular tissue, over its most prominent part. If these phenomena be wanting, it raay be assumed, as a general rule, that there is no adhesion be- tween the liver and the wall of the abdomen, and, consequently, that, if an opening be made, the matter will inevitably run into the peritoneal cavity, causing fatal inflammation. 2d. When the pus is slow in reaching the surface, and the symptoms are urgent, a free incision should be made over the more protuberant part of the swelling, through the abdominal muscles, but no farther, the object being to excite prompt and efficient adhesion between the contiguous surfaces, by means of a tent carried deeply into the bottom of the wound. As soon as this event has been brought about, the abscess may be opened with entire impunity. 3d. Care should be taken not to confound this disease with chronic dis- tension of the gall-bladder, an accident which has, more than once.been followed by fatal results. The signs of distinction are generally sufficiently clear. In enlargement of the gall-bladder, the tumor is globular, uniformly hard, and situated lower down than in hepatic abscess; in which the swell- ing is more diffused, more painful, and also more soft, generally fluctuating at its summit, while at the base it is firm and resisting. 4th. The puncture in hepatic abscess should not be direct, but valvular, so as to exclude the ingress of the air, the presence of which is always a source of severe irritation by causing rapid decomposition of the pus. To obviate this effect, the operation should be performed in the same cautious manner as in paracentesis of the chest, with a trocar having a canula furnished with SPLENIC, RENAL, AND ILIAC ABSCESS. 713 a stopcock and a bladder. The only exception to this rule is where the matter lies just below the skin, ready at any moment to discharge itself. Splenic Abscess.—Abscess of the spleen should be treated upon the same principles as that of the liver. Of this rare disease I have seen only one case, the patient being a young, robust farmer, who suffered immensely for a fortnight. The spleen gradually augmented in volume, and, at the expira- tion of this period, it projected over towards the umbilicus, forming a large, rounded tumor, between the linea alba and the margin of the ribs. In a short time fluctuation was perceived, and, on introducing a trocar, about three pints of fetid, dark-colored matter issued from the incision. The wound was kept open for several days, by means of a tent; but it soon closed, and thence on, the patient's health began gradually to improve. The disease had supervened upon repeated attacks of intermittent fever, and was characterized by excessive irritability of the stomach, great pain and tender- ness, and an impending sense of suffocation, caused, no doubt, by the press- ure of the enlarged organ upon the diaphragm. Renal Abscess.—Surgical interference is sometimes demanded on account of abscess of the kidney, the matter pointing in the lumbar or iliac region. Such an occurrence, however, is extremely uncommon, inasmuch as, when ne- phritis terminates in suppuration, the contents of the abscess usually pass off in some other direction, as the ureter, bowel, or peritoneal cavity. The dis- ease is marked by excessive suffering, both local and constitutional; but, as the symptoms which characterize it do not differ materially from those attend- ant upon abscess of the liver and spleen, no further account of them will here be necessary. Enormous quantities of serum occasionally collect in the kidney frora ob- struction of the ureter, and the consequent conversion of the organ into a mere membranous pouch, capable of holding many quarts of fluid, and con- stituting what is called renal dropsy. The tumor thus produced projects at the lumbar region, forming an immense swelling, soft, fluctuating, fixed in its situation, and unaccompanied by discoloration of the integuments, except when, as occasionally happens, the fluid manifests a disposition to point and discharge itself. The general health suffers greatly, the patient becoming excessively emaciated, and finally sinking from exhaustion. If any doubt exist respecting the diagnosis, recourse is had to the exploring needle. The only chance of relief is tapping, experience having shown that the fluid is not amenable to absorption. When the tumor is multilocular, which, however, is a rare occurrence, it may be obliged to be punctured at several points. Iliac Abscess.—Abscesses are sometimes met with in the right iliac region, the result of disease of the colon, caecum, or vermiform appendix, brought on by the abuse of purgatives, the impaction of some foreign substance, or exter- nal injury. Cases occur where the disease is due to perforative ulceration of the bowel, consequent upon an attack of typhoid fever. The matter, which occasionally collects in large quantities, is generally of an ill-elaborated cha- racter, and excessively fetid, owing, apparently, to the absorption of sulphur- etted hydrogen from the alimentary tube. The symptoms of iliac abscess are always well marked, being invariably such as characterize the development of phlegmonous abscess in other parts of the body. The local distress, however, is generally more than ordinarily severe, owing to the resistance which the accumulating pus meets with from the sur- rounding structures. Great constitutional disturbance is present; the rigors are violent and protracted, and the patient is harassed with gastric irritability, waut of sleep, and a sense of excessive prostration. As the matter advances, the integuments are elevated into a distinct tumor, exquisitely tender to the touch, and marked by an erysipelatous blush, with an appearance of oedema, both so characteristic of deep-seated abscess. Owing to the manner in which 714 WOUNDS OF THE ABDOMINAL ORGANS. the fluid is bound down, it is seldom possible to detect fluctuation until after the disease has committed severe, if not irreparable, mischief. The proper treatment of this affection is an early and free incision; for unless the case be met in this way, the matter will be sure to burrow more or less extensively, and may even find vent by the bowel, thus eventually causing a stercoraceous fistule, since, notwithstanding this occurrence, the abscess will ultimately also discharge itself externally. Before the operation is performed, the nature of the disease should always be carefully explained to the patient and his friends, lest, gas and pus escaping, the surgeon should be accused of having wounded the bowel, when the opening has been made by the pressure of the pus, or the ulceration which preceded and caused the abscess. Finally, there is a forra of iliac abscess which occasionally supervenes upon parturition, coming on within the first fortnight after delivery, in consequence of inflammation of the uterus. It differs from the more ordinary iliac abscess in that the matter is situated lower down towards the anterior superior spinous process of the ilium, or even in the ilio-inguinal region, the fluid extending, perhaps, slightly beneath Poupart's ligament. Yery frequently, indeed, the raatter is strictly lodged in the pelvis, its starting-point being, perhaps, the broad ligaments of the uterus, the ovary, or the retro-peritoneal cellular tissue. An abscess of this kind is fraught with danger, the patient being gene- rally worn out by the intensity of her suffering. Occasionally, however, a recovery takes place, the matter eventually finding an outlet at the upper and external part of the groin, near Poupart's ligament, the opening usually re- maining fistulous for a long time. Now and then the abscess empties itself into the rectum, vagina, uterus, or peritoneal cavity. SECT. VIII.—TUMORS IN THE WALLS OF THE ABDOMEN. Various morbid growths, benign and malignant, form within the walls of the abdomen, and, although they do not differ from those in other regions, they deserve particular attention, from the peculiarity of their situation, and their liability to be mistaken for tumors developed in the cavity of the abdomen. The principal growths in this situation, demanding brief notice, are the fatty, fibrous, and cystic. Malignant tumors of the walls of the abdo- men are exceedingly uncommon. Encephaloid and melanosis are the only heterologous formations that I have ever met with here, and they were both easily recognized; the first by the rapidity of its development and great bulk, and the second by its black color, which was distinctly visible under the skin, where the cancerous tubercles were situated. The fatty tumor is not often found in this situation; it may lie immediately beneath the skin, or it may be developed among the muscles. When it occu- pies the site of the natural outlets of the abdoraen, or the linea alba, it may be confounded with hernia, as in the interesting case of Scarpa, in which that illustrious surgeon was induced to perform an operation, under the supposi- tion that his patient was laboring under strangulation of the bowel, when he had merely some colicky pains and abdominal tenderness. Had due inquiry been made into the history of the case, such a mistake might easily have been avoided. The diagnostic characters of the fatty tumor are, the tardiness of its growth, its perfect indolence, or freedom from pain, its doughy inelastic feel, the ab- sence of discoloration of the skin, and the integrity of the general health. A fibrous, or, more properly speaking, fibro-plastic tumor is occasionally met with in the walls of the abdomen. An interesting case of this kind was TUMORS IN THE WALLS OF THE ABDOMEN. 715 brought under my notice last winter, at the Jefferson College Clinic, in a youth of eighteen. When first perceived, thirteen months previously, it was hard and firm, but perfectly movable, and about the size of a pullet's egg, its situation being on the left side, some distance from the umbilicus. Its pro- gress, for several months, was very gradual, but during the last six or eight weeks it had increased rather rapidly, and when the case came under my ob- servation the growth was about nine inches in length, solid, inelastic, almost immovable, free frora pain, and without any enlargement of the subcutaneous veins, or derangement of the general health. A curvilinear incision being carried down over the long axis of the tumor, it was found to be placed under cover of the abdominal muscles, which were very much stretched and attenu- ated, its posterior boundary being formed by the transverse fascia, from which it was obliged to be separated with great care. Its chief supply of blood was derived from a branch of the superficial epigastric artery, which was enlarged and required a ligature. Under the microscope the tumor exhibited all the characteristics of the fibro-plastic tissue, interspersed with colloid masses, of variable size, and of an irregularly oval shape, their contents being, for the most part, composed of granular matter. The recovery from the operation was rapid, and, thus far, there has been no tendency to relapse. The cystic tumor of the walls of the abdomen is very uncommon. In most of the cases that have hitherto been observed, it was deep-seated, lying im- mediately exterior to the peritoneum. It fluctuates, though usually rather faintly, under pressure, and is capable of attaining so large a bulk as to simu- late ascites, or ovarian dropsy. Its contents are of a serous nature. Its pro- gress is very slow and painless, and the patient's health is commonly excel- lent. These circumstances will generally serve to distinguish this morbid growth from others of a more solid character, but, should any doubt exist upon the subject, it will promptly be dispelled by the use of the exploring needle. In the diagnosis of tumors of the walls of the abdomen, much valuable information may be derived from a careful consideration of the history of the case, and a thorough examination of the parts, the patient lying upon his back, with his limbs well retracted, and the shoulders elevated, so as to cause complete relaxation of the abdominal muscles. The tumor being now grasped with one hand, the fingers of the other may generally be readily insinuated beneath it if it be situated in the abdominal wall, at the same time that it will convey an idea of fixedness, which does not belong to intra-peritoneal growths. If the patient turns upon his side, the tumor will steadily maintain its position; generally, too, there will be a degree of tension in the parts which is altogether foreign to internal formations and enlargements. In the intra-peritoneal tumor, no matter what may be its character, the growth is originally loose, usually moving or floating about when the patient changes his position in bed; in the intra-parietal, on the contrary, it is fixed. Should any doubt exist in regard to its precise position, and an operation be urgently demanded, an exploratory incision will be the only thing likely to clear up the difficulty. In the extirpation of tumors in this situation, the incision should always be made as much as possible in the direction of the muscular fibres of the abdomen; free use should be made of the grooved director; all bleeding ves- sels should be tied as soon as they are divided ; and unusual pains should be taken to tack together, first, the muscular edges of the wound, and afterwards the integumental, lest, when the parts are healed, hernia should take place. The abdomen should be well protected with long, broad adhesive strips, a compress and a broad bandage, which, when the patient is about to rise, should be replaced by an elastic supporter. By observing these precautions 716 WOUNDS OF THE ABDOMINAL ORGANS. all danger of visceral protrusion will be effectually obviated, however lan'e may have been the wound. SECT. IX.—ASCITES AND TAPPING OF THE ABDOMEN. Tapping of the abdomen is required for the removal of dropsical accumu- lations of the peritoneum and the ovary. As it is, in general, intended merely as a palliative measure, it is never resorted to until the quantity of fluid is so considerable as to occasion great local inconvenience and serious embarrass- ment of respiration. It raay be performed at various points, but the most eligible one is the linea alba, midway between the pubes and the navel. The only objection to puncturing the abdomen in this situation is the danger of perforating the urinary bladder, which, when distended, often rises some dis- tance above the pelvis. Any mischief, however, that might be thus induced will be effectually obviated by previous evacuation of the organ. In encysted dropsy, it may be necessary to make the opening at the side of the abdomen; but in doing this there is always danger of wounding the epigastric artery; an accident which has occasionally been followed by fatal results. In ordi- nary dropsy, the intestines are pushed back by the weight of the fluid, beyond the reach of the trocar. It is only when they have contracted adhesions to Fig. 436. the interior wall of the abdomen, as might happen when the operation has been repeatedly performed at the same place, that they would be at all likely to suffer. The fluid of ascites may sometimes be safely and expeditiously evacuated by puncturing the sac of an old umbilical hernia. The only instrument required for this operation is a trocar. In addition to this, however, there should be at hand a broad, flannel bandage, for swathing the belly, and several basins for receiving the water. Fig. 437. Operation of tapping the abdomen. The patient lies on his side near the edge of the bed, and the abdomen n surrounded by the bandage, the ends of which are crossed behind, and give' ASCITES AND TAPPING OF THE ABDOMEN. 717 in charge of an assistant. Holding the trocar firmly in the right hand, with the thumb and index-finger resting upon the canula, the surgeon plunges it into the linea alba, about three inches above the pubes, and by a steady, for- cible pressure, pushes it through the abdominal walls. A sudden cessa- tion of resistance and the escape of a few drops of fluid announce the arrival of the instrument in the peritoneal cavity, and serve as a signal for the withdrawal of the trocar. The water issues in a full stream, and the dis- charge is usually completed in a few minutes. To prevent syncope, so apt to follow the rapid removal of the pressure of the accumulated fluid, the ends of the bandage are gradually tightened by the assistant, which compensates, in some degree, for the loss of support experienced by the diaphragm, the large vessels, and the abdominal viscera. Occasionally the passage of water is interrupted by the intrusion of a piece of omentum, a hydatid, or a mass of lymph within the canula. When this happens, the obstacle should be removed by a director, a large probe, or a female catheter, the latter of which may sometimes be advantageously retained in the abdomen until the discharge is completed. When the operation is over, the canula is carefully withdrawn, and the puncture is closed by adhesive strips, the ends of the roller being pinned firmly over a thick napkin, to afford due support to the parts, and to prevent rapid reaccumulation. The only accidents at all likely to happen in this operation are syncope and hemorrhage. Of these, the first is to be prevented by a proper tighten- ing of the bandage, in proportion as the water is evacuated, and the second, by making the puncture at the linea alba, where there is no important vessel. It is possible that a copious hemorrhage may occasionally proceed from injury of one of the arteries of the omentum ; but such an occurrence must be very rare, and does not, of course, admit of any remedy, since the true nature of the case will seldom be revealed until after death. Should the epigastric artery be wounded, and the blood issue externally, the opening made by the trocar should be plugged with a bougie, or piece of wood, wrapped with linen. This expedient failing, the vessel is exposed, and included in a ligature. When the surgeon is called upon to tap a female, especially a young, un- married one, or one whose husband has long been absent, he should not be too eager to enter upon the undertaking, but assure himself well beforehand that the patient is not laboring under pregnancy, instead of ascites. For want of this precaution, accidents have often occurred, as ludicrous as they were disreputable. The best way to avoid this "dry tapping," as it has been not inaptly termed, is to institute a careful examination into the condi- tion of the mouth and neck of the uterus, if not also of the nipple, and to auscultate the abdomen, with a view to the detection of the foetal and pla- cental sounds. This precaution will be more particularly necessary, if the patient is in excellent health, and has, withal, a ruddy complexion, pheno- mena which are never present in well-established ascites. If pregnancy exist, the hand, plunged into cold water, and suddenly applied to the tumor, will generally cause instantaneous motion of the child, thus at once revealing the true nature of the case. The distinction between abdominal and ovarian dropsy will receive special attention in the chapter on the diseases of the female genital organs. Extra-peritoneal dropsy is occasionally observed, and deserves passing notice. Lieutaud, in his Historia Anatoraico-Medica, refers to several in- stances of the kind in which enormous accumulations of water existed between the peritoneum and abdominal muscles, either in one general cavity, or in separate and distinct cysts. In one of the cases the bag contained one hun- dred and forty pounds of fluid, of a bloody appearance. In the tenth volume of the American Journal of the Medical Sciences, Drs. Scott and Reamer have reported the particulars of the case of a woman, aged twenty, who, in 718 WOUNDS OF THE ABDOMINAL ORGANS. repeated tappings, yielded from fifteen to nineteen gallons and a half of serum at each operation. The disease at length proving fatal, the dissection de- monstrated the existence of an enormous reservoir between the muscular and peritoneal coats of the abdomen, filled with water, and complicated with the presence of several large cysts, containing various kinds of substance, both liquid and solid. Were these cases examples of ovarian dropsy, or were they serous cysts developed in the walls of the abdomen ? SECT. X.—AFFECTIONS OF THE UMBILICUS. The only affections of the umbilicus deserving of notice in a work of this kind are ulceration, fungous excrescences, serous cysts, carcinoma, and fis- tules. 1. Ulceration of the navel is almost peculiar to early infancy, and is usually occasioned by neglect of cleanliness, or rude traction of the cord with a view of expediting its separation. Yarying in degree from the merest ex- coriation to a deep spreading sore, it is always attended by inflammation of the adjacent parts, pain, tenderness, discoloration, and a thin, ichorous, acrid, and offensive discharge. The disease, although in general readily amenable to treatment, is sometimes exceedingly obstinate and rebellious, lasting for many years, now receding and almost entirely disappearing, and then again i breaking out afresh, and proceeding with all its former energy. Occasionally r an ulcer of this kind is the seat of a periodical hemorrhage, vicarious of the i menses; and cases occur in which it is evidently of an eczematous nature, influenced in its origin and march by a strumous condition of the system. The treatment of this disease will be greatly promoted, in most cases, by an occasional laxative, in union with an antacid. When the patient is pale and debilitated, the use of tonics will be necessary. The best topical reme- dies are mild astringent lotions, such as solutions of zinc, lead, or copper, either alone or combined with tannin, Turner's cerate, or the dilute ointment of the nitrate of mercury. Dusting the surface of the ulcer with calomel, or covering it with dry lint, sometimes answers better than anything else. In all cases the greatest attention should be paid to cleanliness. When the sore is prevented frora healing by overhanging integuments, hardly anything short of the removal of the redundant structures will suffice, inasmuch as they serve to retain the secretions and tend to rub and irritate the raw surface. When the affection extends into adult life, a mild mercurial course may be required. 2. The fungoid tumor of the umbilicus is easily recognized by its florid violaceous or purple color, by its soft consistence, and by its rounded or conical shape. Its volume ranges from that of a pear to that of a cherry, its base being at one time narrow, and at another broad or expanded. It generally protrudes from the centre of the navel, although occasionally it is deeply buried at its bottom; with very little or no discharge, and without any appearance of ulceration or inflammation in the surrounding parts. When rudely touched or irritated, it is very apt to bleed. Removal is effected with chromic acid, applied once every other day; aided, if necessary, by the liga- ture, especially when the morbid growth is adherent by a narrow pedicle. When the reverse is the case, the tumor may be shaved off with the knife, repullulation being afterwards prevented by nitrate of silver, astringent lotions, and other suitable remedies. _ . 3. A cyst containing water is occasionally met with at the umbilicus, and may acquire a considerable bulk. The tumor is soft, elastic, and fluctuating, free from pain, and slightly translucent. Its seat is apparently in the sub- peritoneal cellular tissue. The only disease with which it is liable to be con- AFFECTIONS OF THE UMBILICUS. 719 founded is umbilical hernia, but from this it may always be readily distin- guished by its history, by its consistence, and by its fixedness, or our inability to push it into the abdominal cavity. In cases of doubt recourse is had to the exploring needle. The proper remedy is evacuation of the contents of the cyst, and the injection of tincture of iodine, as in the operation for the cure of hydrocele. 4. The existence of carcinoma of the navel is extremely uncommon, and were it not that its occurrence here exhibits some important practical pecu- liarities it would not be entitled to distinct notice. The only form in which it has hitherto been observed is the scirrhous, commencing as a small, indu- rated growth in the cicatricial tissue, from which it gradually extends, on the one hand, to the subcutaneous cellular substance, and, on the other, by means of the fibrous structures of the umbilicus, to the peritoneum. The tumor, which is nearly always very tardy in its progress, and which is met with chiefly in old subjects, is of great hardness, and the seat of sharp, lan- cinating pains; circumstances by which it can always readily be distinguished from other diseases. The skin is of a purple or violaceous color, and finally gives way at one or more parts, thus exposing an ulcer which furnishes a thin, ichorous, and fetid discharge, and is incapable of forming healthy granu- lations. The growth would seem, at first sight, to be superficial, but a more thorough exploration soon shows that it extends inwards towards the abdo- minal cavity, one portion occupying the subcutaneous cellular tissue, and the other the subperitoneal, the shape of the whole mass resembling, as was originally indicated by Mons. Nelaton, that of a shirt-stud, the constricted part corresponding with the navel. The treatment is limited to palliation, excision, owing to the peculiar arrangement of the tumor, being improper, as it could not be effected without the risk of peritonitis. 5. Stercoraceous, urinary and other fistules are sometimes met with at the umbilicus, but their occurrence, besides presenting nothing peculiar, is so uncommon as not to require any special notice. 720 DISEASES AND INJURIES OF THE URINARY ORGANS. CHAPTER XVII. DISEASES AND INJURIES OF THE TJRIXARY ORGANS. SECT. I.—AFFECTIONS OF THE BLADDER. MALFORMATIONS. The bladder is liable to various malformations, but almost the only one of any surgical interest is extrophy, consisting essentially in an absence of the anterior wall of the viscus, complicated with certain defects of the genital apparatus. The occurrence is much more common in males than in females. Of six cases that have come under my notice, all were males. Of nine cases observed by Mr. McWhinnie, of London, seven were males, and two were females. The urinary tumor, situated at the lower part of the abdomen, is generally somewhat ovoidal or globular. Its volume is greatly influenced by the age and position of the subject. In the child, it rarely exceeds that of a walnut, while, in the adult, it may be as large as a fist, or a goose's egg. Very small when the subject is recumbent, it becomes quite prominent when he stands up, coughs, sneezes, or exerts himself. The surface of the tumor is of a bright red color, and is constantly covered with mucus, which thus protects it, in some degree, from the injurious impression of the atmosphere. In elderly subjects, the part is sometimes partially invested with a cutaneous pellicle, in consequence of which it is much less sensitive, or irritable, than in infancy, childhood, and adolescence, in which it is generally very tender, and apt to bleed on the slightest touch. The orifices of the ureters, gene- rally situated at the inferior part of the tumor, are usually marked each by a small, conical eminence, from which the urine constantly dribbles, rendering the person uncomfortable to himself, and disgusting to those around him. The distance between the two apertures varies frora one to two inches, ac- cording to the age of the subject. The penis, preternaturally short and flattened, is bent backwards, and fur- nished with an imperfect prepuce. The cavernous bodies, attached below to the ischium, as in the natural state, are small and narrow, and are not always united along the middle line, except just behind the head of the penis. This organ is sometimes imperforate, and at other times it presents a gutter along its upper surface for the lodgment of the lower half of the urethra? When this is the case, the posterior part of the canal displays the verumontanom, the months of the ejaculatory ducts, and the orifices of the prostatic canals. From the peculiar conformation of the penis and urethra, the individual is necessarily impotent. The prostate gland exists generally in a rudimentary state. The seminal vesicles are also very diminutive, and are invariably situated behind the inferior part of the tumor. The ejaculatory ducts pursue their natural route, but are unusually small. _ The scrotum is sometimes absent; at other times it exists merely in a rudi- mentary state. In the latter case, it may contain the testicles, while in the former, these organs are either lodged in the groins, or in a cutaneous bag MALFORMATIONS OF THE BLADDER. 721 at each side of the tumor. The testicles are sometimes normal; at other times they are absent, or much diminished in volume. The bodies of the pubic bones are absent, the pelvis is unusually broad and flat, and the groins are often the seat of hernia. An excellent idea of the ordinary appearances of this form of malformation maybe obtained from an examination of the accompanying drawing, fig. 433, taken from a young man whose case is well known in this country. Fig. 438. Extrophy of the bladder, a. Everted bladder. b,b. Orifices of the ureters, c. Penis without urethra. d, d. Pubic symphysis, e. Scrotum and testis. /. Congenital inguinal hernia. In the female, equally important chauges are noticed in the geuital organs. Thus, the clitoris may be absent, or deviate remarkably from the normal standard; the nyrnphae are small and disjoined, and the labia extend frora the sides of the tumor towards the anus, without coalescing behind. The uterus and ovaries are either absent, or they exist in a rudimentary state. Sometimes, however, these organs are fully developed, as is shown by the fact that the woman both menstruates and conceives, as in the interesting cases reported by Thiebault and Ayres. Extrophy of the bladder was, until lately, universally regarded as utterly irremediable. In fact, all that can generally be done is to palliate suffering by attention to cleanliness, and by the use of a closely-fitting cover of gutta- percha, furnished with a bottle for receiving the urine. When this cannot be obtained, the part must be kept constantly covered with a thick, soft com- press, renewed as often as it becomes wet and disagreeable. The skin around may be protected, if necessary, with suet, pomatum, or simple cerate. It has recently been proposed to establish a channel for the conveyance of the urine from the bladder to the rectum, and, in one instance, the plan has actually been successfully employed, though not without seriously jeoparding the patient's life. The operator was Mr. Simon, of London. The method consisted in making the ureters open into the rectum ; a circumstance which was effected by passing instruments, armed with threads, from the former into the latter, the threads being afterwards retained until the communication was perfected. Violent constitutional symptoms ensued, and for a while the patient vol. n.—4 6 722 DISEASES AND INJURIES OF THE URINARY ORGANS. was in great danger; but he ultimately recovered, and was able to wear a pad, by which the opening in the abdomen was closed, and the urine forced into the bowel. In a case in the hands of Mr. Lloyd, in which an attempt was made to establish an opening between the bladder and the rectum by means of a seton, the result was still more unfavorable, the man dying in a few days from peritonitis. Occasionally an attempt has been made to form a cover for the tumor by autoplasty, by borrowing the integuments from the adjacent parts, and invert- ing them, in the hope that the cutaneous tissue may ultimately assume the properties of the mucous, and so adapt itself to the presence of the urine. The flaps are united by suture, and great care is taken during the treatment to protect them from the contact of the water. The extensive wound in the neighborhood should be as well closed as the case will admit of, the bowels should be locked up with morphia, which should also be freely used to allay pain, and the wallsof the abdomen should be maintained, throughout, in a relaxed condition. 'The greatest possible attention should also be bestowed upon cleanliness. I raust candidly confess my want of confidence in this operation, for the very nature of the affection which it is intended to remedy forbids the idea that it can ever be sufficiently successful to compensate the patient for the pains and perils incurred in its performance. The great danger after the operation will be erysipelas, likely to eventuate in sloughing of the flaps; but in addition to this there will certainly be some risk both of peritonitis and empyema, if not also of congestive disease of the lungs. Much of this danger may, of course, be avoided by proper preliminary treatment. This operation, so far as I know, has been performed only twice in this country. In the winter of 1858, Professor Pancoast resorted to it at the Clinic of the Jefferson College, but, although it was executed with great skill, the edges of the flaps only partially united. Soon afterwards, it was repeated by Dr. Ayres, of Brooklyn, New York, upon a woman, twenty-eight years of age, with results, apparently, highly gratifying, the cutaneous cover being nearly perfect, and the patient, consequently, much improved in com- fort. A full report of the case, illustrated by drawings, has been published by the operator. WOUNDS. Wounds of the bladder may be incised, punctured, lacerated, or gunshot, according to the kind of weapon with which they are inflicted. From the situation of the viscus, these injuries must always necessarily be complicated with lesion of the soft parts by which it is surrounded, and also not unfre- quently with fracture of the pelvic bones. The best example of an incised wound of the bladder is the incision made in the supra-pubic and recto-vesical operations for stone. In perineal litho- tomy, the knife divides the prostate gland rather than the bladder. A good example of a punctured wound is that made by the trocar, for the purpose of drawing off the urine in cases of permanent retention from obstruction of the urethra. The symptoms of this lesion are, the existence of an opening in the lower part of the hypogastric region, the groin, or the perineum; sudden and acute pain in the situation of the affected organ, extending along the urethra, and often accompanied by slight priapism; an escape of urine, or urine and blood, at the external wound; frequent, but ineffectual attempts at micturition; violent tenesmus; and a discharge of blood by the urethra. The system labors under all the effects of violent shock. When the injury is complicate'! with perforation of the bowel, fecal matter, mucus, bile, or gas, mixed with WOUNDS OF THE BLADDER—TREATMENT. 723 urine, or urine and blood, may issue both at the external opening and at the urethra. When the pelvic cavity is pierced, the state.of collapse, the usual consequence of the accident, is speedily followed by symptoms of peritonitis, of which the patient almost always dies in a few days. When the bladder is wounded through the perineum or above the pubes, at a point where it is uncovered by serous membrane, urinary infiltration is liable to take place, and the probability of the occurrence will be so much the greater if the external opening is disproportionately small, if the track of the wound is narrow and devious, and if the organ was much distended at the time of the accident. Gunshot wounds of the bladder, although, perhaps, less fatal than punc- tured and incised wounds, are always extremely formidable, destroying the patient immediately or remotely, producing extensive mischief among the soft parts, as well as in the pelvic bones, and leading to the formation of abscesses, sinuses, and fistules, which raay last for an indefinite period. When the ball is impelled with great velocity, it will be apt to enter the organ at one point, and pass out directly opposite at another, thus leaving two apertures, and either lodging in the neighborhood, or issuing at the surface of the body. If, on the contrary, it move slowly, or be nearly spent, it will be likely to make only one opening, and to be arrested in the bladder, from which it may be discharged by the urethra, or by a fistulous passage; or, what is more pro- bable, it will become incrusted with earthy matter, and thus form the nucleus of a calculus. The lesion is often complicated with fracture of the pelvic bones, injury of the large vessels, and perforation of the rectum, the small intestines, the uterus, or the vagina. In the former case, serious mischief is sometimes done by the osseous splinters which the ball makes and detaches in its course towards the bladder, and which not unfrequently find their way into the interior of this organ, where they may give rise even to more disas- trous consequences than the ball itself. Wadding, pieces of cloth, or portions of the patient's dress, may accompany the ball. In the treatment of a wounded bladder, two prominent indications are pre- sented; first, to prevent extravasation of urine, and, secondly, to guard against undue inflammation. Unfortunately, the first of these accidents often takes place at the moment of the injury, and, consequently, before the surgeon has an opportunity of interfering. The bladder should instantly be evacu- ated, the patient placed almost semi-erect in bed, and the catheter, which should be of gum-elastic, should be permanently retained, to enable the urine to pass off as fast as it comes down from the ureters. In a word, the organ should be kept constantly empty and contracted for the first few weeks, or until there is reason to conclude that the wound is closed and all risk of in- filtration over. The end of the instrument must not be permitted to become clogged, or to rise up in the bladder. Care should also be taken that it does not irritate the mucous membrane, and thereby excite pain and spasm, ren- dering its presence uncomfortable, if not intolerable. Should the latter re- sult, however, follow, the catheter must be withdrawn, and an attempt made to obviate the danger of distension by its frequent reintroduction. The development of undue inflammation is to be prevented by the employ- ment of antiphlogistic means, as general and local bleeding, calomel and opium, fomentations, and vesication of the abdomen. Anodynes raust be given in full doses, both by the mouth and by the rectum, to allay pain and spasm of the bladder, induce sleep, and diminish the renal secretion. Hardly any drink is admissible ; the diet must be very light and bland, and the bowels must be disturbed as little as possible during the first fortnight. Abscesses, the result of urinary infiltration, are to be opened by early and free incisions. nothing can be gained by an attempt to extract the foreign body, when the injury has been produced by fire-arms; for the very moment it is inflicted 724 DISEASES AND INJURIES OF THE URINARY ORGANS. the urine escapes, and the bladder contracts upon itself so as to destroy the relations between the external and internal wounds. If the ball has fallen into the bladder, it may, if not too large, either pass off spontaneously, or be removed with the forceps; should it be otherwise, and severe symptoms be caused by its presence, it must be cut out through the perineum by an opera- tion similar to that of lithotomy. This may be done immediately, or within a short period after the accident, if the ball has entered beneath the pubes, for the reason that the organ will not only be freed thereby of a disagreeable intruder, but also because there will be less risk of urinary infiltration. When the bladder has been transfixed, or wounded through the peritoneum, the accident inevitably terminates fatally. In view of this event, would it be proper to make an incision through the linea alba, and sponge out the extra- vasated fluid? My opinion is that it would, on the ground that it would be much more creditable to a surgeon to perform such an operation, provided it can be done immediately after the injury has been received, than to stand by and see his patient perish from the effects of peritonitis. The only difficulty in the case might be the uncertainty of the abdominal effusion. LACERATION. The urinary bladder is liable to laceration. When the laceration takes place as a consequence of the inordinate accumulation of urine from paralysis of the muscular fibres of the bladder, hypertrophy of the prostate gland, or obstruction of the urethra, there is always some degree of softening of the different coats of the organ, thus predisposing them to the occurrence. In such a case, any unusual or sudden exertion may produce the effect in question. But the most common cause of the accident is external violence, and it is worthy of remark, both in a surgical and medico-legal point of view, that it may occur from the most trivial injury. Any force suddenly applied to the hypogastric region, while the bladder is distended, as a smart blow, a kick, or a fall, will frequently suffice to produce it. The accident is liable to occur in females during parturition, in consequence of the pressure of the child's head, when the patient has neglected to empty the bladder. The accident usually reveals itself by well-marked symptoms, both general and local. Violent pain is instantly experienced in the hypogastric region, the face is pale and ghastly, the pulse is small, rapid, and fluttering, the re- spiration is hurried and difficult, the extremities are cold, and the surface is covered with a clammy perspiration. The patient occasionally falls down in a state of insensibility, and not unfrequently he feels as if something had sud- denly given way in his abdomen. In nearly all cases, there is a constant desire to urinate, and an inability to pass a single drop of water. A small quantity of blood often flows by the urethra. These symptoms are soon fol- lowed by nausea and vomiting, intense thirst, excessive restlessness, and an expression of great suffering, with swelling and tenderness of the abdomen. Laceration of the bladder is nearly always fatal; usually in from three to six days after the occurrence of the accident. The immediate sources of danger are hemorrhage, pain, and the poisonous effect which the urine exerts upon the blood and brain, generally promptly collapsing the system. The treatment must be conducted upon the same general principles as that of wounds of the bladder. Our only reliance is upon the catheter, anodynes, and stimulants. INFLAMMATION. Inflammation of the bladder, technically termed cystitis, generally begins in the mucous membrane, and presents itself under two varieties of forra, the INFLAMMATION OF THE BLADDER. 725 acute and the chronic. Of these, the first is exceedingly infrequent; the chronic form of the malady is, however, sufficiently common, and often en- tails a vast amount of suffering. Acute inflamraation rarely occupies the whole mucous surface of the bladder; on the contrary, it usually occurs in irregular, circumscribed spots, from the size of a twenty-five cent piece to that of the palm of the hand. Any portion of the organ is liable to suffer, but the parts most frequently affected are the neck and bas-fond. During its progress, the inflammation often spreads from the mucous mem- brane to the subjacent cellular tissue, and from thence to the muscular tunic. The peritoneal investment is rarely implicated, in any considerable degree, however serious the attack. The principal causes of acute cystitis are, wounds of the bladder, the pre- sence of calculous concretions, rough horseback exercise, the excessive use of stimulating drinks, enlargement of the prostrate gland, stricture of the urethra, injury sustained during parturition, and the protracted retention of uriue. The more important anatomical characters of acute cystitis are, increased vascularity, loss of transparency, softening, and deposits of lymph, with altera- tion of the natural secretion, and discoloration. Generally speaking, the malady is ushered in by bold and well-marked symptoms. The first circumstance which usually attracts attention is a dull, obscure, deep-seated pain, or, rather, a sort of gnawing uneasiness, in the region of the bladder, which, rapidly increasing in intensity, soon extends to the neighboring organs. At this early stage, there is little or no constitutional disturbance ; or, if there be any, it is manifested by slight chills, alternating with flushes-of heat, some thirst, and a little excitement of the pulse. The patient now begins to experience frequent calls to void his urine, which is expelled either in small quantities, or drop by drop, accompanied with violent straining, distressing spasm, and a peculiar scalding sensation at the neck of the bladder, and along the course of the urethra. The hypogastrium is dis- tended, painful, and so exquisitely tender as to render even the weight of the bedclothes intolerable. The limbs are drawn up, and the body bent forward, to relax the abdominal muscles, and relieve the tension of the bladder. The urine becomes thick, ropy, turbid, reddish, or tinged with blood ; and the pain shoots along the testicles, groins, upper part of the thighs, and spermatic cord, to the sacro-lumbar region, where it is often almost insupportable. The urine, never entirely expelled, gradually accumulates, and the bladder at length ascends above the pubes into the hypogastric region, forming a globu- lar and elastic tumor, exquisitely sensitive under the slightest touch. When the disease is fully developed, there is always more or less constitu- tional derangement, as indicated by the frequency and hardness of the pulse, the anxious countenance, and the coated appearance of the tongue. Nausea and vomiting, with severe precordial oppression, are rarely absent in this stage of the complaint. Sometimes there is complete suppression of the urine. Some diversity occurs in the symptoms of cystitis, dependent upon the particular seat of the morbid action. When the neck of the bladder is mainly affected, excessive pain and a sense of weight and fulness are experienced in the anus and perineum, there is obstinate retention of urine, with an incessant desire to micturate, and severe scalding is felt along the urethra. When the anterior wall of the bladder is inflamed, there is great tenderness on pressure and percussion, with a sense of constriction in the hypogastric region. When the inflammation occupies the bas-fond of the organ, the rectum is most apt to suffer, and the patient is harassed with constant straining and tenesmus. Acute cystitis usually runs its course with considerable rapidity. It sel- dom continues beyond the sixth or eighth day without terminating in resolu- 726 DISEASES AND INJURIES OF THE URINARY ORGANS. tion, tending to suppuration, passing into gangrene, or assuming a chronic type. The leading indications, in every case of acute cystitis, are, first, to subdue symptomatic excitement; and, secondly, to quiet local irritation. For accom- plishing the first of these ends, the remedies mainly relied upon, in the earlier stages of the complaint, are general and topical bleeding, cathartics, and diaphoretics, aided by an antiphlogistic regimen. The bowels should be early moved by some mild purgative, as castor oil, or sulphate of magnesia, followed by an enema of cold water, thin gruel, or soap and water. If the biliary secretion be deranged, a dose of calomel should be given. All drastic cathartics must be avoided. As soon as proper depletion has been practised, diaphoretics are indicated, and the one which I have found most useful is the antimonial and saline mixture, in union with full doses of morphia and aconite. Dover's powder is beneficial where the skin is already soft. If the stomach be irritable, the effervescing draught is preferable to the other diaphoretics. The action of these medicines may be favored by tepid drinks, the warm bath, and hot fomentations to the hypogastrium and genitals. Diuretics, strictly so called, are improper in this affection. When the urine is acrid, high-colored, or very scanty, a small quantity of nitrate of potassa, or spirit of nitric ether, mixed with some demulcent fluid, may be administered, to modify the renal secretion and to allay vesical irritation. In the latter stages of the disease, an infusion of uva ursi and hops, in the proportion of one ounce of the former, and half an ounce of the latter, to the quart of water, proves sometimes highly advantageous. Among the more important local remedies for arresting cystitis, and tran- quilizing the affected organ, are leeching and cupping, anodyne enemata or suppositories, fomentations, and the hip-bath. The pain in the back is re- lieved by cups, either wet or dry, applied to the sacro-lumbar region. Cer- tain modifications of treatment are made, according to the nature of the exciting cause of the disease. Finally, should retention of urine occur, no time is to be lost in having recourse to the catheter. SUPPURATION AND ABSCESS. A discharge of pus, or muco-purulent fluid, from the lining membrane of the bladder, although sufficiently common in connection with chronic cystitis, is infrequent as a consequence of the acute form of the disease. The dis- charge, moreover, is usually of brief continuance, and small in quantity, while in chronic cystitis it often lasts for a long time, and is occasionally remark- ably profuse. The matter, instead of being furnished by the free surface of the mucous membrane, occasionally presents itself in the form of a small abscess, situated in the submucous cellular tissue, or between the muscular and serous tunics. It may occur in any part of the viscus, but is most frequently observed at its neck, as a solitary deposit. In the great majority of cases, the abscess points inwards towards the cavity of the bladder, but it may also open into the rectum, the sigmoid flexure of the colon, the ileum, the vagina, or the abdominal cavity. Finally, the matter is sometimes diffused through the cel- lular tissue of the coats of the bladder, which, in consequence, exhibit a soft, cedematous aspect. Suppuration of the bladder may be the result of idiopathic inflammation, either acute or chronic, external violence, or the presence of some foreign body, as a calculus, bougie, or catheter. In the latter case, abscesses are generally produced under the influence of protracted irritation, operating directly upon the tunics of the organ. GANGRENE OF THE BLADDER. 727 The occurrence of suppuration is always denoted by well-marked symptoms. The most important are frequent rigors, alternating with flushes of heat; an increase of thirst, anxiety and restlessness; the character of the pain, which is dull, aching, and throbbing; and a feeling of weight in the perineum. The mind generally wanders, and, in many cases, there is confirmed delirium. These symptoms, however, may be simulated by other diseases, both of the bladder and of the neighboring organs. In abscess, the diagnosis is some- times determined by the sudden appearance in the urine of a large quantity of pus, after a violent effort at micturition, or an attempt to draw off the urine. Infiltration of pus into the coats of the bladder cannot be distin- guished during life. The prognosis of suppuration of the mucous membrane of the bladder is usually favorable; the reverse being the case in abscess. Much, however, must necessarily, under such circumstances, depend upon the nature and ex- tent of the injury. The treatment of this disease is to be conducted upon general antiphlo- gistic principles in its earlier stages, and, subsequently, upon the tonic and invigorating'plan. If abscesses point externally, they must be opened with the knife. GANGRENE. Acute inflammation of the bladder sometimes ends in gangrene. This mode of termination, however, is fortunately infrequent, as the morbid action which gives rise to it is generally easily arrested by the early and vigorous employment of antiphlogistic remedies. It is particularly to be apprehended when the cystitis is marked by great violence, when it has been induced by external injury, and when it occurs in old persons, whose health has been much impaired by previous suffering. Gangrene of the bladder, although it may occur as a consequence of idio- pathic inflammation, is almost always a result of external violence or over- distension of the organ from urine. One of its most common causes is com- pression of the viscus during the passage of the child's head in parturition. Gangrene occasionally follows the operation of lithotomy, and laceration of the mucous membrane consequent upon the employment of instruments. The occurrence of mortification of the bladder is announced by great pros- tration of strength: sudden cessation of pain; coldness of the extremities; small, weak, frequent, and tremulous pulse; profuse, clammy, and offensive perspiration; cadaverous expression of the countenance; mental confusion, delirium, and coma; hiccup; twitching of the tendons; and, towards the close, by colliquative diarrhoea and involuntary discharge of the feces. The urine is of a dark brownish, or blackish color, emits a peculiarly fetid, sick- ening odor, and is effectually retained by the dead, crippled, or paralyzed organ. On dissection, the mucous membrane is found to be of a dark red, livid, or purple complexion, very soft, easily torn, and bathed with a thin, sanious fluid, of an excessively fetid odor. Gangrene of the bladder is sometimes followed by a rupture of the coats of this organ, and the escape of its contents. This event is most likely to happen when there has been protracted retention of urine, with inordinate distension, and may take place very suddenly, or slowly and gradually, as a result of ulceration. Whether the urine escape into the cavity of the abdo- men, or into the cellular tissue of the pelvis, death is equally inevitable. The treatment of this affection is easily told. The object is to prevent the lesion, rather than to cure it after it has been established. Should gangrene be inevitable, the indication is to support the system, and by means of quinine, ammonia, brandy, opiates, and nutritious food, assist the patient in throwing 728 DISEASES AND INJURIES OF THE URINARY ORGANS. off the effects of the local disorder. The distension of the bladder is obvi- ated by the catheter. ULCERATION. Ulceration of the bladder is uncommon. Judging from the results of my own observations, I am disposed to rank it amongst the rarest accidents to which this organ is obnoxious. The ulcers are usually neither numerous nor large. Their most common appearance here, as in the bowels, is that of depressed breaches of continuity of the mucous membrane, of a circular or oval form with edges slightly elevated. Occasionally, their edges are hard, thick, fis- sured, and puckered. Appearances like these are most common in old, chronic cases. The bottom of the ulcer is originally formed by the submucous cel- lular substance; but as the disease progresses it may erode the muscular fibres, and even the serous investment, leading, perhaps, eventually to per- foration, and to the escape of urine into the abdominal cavity. Or, instead I of this, adhesions may take place between the bladder and the neighboring ; viscera. In the great majority of instances, the ulceration can be distinctly traced to chronic cystitis. Paralysis of the bladder, injury of the spinal cord, and I organic lesion of the kidneys, are very apt to induce the affection, from the i changes which they create in the composition of the urine. Calculous con- cretions, and earthy deposits often occasion ulceration solely by the pressure which they exert upon the mucous membrane. Sometimes the disease is the result of the softening of tubercular matter; and in this event the muscular fibres are occasionally as completely denuded, as if they had been dissected with the knife. The symptoms of ulceration of the bladder do not differ essentially, in the early stage of the disease, from those of subacute or chronic inflammation. Even at a later period, they are not always well marked. The most promi- nent local phenomena are pain and uneasiness in the pelvic cavity, with spasm, frequent micturition, and an offensive state of the urine. The pain is of an acute, burning, or scalding character. The inclination to urinate is not incessant, but comes on in paroxysms, which gradually increase in fre- quency, and are attended with intense suffering. The urine is seldom per- mitted to accumulate to any extent, and is, therefore, generally voided in small quantities at a time. The fluid, which is commonly acid and slightly albuminous, deposits, on cooling, a considerable amount of thick, ropy mucus, and sometimes contains shreds of lymph, or the debris of the affected mem- brane. In the advanced stages of the complaint, it is excessively offensive, of a dark color, occasionally like coffee-grounds in appearance, and often mixed with pus, and tinged with blood. An ammoniacal state of this fluid is not uncommon at this period. When there is extensive destruction of the lining membrane, very little mucus is seen in the urine. As the disease progresses, the sympathies and functions of the urinary organs are completely subverted, and the patient's health is materially im- paired by the local derangement. Sometimes, however, on the other hand, the symptoms are comparatively mild, and but little distress is experienced in the urinary apparatus. This is more particularly liable to happen when the disease is of a tubercular character. The diagnosis of this disease is difficult, and cannot always be determined during life. The affections for which it is most liable to be mistaken are simple cystitis, catarrh, and stone. Frora the first, it can generally be dis- tinguished by its obstinate persistence, by the greater extent and violence of the local distress, by the incessant desire to void the urine, by the more frequent recurrence of spasms, by the more severe burning or scalding along ULCERATION OF THE BLADDER — TREATMENT. 729 the urethra, and, lastly, by the presence of pus in the urine, and, in the raore aggravated forms of the complaint, by the absence of mucus. In catarrh, the characteristic symptom is a copious secretion of thick, tough, ropy mucus, with a turbid appearance and an amraoniacal smell of the urine. The local and constitutional distress are less severe than in ulceration, the desire to micturate is not so frequent, there is less sensibility in the urethra, and there is often complete intermission of the vesical disturbance, the patient reraain- in* comparatively comfortable for days and weeks. In ulceration, the symp- toms are persistent, the disease steadily proceeding from bad to worse. In stone, the pain is most severe immediately after passing the urine, and is generally much aggravated by rough exercise; the urine is more frequently bloody; there is less irritability of the urethra ; and the intervals between the paroxysms are longer than in ulceration. If doubt exists, the sound is used, cautiously and gently, lest, if the case be one of ulceration, it increase the local inflammation, and thus endanger life. In ulceration there is sometimes a discharge of the debris of the mucous membrane, which never happens in simple cystitis, catarrh, and calculous disorder. The pain also is much greater, and the desire to pass water raore frequent. When perforations exist, a discharge of gas, fecal matter, ingesta, and other substances, along with the urine, leaves no doubt respecting the nature of the disease. The treatment of this complaint is most unsatisfactory. At its commence- ment the means employed to arrest it must be strictly antiphlogistic. Active depletion by the lancet will, however, seldom be called for after the expira- tion of the first fortnight, while the local abstraction of blood by leeches is proper in every stage of the disorder, and constitutes, indeed, one of our most valuable therapeutic resources. The bowels should be kept in a soluble condition, but active purgation is injurious. The diet should be light, but nutritious, and consist chiefly of bread, toast, potatoes, rice, hominy, and mush, with weak tea at breakfast and supper. The patient should constantly near flanuel next the skin, aud carefully guard against sudden vicissitudes of weather. Sexual intercourse, and rough exercise of every description, must be carefully avoided. Of the internal remedies calculated to act directly upon the urinary appa- ratus, the most important are, the balsam of copaiba, uva ursi, hops, cubebs, hyoscyamus, the bicarbonate of soda, the mineral acids, and the tincture of the chloride of iron, either alone, or variously combined. Anodynes, in full doses, are indispensable for quieting the bladder, and procuring sleep. Local remedies, or means addressed directly to the affected surface, are sometimes highly serviceable. The best undoubtedly are such as are of an anodyne character, as infusion of poppy, opium, hop, aconite, and cicuta, or tepid water, either simple or medicated with tar, tannin, sulphate of zinc, ,creasote, nitrate of silver, and other substances. Lime-water, black wash, and a weak solution of iodine have occasionally proved advantageous. The best mode of introducing them is by means of a gum-elastic bag, carefully adapted to the end of a medium-sized silver catheter. The quantity of any jnjection should not exceed, at first, an ounce and a half. An anodyne in- jection should be retained as long as possible; an astringent one not more than a few minutes. Counter-irritation, in the form of issue, seton, or pustulation with tartar- emetic, is often advantageous in this affection, and should always be resorted to as early as practicable. 730 DISEASES AND INJURIES OF THE URINARY ORGANS. CHRONIC INFLAMMATION, CATARRH, OR CYSTORRHfEA. Catarrh of the bladder, technically denominated cystorrhoea, signifies an inordinate secretion of white, glairy raucus, essentially dependent upon chronic inflammation of the lining membrane. It is analogous in its character to gleet, leucorrhcea, and kindred affections, and is generally merely a symptom of a more serious disease. It raay occur at any period of life, but is most common in elderly subjects. The immediate cause of cystorrhoea is always some obstacle to the evacua- tion of the urine, or a diseased condition of the bladder. Hence, it is most commonly observed as an effect of stricture of the urethra, of vesical calcu- lus, and enlargement of the prostate gland. Paralysis of the bladder, whether produced by over-distension of the organ by urine, or injury of the spine, frequently gives rise to it. Cystorrhoea is a constant attendant upon saccu- lation, ulceration, hypertrophy, and carcinoma of the bladder. AVhen the affection is once established, it is easily aggravated or reinduced by exposure to cold, excesses in diet, irritating injections, diuretics, over-distension of the bladder, neuralgia, retrocession of gout, repulsion of cutaneous eruptions, local injury, and disease of the adjoining parts, as the anus, rectum, vagina, and uterus. Cystorrhoea generally comes on in a slow, gradual, and insidious manner. The inflammation which accompanies the affection, and which is always the immediate cause of the cystorrhoea, is of a chronic character, and, in the first instance, of a very mild grade. It is for this reason that the term subacute has sometimes been applied to it. The characteristic symptom of the disease, as was before stated, is an in- ordinate secretion of mucus. This is associated, in nearly all cases, with an altered condition of the urine, frequent and difficult micturition, pain in the region of the affected organ, as well as in the adjoining parts, and more or less constitutional derangement. The quantity of mucus secreted varies remarkably in different cases and under different circumstances. In the incipient stages, and in the milder forms of the affection, it is generally small, not exceeding, perhaps, a few drachms in the twenty-four hours. At a more advanced period, the quantity is often considerable, and in some instances it is truly enormous. During the progress of the disease the urine always becomes highly acrid, so that the bladder can hardly tolerate its presence, even for a few minutes. It generally emits an amraoniacal odor, is rapidly decomposed, both in the bladder and out of it, and is nearly always mixed with purulent and phos- phatic matter. If a silver catheter is used late in the disease, it usually comes out of a bronze, brownish, or black color, in consequence of the presence of a minute quantity of sulphuretted hydrogen. The pus which is present in this disease is derived frora various sources;* sometimes from the bladder, sometimes from the ureters, or the prostate gland, but more generally from the kidneys, which are often seriously involved in the mischief. Its presence is always to be regarded with great attention, as it is generally indicative of serious disease of the organs from which it is de- rived. The urine is voided frequently, in small quantity, and with more or less difficulty. Generally it passes off in interrupted jets, in a small, feeble, stream, or in drops, accompanied by violent spasm and straining. When the urine is loaded with thick, ropy mucus, the difficulty of voiding it is much increased, and the patient is obliged to have frequent recourse to the catheter. The diagnosis of this disease is always easy. Almost the only affection with which it is liable to be confounded is seminal emission; but thisi can happen only when the seminal fluid flows into the bladder, and mixes with the CHRONIC CYSTITIS — PROGNOSIS — MORBID ANATOMY. 731 urine, in consequence of stricture of the urethra, or enlargement of the pros- tate gland. The distinction is^hat, in catarrh, the discharge is always greater and more constant, and also more ropy, tenacious, and offensive, the local suffering is more severe, and there is a more frequent desire to urinate. In seminal disease, the matter is voided in small quantity, and at remote inter- vals ; it has a peculiar odor, is of a light color, and is partially insoluble in water, in which it floats in shreds. When there is any doubt, the best way is to submit a few drops of the suspected fluid to microscopical examination. If it be semen, it will be found to consist of small oblong bodies, with deli- cate, tapering tails. The prognosis in cystorrhoea varies with many circumstances which hardly admit of precise detail. Much will necessarily depend upon the age and constitution of the patient, the duration of the disease, and the condition of the bladder and of the associated organs. In its incipient stage it is some- times not difficult of cure; but when, commencing gradually, it has at length come to disorder the whole system, it rarely terminates favorably. The morbid alterations observed in those who die of this disease are vari- ous. In the early stage, and in the milder forms, the mucous membrane usually presents slight marks of inflammation, with little or no lesion of the other tunics. After some time, however, the muscular fibres become hyper- trophied, and exhibit the peculiar retiform arrangement delineated in fig. 439, Fig. 439. Columniform bladder. from a specimen in my collection. Occasionally a large bar-like ridge lies just behind the neck of the bladder, offering a considerable obstacle to the passage of the catheter. The cellulo-fibrous lamella is also much thickened, as well as increased in density, and the mucous membrane, particularly the portion which corresponds with the bas-fond of the organ, is often thrown into large, heavy ridges. In some instances the lining membrane is ulcerated, covered with patches of lymph, or protruded across the muscular fibres, in the form of one or more pouches. The walls of the bladder are frequently from five to ten times the natural thickness. The kidneys, ureters, and prostate gland, are generally implicated in the mischief; sometimes to a fatal extent. The sacculated appearance of the bladder, which so often accompanies 732 DISEASES AND INJURIES OF THE URINARY ORGANS. chronic inflammation, is well shown in fig. 440, from a preparation in my private cabinet. It is formed by a projection t>f the mucous coat across the Fig. 440. Section of the bladder and prostate, a. Mucous surface of the bladder. 6, &. Lateral lobes of the prostate, c. Middle lobe. d. Large cyst or pouch, partially laid open, and communicating with the bladder by a small orifice. hypertrophied muscular fibres, and varies in size, from a pigeon's egg to a cavity nearly as large as the bladder itself. It always contains urine, and, occasionally, also calculi. In entering upon the treatment of this affection, it is of great importance to ascertain the nature of the exciting cause. If there be stricture of the urethra, stone in the bladder, hypertrophy of the prostate gland, or disease of the neighboring and associated organs, it will be imperative upon the practitioner to pursue the respective modes of treatment usually adopted for these several complaints. It would be useless to repeat here what has already been said in other por- tions of the work, respecting the employment of antiphlogistics. They are imperatively demanded in all cases attended with violent pain and frequent micturition, even when there is no marked constitutional disturbance. When the lancet is inadmissible, from twenty to thirty leeches may be applied to the perineum and inside of the thighs, or to the lower part of the hypogastric region. The topical bleeding should be followed by the warm bath, warm fomentations, and warm enemata. The bowels must be opened with saline cathartics, or, when the secretions are much deranged, with calomel and jalap. All articles tending to irritate the rectum should be carefully avoided. The most perfect quietude, both of mind and body, must be enjoined; the diet should be as light and unirritant as possible; and the patient should be requested to make free use of demulcent drinks, as gum Arabic water, flax- seed tea, or slippery elm water. When, by these means, the violence of the disease has been subdued, I know of no remedy so well calculated, in ordinary cases, to ameliorate the morbid condition of the bladder as the balsam of copaiba. It should be given in doses not exceeding ten, fifteen, or twenty drops, three or four times in the twenty-four hours. The best form is that of emulsion. Its nauseating, CHRONIC CYSTITIS — TREATMENT. 733 griping, and purging tendencies should be counteracted by laudanum or morphia. When the patient is troubled with pyrosis or acid eructations, the medicine may be advantageously conjoined with bicarbonate of soda. The terebinthinate preparations are sometimes highly beneficial in this affection. The pareira brava and buchu are articles which have been much extolled in the treatment of catarrh of the bladder, but I have never derived much advantage from them. Uva ursi is another medicine which has a spe- cific tendency to the urinary organs. I have found it particularly serviceable in cases attended with excessive morbid sensibility of the neck of the bladder. It may be advantageously combined with buchu and lupuline, and, in the class of cases just mentioned, with carbonate of soda and potassa. A combination of some of the articles above mentioned may often be advantageously employed. Indeed, the effect is usually much more conspicu- ous when they are given in this manner than when they are used separately. I have long been in the habit of administering, with the happiest effect, a combination of buchu, uva ursi, and cubebs, sometimes in the form of an infusion, but more generally in that of a tincture, given several times a day, in conjunction with a small quantity of bicarbonate of soda. Occasionally, a few drops of the balsam of copaiba, the tincture of the chloride of iron, or dilute nitric acid, may be advantageously added to each dose of these medi- cines. The tincture of the chloride of iron, given by itself, sometimes answers an excellent purpose. When the disease is associated with a gouty or rheu- matic state of the system, colchicum should be employed, and the best form of exhibiting it is in combination with a full anodyne. Benzoic acid is some- times used in this disease, and occasionally answers when everything else has failed. In all cases of vesical catarrh, the urine should be subjected to the usual tests. If it be found to be acid, the carbonated alkalies should be freely exhibited, and acids if it be alkaline. To allay pain, and induce sleep, anodynes are indispensable in almost every stage of this disease. They should be given in full doses, either alone or with other medicines. Counter-irritation, in the form of seton, issue, or tartar-emetic pustulation, is often highly beneficial in this disease, and should never be neglected in obstinate cases. Blisters, except at the commencement of the complaint, or when there is a sudden aggravation of the discharge, seldom afford much relief. In truth, it is doubtful whether their beneficial effects are not fully counterbalanced by the injurious impression which they sometimes make upon the neck of the bladder, leading to an increase of the local suffering. The remedies addressed directly to the suffering organ itself are irrigations, astringent and other injections, and cauterization. Irrigation of the bladder is sometimes employed in the treatment of this affection, and is, in many cases, a valuable auxiliary to the other means already pointed out. It is particularly serviceable when there is an abundant dis- charge of thick, tenacious mucus, attended with atony of the muscular fibres of the bladder. The operation is performed with tepid water, injected with a large syringe through a double catheter. Fluids of various kinds, astringent, anodyne, and alterant, are sometimes introduced into the bladder, for the purpose of making a direct impression npon the inflamed surface. The articles most commonly resorted to are alum, zinc, copper, iodine, nitrate of silver, creasote, opium, morphia, laudanum, cicuta, bichloride of mercury, and nitric acid. Cauterization with the solid nitrate of silver is occasionally used. I have tned it in a number of instances, but without any decided benefit. It is chiefly applicable to those cases in which the catarrh is dependent upon inflam- 734 DISEASES AND INJURIES OF THE URINARY ORGANS. mation of the neck of the bladder, and should be employed with the greatest possible caution, lest it aggravate the morbid action. In obstinate cases of cystorrhoea, when all other remedies have failed to afford relief, it has been proposed to penetrate the neck of the bladder by means of an incision, similar to that made in the lateral operation of litho- tomy. The object is to afford a free outlet to the mucous secretion as fast as it takes place, and to put the organ thereby into a state of repose. The proposal is plausible, but has not been sufficiently tested to enable us to form an opinion of its value. Finally, in the management of this affection, the utmost attention must be paid to the diet, which should always be of a light, farinaceous character. Between the paroxysms, or when convalescence is fairly established, animal broths, and a little of the lighter kinds of meat, may be used. But neither at this, nor at any previous period, are condiments admissible. Even salt should be employed most sparingly. Vegetable acids, subacid fruits, wine, spirits, and fermented liquors are prejudicial. The best drink is cold water, either alone or with good Holland gin. Exposure to cold must be carefully avoided. Flannel must be worn next the skin, both summer and winter; riding on horseback must be interdicted; sexual intercourse is to be abstained frora; and the bladder must, for a long time, be emptied daily at stated intervals. When the kidneys, ureters, and prostate gland are seriously affected, no remedy has the power of checking this distressing malady. All that we can do is to enjoin perfect tranquillity, a light but generous diet, anodynes by the mouth and the rectum, the warm bath, and attention to the bowels. IRRITABILITY OR MORBID SENSIBILITY. The characteristic symptom of this disease is frequent micturition. The urine is voided every few hours, perhaps, indeed, every few minutes, and the process is commonly attended with raore or less pain, spasm, and burning at the neck of the bladder, and along the urethra. The fluid may be perfectly natural, both in its physical and chemical properties; or it may be increased or diminished in quantity, and variously altered in quality. In general, it is acid, high-colored, and surcharged with mucus, of a whitish or grayish com- plexion. The urethra and the prostate gland are usually unnaturally sensitive to the touch, and a very common accompaniment of the affection, especially in young men, is a tendency to erections and seminal discharges. In time, the general health, perhaps originally good, gradually suffers. The disease is most frequently met with in children and youths of a nervous, irritable dis- position. It is also sufficiently common in persons who are predisposed to attacks of gout and rheumatism. Irritability of the bladder may be arranged under different heads, according to the causes by which it is induced, as—1st. Disease of the urinary appa- ratus. 2d. Altered state of the urine. 3d. Diuretic medicines. 4th. Dis- order of the genital organs. 5th. Derangement of the alimentary canal. 6th. Lesion of the brain and spinal cord. 7th. General debility. 8th. Ex- posure to cold and heat. 9th. Disease of the pelvic viscera. The pathology of this disease is not well understood. The most plausible conclusion, perhaps, in the absence of facts, is that the complaint consists in an exaltation of the nervous sensibility of the mucous membrane, similar to that which is occasionally witnessed in the retina, the fauces, urethra, and other mucous canals. When the disease depends upon local causes, as stone in the bladder, stricture of the urethra, or enlargement of the prostate gland, the anatomical changes are more distinct, and afford a more satisfactory solu- IRRITABILITY OF THE BLADDER. 735 tion of the real nature of the case. Yery frequently the irritability is purely sympathetic. The prognosis is variable. The idiopathic form of the complaint, although frequently very obstinate, generally, after a time, yields to a well-directed course of treatment. When the disease occurs in weak, scrofulous subjects, it is always remarkably refractory. The irritability of the bladder of young children, attended with nocturnal incontinence of urine, sometimes disappears spontaneously towards the approach of puberty. When dependent upon local causes, of a curable nature, relief may generally be obtained. In the treatment of this complaint, so Protean in its character, a strict inquiry should, in every instance, be instituted into its origin, and the prac- tice be regulated accordingly. When the irritability depends upon congestion or inflammation, the appli- cation of leeches to the perineum, the hip-bath, and, in plethoric subjects, venesection, are indicated. Purgatives, rest, low diet, the internal use of balsam of copaiba, anodyne injections, and demulcent drinks, should not be neglected. If the disorder depend upon an acid state of the urine, alkalies will be indicated, and the one which I usually prefer is the bicarbonate of soda, either alone, or in union with the bicarbonate of potassa. If the patient be of a rheumatic or gouty habit, colchicum will be useful, especially if it be given in combination with morphia and spirit of nitric ether. The best form of exhibition is the wine, in the dose of one drachm every night at bedtime. When the disease has been induced by the improper employment of diure- tics, a discontinuance of the remedies, demulcent drinks, the hip-bath, hot fomentations, and a full anodyne by the mouth or rectum, will, in general, put a speedy stop to it. All venereal excesses must be abandoned, and means taken to improve the disastrous effects produced by them. Of these, the most important are quinine and the chalybeate tonics, blue mass and rhubarb as a purgative, a light but nutritious diet, cold ablutions, the cold shower bath, and exercise in the open air. If spermatorrhoea be present, nothing short of cauterization will be likely to answer. In this form of irritability of the bladder, good effects sometimes result from the exhibition of bromide of potassium, in doses of from five to ten grains three times in the twenty-four hours. When the irritation has arisen frora disorder of the digestive organs, particular attention should be given to the correction of the secretions ; the diet should be carefully regulated, and the bowels should, from time to time, be duly evacuated. If symptoms of worms be present, anthelmintics are indicated, of which calomel, spirits of turpentine, and chenopodium are the most valuable. In those forms of the complaint which are dependent upon the presence of piles, ulcers, fistule, and other organic changes of the rectum and anus, there can, of course, be no hope of relief without striking at the root of the evil. Tumors must be removed, ulcers cauterized or incised, and sinuses laid open. Within the last few years carbonic acid gas has been a good deal employed as a local sedative in this complaint, and there is no doubt that it occasionally exerts a very happy influence in relieving pain and checking the disposition to frequent micturition, the effect being sometimes more anodyne than that of strong opiates, while it is destitute of the disagreeable consequences which so often follow the exhibition of the latter articles. Lesion of the brain and spinal cord, leading to irritability of the bladder, wust be treated upon general principles. In that variety of vesical irritability which is so common in young girls, ftt or soon after the age of puberty, and which is probably of a mixed charac- 736 DISEASES AND INJURIES OF THE URINARY ORGANS. ter, depending partly upon spinal irritation, and partly upon disorder of the uterine functions, much benefit will be derived from a proper regulation of the bowels, chalybeate tonics, particularly Griffith's mixture, Plummer's pills, the shower bath, and daily exercise in the open air. In protracted cases,' the uterus should be examined, as the cause may depend upon displacement of that organ. When the disease has been caused by general debility, the patient must be put upon an invigorating diet, nutritious drinks, and tonics. If the disease has been induced by cold, and the patient is robust and plethoric, venesection, carried to syncope, will generally afford prompt relief, especially if it be aided by diaphoretics, such as a combination of antimony and morphia, or Dover's powder, brisk cathartics, anodyne injections, and hot fomentations. The neuralgic form of the disease is best controlled by quinine, strychnin, and arsenic, in union with morphia and aconite. Sometimes prompt relief is afforded by wine of colchicum. NEURALGIA. Neuralgia of the bladder is a nervous affection, characterized by severe suffering, which is generally referred to the neck of the organ, and is distinctly paroxysmal in its attacks, recurring daily or every other day, about the same period, generally early in the evening or towards morning. The attacks vary in their duration from two to six hours, and the suffering is often of the most racking and agonizing nature. The pain is reflected to the neighboring parts, and is accompanied with a sensation of heat and burning in the urethra, with a frequent desire to pass water, the urine being thrown out in jets, or in a small, and, perhaps, interrupted stream. The paroxysm gradually goes off, leaving no other inconvenience than a feeling of soreness or aching in the neck of the bladder, perineum, and posterior part of the urethra. The general health eventually becomes affected. In obstinate cases there is also a thin, gleety discharge, with great soreness in the perineum and hypogastric region. The urine is almost always natural. The diagnostic signs are not always very distinct. The attacks, especially when very seVere, bear the closest resemblance to the paroxysms produced by calculous concretions. Hence, in doubtful cases, sounding of the bladder is advisable. Of the causes of vesical neuralgia very little is known. In general, indeed, they are wholly unappreciable. The disease is observed, for the most part, in persons of a nervous temperament. Yenereal indulgences, masturbation, stricture of the urethra, stone in the bladder, and organic disease of the uterus, are all capable of producing it. What influence miasm may exert upon its development is not ascertained, but it is doubtless a very frequent cause of the complaint. Vesical neuralgia, although an exceedingly painful and distressing disease. seldom terminates fatally. Its long continuance, however, or its frequent recurrence, may render the patient miserable for life. The treatment must be regulated by the nature of the exciting cause. When it is connected with an inflammatory state of the system, prompt and efficient blood-letting is the proper remedy, especially at the commencement of the attack. Purgatives are particularly useful when the affection is dependent on the effects of miasm, and should be administered in doses adequate to procure free evacuations. If the tongue is much coated, the best article will be calomel, followed by castor oil. A blue pill, given every other night, after this, will serve to keep the bowels in a laxative condition. , When the disease is plainly of a miasmatic character, the most suitable NEURALGIA OF THE BLADDER — PARALYSIS. 737 remedy is quinine, administered in doses of five grains every five hours, until twenty grains have been taken. It should then be discontinued until the next day, when it should be resumed, and persevered in until the same quantity has been used. By this time the paroxysm will usually have abated very much in violence, if not altogether subsided. When the disease has been thus moderated, the best medicines to eradicate it are arsenic, strych- nine, and aconite, in union with morphia. During the violence of the paroxysm, large doses of narcotics are frequently indispensable. Of these, the most efficacious are the salts of morphia, either alone, or combined with nauseants, and tincture of aconite, according to the state of the vascular system. An emetic of ipecacuanha at the approach of the attack, will sometimes cut it short. Much benefit will also accrue, in many cases, from the use of the warm bath. In persons of a gouty, rheu- matic habit, no remedy will be so likely to be successful as colchicum. In the more aggravated and intractable forms of the malady, recourse must be had to counter-irritation over the perineum, the supra-pubic region, the sacrum, or inner part of the thighs. The best forms are the moxa and the caustic issue. When the neuralgia depends upon stricture of the urethra, foreign bodies in the bladder, hemorrhoids or other disease of the anus, none but the most transient amelioration can be expected frora any mode of treatment, until these causes have been removed. The strictest attention should be paid to the diet. Everything calculated to disorder the digestive apparatus, and induce acidity and flatulence, should be avoided. When indigestion prevails, the carbonate of soda may be re- sorted to, either alone, or, what is better, combined with some of the simple tonics, such as columba, gentian, hop, or cascarilla, in infusion. Occasion- ally, great relief follows the use of large doses of subnitrate of bismuth. Exposure to cold is avoided ; flannel is worn next the surface; sexual in- tercourse is abstained from ; and all sources of irritation are removed. PARALYSIS. Paralysis of the bladder may arise from various causes, some of which are seated in the organ itself, others in the cerebro-spinal axis, and others, ap- parently in the mind. Thus, the organ is often palsied by external injury, as a blow or kick upon the hypogastrium, or the pressure of the child's head in parturition ; inflammation of its different tunics ; or over-distension of its muscular fibres from protracted retention of urine. Compression of the brain and spinal cord is always followed by loss of power of this organ. Want of tone in the general system may induce the disease, as is so often witnessed during the progress of encephalitis, apoplexy, and fever, especially typhoid. The bladder first loses its sensibility, in consequence of which the urine ceases to make its accustomed impression, and continues to accumulate, without awakening any desire to evacuate it, until the muscular fibres become so much stretched that they are incapable of fulfilling their office. Severe injuries, amputations, the ligation of hemorrhoidal tumors, and va- rious other operations, are liable to be followed by transient paralysis of this organ. Lying-in females are often unable to pass their urine for several days after delivery. There is a form of paralysis of this organ to which the term senile may be aPplied. It is most common in elderly men who have led a life of indolence and inactivity, who have indulged freely in the pleasures of the table, and who have habitually neglected the calls of nature. The paralysis usually comes on in a slow, stealthy manner. One of the first symptoms which attract attention is a slight difficulty in starting the urine. As the disease vol. 11.—47 738 DISEASES AND INJURIES OF THE URINARY ORGANS. advances, the muscular contractility is still further impaired; and the water instead of being ejected in a bold, full stream, falls between the patient's legs' and upon his shoes. As soon as the bladder has lost its power of contraction, its contents accu- mulate and distend its walls. The organ gradually rises above the pubes forming a tumor which sometimes reaches as high as the umbilicus, and as far outwards as the brim of the pelvis. The swelling is of an ovoidal shape, fluctuating, indolent at first, but painful afterwards, and attended with com- plete retention, which constitutes one of the characteristic symptoms of the disease. The duration of the paralysis varies from a few hours to several weeks, months, and even years. Occasionally it ceases only with life. When the paralysis is produced by injury of the spinal cord, the urine is usually highly alkaline, turbid, of an ammoniacal odor, and surcharged with thick, ropy mucus. Phosphatic matter soon makes its appearance, and the lining membrane speedily becomes inflamed, if not ulcerated, followed by a dis- charge of blood and pus. Persons thus affected are very prone to calculous diseases. The prognosis of vesical paralysis will depend upon the nature of its causes, the character of the treatment, and the age of the patient. If the bladder has been very greatly and protractedly distended, it will necessarily be along time in recovering its former vigor, if, indeed, it ever does. It must be obvious that an affection depending upon so many and such opposite causes, must require, for its removal, a variety of modes of treatment. In every case of this disease, the urine should be drawn off at least three times a day. Occasionally the catheter may be constantly retained, espe- cially when there is a good deal of pain and spasm of the neck of the bladder, with a frequent desire to pass water. When the accumulation is very great, and has continued for several days, it is a good rule not to evacuate all the fluid at once. The use of the instrument should be discontinued as soon as the organ has regained its expulsive power. Another indication, in the treatment of this disease, is to impart tone to the bladder. For this purpose, various remedies may be used. A brisk cathartic, consisting of calomel and jalap, will often produce the raost prompt and happy effect, and should be one of the first remedies that are administered after the bladder has been relieved of its burden. The medicine may be repeated, in small doses, at first every other day, and afterwards twice a week. Emetics are sometimes of signal benefit in this disease. They are particu- larly valuable when the paralysis is coincident with disorder of the digestive organs, and torpor of the general system. They are contraindicated in the traumatic form of the disease. After the bowels have been well evacuated, and the secretions restored, recourse may be had to remedies calculated to make a more direct impression upon the nervous system. At the head of this class of agents may be placed strychnine, cantharides, and arnica. An excellent formula, when they are given in combination, is the twenty-fourth of a grain of strychnine, a twelfth of a grain of cantharides, and from three to five grains of the extract of arnica, three times in the twenty-four hours, care being taken to watch the effect. If spasmodic twitchings, strangury, or gastric irritability ensue, it may be assumed that they have been carried far enough, or that some modification should be made. In paralysis of the bladder, consequent upon typhoid and other fevers, masturbation, and general exhaustion, few remedies are so ser- viceable as arnica. Strong testimony has recently been published in favor of the ergot of rye in the treatment of this affection. The dose usually given, in the twenty- four hours, was from one to two scruples of the recent powder. Dr. Day, ot London, generally administers it in the form of a very strong tincture, pre- RETENTION OF URINE. 739 pared with six ounces of the substance to a pint of spirit, the dose being a drachm three times a day, in an effervescing draught of citrate of ammonia. The fluid extract is also a convenient method of. administration. In the inflammatory form of the disease, characterized by pain and spasm of the neck of the bladder, with a constant desire to urinate, and more or less febrile commotion, the treatment should be conducted strictly upon antiphlo- gistic principles. When the disease is associated with general debility, tonics are indicated. Ordiuarily, a preference is given to the chalybeate preparations, combined, if necessary, with strychnine, cantharides, arnica, and other articles. In hysterical paralysis, the mind is affected rather than the bladder. The want of power is, no doubt, sometimes real, but oftener it is feigned. Such cases are always promptly relieved by assafoetida, valerian and morphia, aided by the catheter. These remedies, however, are merely palliative, not radical. To effect a permanent cure, the treatment should be directed to the improve- ment rather of the mind and of the general health than of the condition of the bladder. Counter-irritation is a useful auxiliary to the other remedies. A succession of blisters over the ^dorso-lumbar region often proves highly beneficial, by stimulating the spinal cord. The vesicated surface may be sprinkled over the space of about the size of a dollar, with the fourth of a grain of strych- nine. The application may be repeated every twelve hours. I am not partial to pustulations with tartar-emetic ointment, but this mode of counter-irritation is occasionally advantageous. With the moxa I have no experience in the treatment of this affection. The actual cautery is a most energetic and suitable agent, especially in the more rebellious forms of vesical paralysis. The best place for applying it is about the junction of the last lumbar vertebra with the sacrum ; in traumatic cases, however, depending upon injury of the spine, it ought sometimes to be used much higher up. The cautery which I generally employ for this object is fully one inch in diameter. Counter-irritation by seton is hardly to be recommended in any case. Frictions over the perineum and hypogastrium with stimulating embroca- tions, such as turpentine and ammonia, are sometimes serviceable. Another remedy of great potency, in many cases of this disease, is the cold douche. It is a most powerful stimulant, and sometimes rouses the dormant energies of the bladder when almost everything else has failed. Finally, galvanism, as a local stimulant, should not be neglected. It is particularly indicated in senile palsy, attended with a partial failure of the muscles of the lower half of the body. No very satisfactory observations have yet been made in regard to direct medication in the treatment of vesical paralysis. Paul of iEgina and some modern practitioners have advised astringent injections; and Deschamps states that he cured several cases with cold water thus employed. In a very obstinate case, which resisted every known method of treatment, both gene- ral and local, for ten weeks, a cure was speedily effected by injections of strychnine. RETENTION OF URINE. Ihe symptoms of retention of urine are generally well marked, even at an early stage of the complaint. In this respect, however, there is, as might be upposed, considerable diversity in different cases, depending mainly upon we natural tolerance of the bladder, and the character of the exciting cause the disease. In paralysis of the muscular fibres of the organ, attended 1" loss of sensation, the accumulation may make great progress, and yet 740 DISEASES AND INJURIES OF THE URINARY ORGANS. the individual not be aware of his real condition. A slight discharge of urine, perhaps, occasionally takes place ; or if, as often happens, incontinence is soon superadded to the original disorder, the fluid dribbles off incessantly, and thus both patient and physician are lulled into a false security. When, on the contrary, the retention is inflammatory, more or less pain, and frequent inclination to void the urine, with inability to do so, attend the complaint, and at once expose its true nature. The characteristic symptoms of this affection are, the existence of a hard, pyriform, circumscribed tumor, corresponding with the middle line, more or less tender on pressure, fluctuating, not affected by change of posture, and gradually increasing in volume; a frequent desire to void the urine, which, if passed at all, is discharged in drops, or small jets, never in a full stream, or in any considerable quantity; uneasiness and a sense of weight in the pelvic region, soon followed by pain and spasm; straining, forcing, or tenes- mus at every attempt at micturition ; at first absence of fever, and then rigors, alternating with flushes of heat, and, in the latter stages of the complaint, excessive restlessness, an indescribable sense of oppression, urinous breath and perspiration, typhomania, and a Hippocratic condition of the counte- nance. In addition to these signs, which none but a heedless practitioner can mistake, there is also generally, after the first few da"ys, a constant drib- bling of urine, and the disteuded bladder can easily be felt by the finger introduced into the rectum or the vagina. In ascites, with which this affection is most liable to be confounded, the abdominal tumor is diffused, not circumscribed, and changes its form and situation with the position of the body; there is little, if any, tenderness on pressure and percussion ; the sense of fluctuation is more distinct; the pro- gress of the disease is more tardy; the urine, although more scanty than in health, is voided several times in the twenty-four hours, generally without pain or difficulty; there is commonly anasarca of the lower extremities; the skin is remarkably dry and harsh ; and there is usually an absence of febrile disturbance and always of typhomania and of urinous perspiration. The treatment of retention of urine is, in the first instance, by the catheter; for the indication is to relieve the distended organ without delay, before the part and system have sustained serious mischief. When there is great dis- tension, amounting to several quarts, it will be most safe, as a general rule, not to empty the bladder completely at a single operation, but gradually. The catheter is introduced, and half the fluid is evacuated, to afford the over- stretched fibres an opportunity of contracting and regaining their power. Some hours afterwards the instrument is again used, and the remainder of the urine withdrawn. When this precaution is neglected, or unavoidable, the abdomen should be supported by a compress and a broad roller. A large opiate should be given just before or immediately after the operation, if not contraindicated by cerebral oppression. Retention of urine may be produced, 1st, by mechanical obstruction ; 2dly, by paralysis; 3dly, by spasm; 4thly, by inflammation ; and 5thly, by the presence of some pelvic tumor. Finally, it may depend upon the effects of miasm. 1st. The first class of causes raay affect either the urethra, the bladder, or the head of the penis. a. The urethra may be obstructed by an organic stricture, a calculus, a small tumor, clotted blood; coagulating lymph, or inspissated mucus. A catheter, bougie, or other foreign body may break off in the canal, and thus become an impediment to the egress of the urine. .. In organic stricture, the ordinary means are resorted to; when these fail. our only resource is puncture of the bladder. An impacted calculus may, in general, be pushed back into the bladder, or RETENTION OF URINE — TREATMENT. 741 extracted with the urethra-forceps. When these means fail, it is removed by incision. Pieces of bougie, and other foreign bodies, are managed on the same principle. Clotted blood, coagulated lymph, and inspissated mucus, are easily displaced by the catheter, or forced out by the urine. When the sides of the urethra are glued together by adhesive matter, the obstacle can only be overcome by the gentle use of the instrument. The retention is sometimes occasioned by congenital occlusion of the urethra, of which there are several varieties. However induced, or in what- ever form it may present itself, the obstruction is almost always easily over- come by the knife, aided by the catheter; or, when the occlusion is owing to simple narrowing of the canal, a cure may be effected by the steady and judi- cious use of the bougie. Retention in the female is occasionally caused by maldirection of the urethra. The obstacle may lie exterior to the urethra, as an abscess in the perineum, or a deep-seated collection of blood, an effusion of lymph, or the presence of a malignant tumor. Cancer of the penis and contusions of the perineum are frequently followed by the worst forms of retention of urine. When the obstacle is seated externally, and bulges inwards, so as to occlude the canal, the knife supersedes the catheter. Extravasated blood is to be treated by sorbefacients, as the application of acetate of lead, hydrochlorate of ammonia, or spirituous embrocations. In contusions of the perineum, without rupture, the catheter is to be used; but when the accident is at- tended by laceration, a large incision is made, to save the tissues from urinary infiltration. b. In the second place, the obstruction may be seated in the bladder. Of this class of causes, the most frequent are hypertrophy of the prostate gland, coagulated blood, inspissated mucus, lymph, and urinary concretions. The gravid uterus, or any other pelvic tumor, may, by compressing the neck of the bladder, give rise to a similar effect. The most common form of obstruction of the bladder, productive of reten- tion of urine, is hypertrophy of the prostate gland. The hypertrophy raay involve the entire organ, or may be limited to one of its lateral lobes, or even to its maramillary process. Retention of urine, dependent upon enlargement of the prostate gland, is usually of a temporary character, but is liable to be produced by the slightest exposure to cold, irregularity of diet, horseback exercise, sexual indulgence, or neglect to empty the bladder. The treatment is by the catheter; and one of silver is far preferable to one of gum-elastic. It must not be too abrupt in the curve, and should be at least ten inches and a half in length, otherwise it may fail to reach the dis- tended reservoir. When the instrument comes in contact with the enlarged gland, the surgeon introduces the left index-finger, well oiled, into the rec- tum, and placing it against the beak, he guides it into the bladder, by pushing it gently towards one side, or upwards towards the pubes, at the same time that he urges the handle on with the right hand. In order to empty the bladder entirely, it is necessary, as the point of the catheter cannot reach the cavity behind the gland, to raise the patient's hips, or to turn him on his oelly, so as'to force the urine out of its hiding-place. Retention of urine from coagulated blood in the bladder is a very serious affair. When the quantity is very large, relief must be sought by an open- ing in the perineum, similar to that in lithotomy. Under ordinary circum- stances, however, evacuation is attempted by a full-sized silver catheter, with four large eyelets, aided by injections of warm water, and an exhausting syringe. The usual hemostatic means are also employed. When the blood has been recently effused, it is best to wait from six to ten hours, until the fluid has 742 DISEASES AND INJURIES OF THE URINARY ORGANS. subsided to the bottom of the bladder, when the urine may generally be with- drawn without difficulty. Retention caused by inspissated mucus, coagulating lymph, worms, or cal- culous concretions, is, in general, easily relieved by the catheter. When it depends upon the presence of the gravid uterus, it can be remedied only by rectifying the position of the displaced organ. Retention of urine is sometimes occasioned by pressure of the rectum upon the neck of the bladder. Anything having a tendency to cause inordinate distension of the bowel may produce such a condition. c. Retention of urine may be occasioned by an imperforate prepuce. When this is the case, relief is sought by a free incision. In the female, the ob- struction is sometimes caused by fleshy excrescences in the orifice of the tube. Excision is, of course, the proper remedy. d. Retention may depend upon priapism, induced either by inflammation of the penis, by excessive cerebral irritation, as in lesion of the brain, or by the inordinate use of cantharides. However this may be, recourse is at once had to the catheter, attention being afterwards paid to the removal of the exciting cause. 2d. Retention of urine from paralysis is of frequent occurrence. The most common causes of this condition of the bladder are apoplexy, injury of the spine, over-distension of the organ, the effects of fever, contusions, lacerated wounds, and capital operations. The use of anodynes, in large doses, will sometimes induce temporary paralysis of the bladder. In low fevers, especially when delirium is present, in compound fractures and dislocations, in lacerated wounds, in contusions of the abdoraen, and in strangulated hernia, frequent inquiry should be made into the condition of the bladder, in order to guard against retention, or to relieve it speedily, if it be found to be unavoidable. The liability of this form of retention to be followed by incontinence can- not be too forcibly or too frequently urged upon the mind of the reader. It is to this form of the affection that I have applied, in my Treatise on the Urinary Organs, the term incontinence of retention, in the hope that, by an antithetical expression, I might be able to attract to it the particular atten- tion of medical men. Retention from paralysis is relieved by the catheter, and it is better to in- troduce the instrument frequently than to permit it to remain. When the return of contractility is slow and imperfect, our chief reliance raust be upon gentle but steady purgation, the internal use of strychnine, cantharides, and tincture of the chloride of iron, the cold shower bath, vesication of the sacro- lumbar region, and irritating frictions to the spine. When the loss of power is dependent upon the use of anodynes, cold applications to the head, the hypogastrium, perineum, and genitals will usually suffice to afford relief. Retention of urine from paralysis of the bladder, whether induced by trau- matic or internal causes, often ceases very suddenly of its own accord, or under the use of mild remedies. Under this head may be noticed a variety of retention of urine which is occasionally met with in hysterical females, and which seems to be dependent rather upon a deficiency of volition than upon paralysis of the muscular fibres of the bladder. The affection is, in general, only temporary, but may last for several days or weeks. Purgatives, assafoetida clysters, and the internal use of antispasmodics, are the remedies mainly to be relied upon. Cold water, poured upon the sacro-lumbar region in a continuous stream, from a height of three or four feet, often affords speedy relief. The catheter must, if possible, be avoided. Moral treatment is often the most successful, loo much kindness will only tend to prolong the case. . 3d. Retention of urine from spasm of the neck of the bladder, or of this CATHETERISM. 743 organ and of the urethra, is commonly produced by cold, suppression of the cutaneous perspiration, the irritation of ascarides, hemorrhoidal tumors, stone in the bladder, disorder of the digestive apparatus, the use of fermented, vinous, or alcoholic drinks, and the effects of cantharides. The warm bath, hot fomentations, and the inhalation of chloroform, followed by the free use of camphor and morphia, or morphia alone, either by the mouth or rectum, generally afford prompt relief. Cold applications sometimes answer better than warm. Wfhen the symptoms are urgent, recourse is had to the catheter. 4th. Retention of urine may be produced by inflammation of the urethra and the neck of the bladder. The symptoms are a frequent desire to urinate, with an inability to pass more than a few drops of water at a time; a sense of smarting, burning, or scalding in the urethra and the head of the penis; violent straining; a feeling of weight about the anus ; and throbbing in the perineum. Occasionally, the urine is mixed with blood and pus. The treatment is, of course, antiphlogistic. Spasm is allayed by anodyne enemata and mucilaginous drinks. General and local bloodletting is to be used. The warm bath is eminently useful. The bowels are moved by mild laxatives. When the symptoms are urgent, and the means here indicated are inefficacious, the catheter must be used, but with great care and gentle- ness. In inflammatory retention of urine, accompanied by spasm of the blad- der and urethra, prompt and decided relief is occasionally obtained from the inhalation of chloroform. 5th. Retention of urine may, in the fifth place, depend upon the presence ofa pelvic tumor. The difficulty may arise from a serous, bloody, or hydatic cyst between the bladder and the rectum. Inordinate distension of the bowel by hardened feces and displacement of the uterus, especially retroversion of the organ, may also produce it. Retention occasionally takes place during utero-gestation and parturition. The treatment in these cases is sufficiently obvious. Finally, there is a form of retention of urine which may be said to be periodical in its character, as it comes on at a particular time, very much like an attack of intermittent fever, being evidently dependent upon similar causes. It is met with chiefly, if not exclusively, in miasmatic regions. The treatment must, of course, be by quinine, either alone, or in union with arsenic, and other antiperiodic remedies. CATHETERISM. The introduction of the catheter, although apparently very simple, is one of the nicest and most delicate processes in surgery. It requires skill of the highest order, as well as the most intimate knowledge of the anatomy of the urinary organs. My conviction is that few men perform the opera- tion well. Catheters are cylindrical tubes, varying in their composition, size, and shape. The best are made of silver, and are, for an adult, about nine inches and a half long, by two lines and a half in diameter; they are perfectly smooth, light, and bent for one-third of their length, to accommodate them to the natural curvature of the urethra. The vesical extremity, which is rounded off, but closed at the point, and nearly of the same thickness as the rest of the instrument, has an oval bole on each side, as exhibited in fig. 441, a quarter of an inch long, and about a line in width, for the entrance of the m'ine. Instead of this arrangement, this part of the tube is sometimes pierced with numerous little apertures, as in fig. 442, but these are objec- tionable, because of their liability to become clogged with blood and mucus. * or the removal of urine, mixed with these substances, I have recently had a catheter constructed with eight eyelets. A catheter with the opening at 744 DISEASES AND INJURIES OF THE URINARY ORGANS. the extremity, and provided with a closely-fitting conical stopper, secured to a stylet, is also well adapted to this object, as the orifice remains closed until Fig. 441. Fig. 442. Fig. 443. Different forms of catheters. the tube is fully in the bladder. The other extremity, usually called the handle of the instrument, is open, and is provided on each side with a small ring, for securing it in its place when it is necessary to retain it in the blad- der. The French pocket catheter consists of two pieces, united by a screw, and is adapted for either sex. The gum-elastic instrument, so much lauded by some practitioners, I never employ, as it is extremely liable to bend when- ever it meets with the slightest resistance, and is also very easily injured by the urine. Every practitioner should have an assortment of catheters of dif- ferent dimensions, that he may be prepared for any emergencies that may arise. For washing out the bladder, for the removal of blood and mucus, or for introducing fluids, a double catheter, represented in fig. 443, is neces- sary. When the object is to throw up medicated fluids, such as nitric acid and water, a silver instrument is required. When the urethra is entirely sound, a tolerably large catheter, one that will distend the parietes of the tube, is selected. An instrument of this size is not so likely to be arrested by the folds and follicles of the mucous mem- brane, or to impinge against the margins of the opening in the triangular ligament. Immediately previously to inserting it, it should be well warmed and oiled. The catheter may be introduced while the patient is standing, sitting, or lying ; but, whatever posture may be selected, it is important that the thighs should be moderately separated from each other, and flexed upon the pelvis, to relax the abdominal muscles. In the first case, the patient leans with his back against the wall, and inclines his chest slightly forwards, so that he may not change his position during the operation. The surgeon may take his place either at the front or side. If he sit, the breech should project over the chair, and the body be directed backwards. The position of the operator is the same as before. The most convenient posture, however, is the recum- bent. The patient lies on his back, near the edge of the bed, the head being supported by a pillow, and the knees, slightly separated from each other, somewhat raised. The surgeon, standing at the left side of the bed, takes the penis in the left hand, and raises it to a right angle with the body to efface the curve which it forms at the pubes. The catheter, held in the right hand, between the thumb and first two fingers, is inserted kito the orifice of the urethra, its concavity being directed towards the pubes, while the handle PUNCTURE OF THE BLADDER. 745 is nearly in contact with the median line of the abdomen. The instrument is now passed on, until its beak reaches the sinus of the bulb, which lies upon the anterior surface of the triangular ligament, rather deep in the perineum. To disengage it from this depression, the handle is changed from the hori- zontal direction, in which it has hitherto been held, into the vertical, at the same time that the point is slightly retracted. By this manoeuvre, the curved portion is brought under the arch of the pubes, and immediately opposite the opening in the triangular ligament. By now depressing the handle of the instrument on a level with the thighs, or, rather, a little between them, its point glides readily over the prostatic part of the urethra into the bladder. In performing this operation, no force is employed; on the contrary, the whole proceeding is conducted with the utmost gentleness. The catheter, held as lightly as possible, is made to glide along, as it were, by its own weight, and by that of the hand. The penis should be drawn slightly for- ward over the instrument, just sufficiently to render the urethra a little tense. Everything like stretching and pulling should be avoided. In introducing the straight catheter, the patient lies on his back, and the surgeon stands on the right side of the bed, instead of on the left, as in the other case. The penis is held in the left hand, at a right angle with the body, and the instrument is carried down perpendicularly as far as the sinus of the bulb. To free it from this depression, the point is retracted a few lines, and then, while the penis is lowered between the thighs, it is at once pushed onward into the bladder. Fig. 444. Various contrivances, are used for retaining the cathe- ter in the bladder. The one which I usually prefer consists of a broad waistband, with two thigh-pieces fastened in front and behind, so as not to interfere with the anus and the scrotum. The instrument, having been introduced, is secured by two strips of linen, tape, or oiled silk, by tying the middle of each to the ring of the catheter, and the ends to the vertical bands. Another very good plan is to surround the penis with an ivory, elastic, or linen yoke, and to se- cure this against the pubes by means of four pieces of tape, carried round the thighs and pelvis. The cathe- ter is then fastened to the ring or yoke in the usual manner. In the annexed drawing, fig. 444, the instru- ment is secured to a piece of linen, passed round the Mode of 6ecuring the cathe. penis, just behind its head. The contrivance, how- ter in the bladder. ever, is objectionable, on account of its liability to injure the penis, in case of erection, and to slip when the organ is flaccid. To prevent undue pressure upon the mucous membrane of the bladder, the catheter, if intended to be retained, should be at least from one to two inches shorter than one used for merely drawing off the urine. PUNCTURE OF THE BLADDER. When the bougie, catheter, and other means have failed to procure relief, the only thing that remains is to puncture the bladder. Fortunately, this operation is seldom necessary. It is only in cases of excessive enlargement of the prostate gland, attended with great tenderness and swelling of the surroundiug parts, in laceration of the urethra, infiltration of urine into the scrotum, and in deep-seated, impassable stricture, that the operation should ever be seriously thought of. I have myself been obliged to perform it only once, and then the case was not my own. There are four routes by which the organ may be approached when this 746 DISEASES AND INJURIES OF THE URINARY ORGANS. operation becomes necessary, namely, the rectum, the perineum, the hypo- gastrium, and the pubic symphysis. Of these, the first is the one usually preferred, on account of the facility of performing the operation, and its sup. posed freedom from the danger of urinary infiltration. It is, of course contraindicated when there is great enlargement of the prostate gland or serious disease of the anus, rectum, or bas-fond of the bladder. a. The rectal puncture is executed with a curved trocar, about four inches in length, and provided with a suitable canula. The breech of the patient is brought over the edge of the bed, and his legs are supported by two assistants, as in the operation for stone. The surgeon, oiling the index and middle fingers of the left hand, introduces them into the bowel, in contact with its anterior wall; he then takes the instrument in the right hand, and retracting the point of the trocar within its sheath, places it in the groove formed by the junction of the two fingers. When the instrument has passed the posterior margin of the prostrate glaud, the handle is depressed, and the point urged on through the superimposed structures into the interior of the bladder, as shown in fig. 445. The want of resistance, and a slight escape Fig. 445. Rectal puncture of the bladder. of urine, will indicate that the instrument has reached its destination. By a sort of double movement, the trocar is now withdrawn, and the cauula pushed farther on into the distended viscus. The urine being evacuated, the canula is either at once'removed, or, if there be any serious obstacle along the natural passage, it is retained until this is surmounted. b. The perineal puncture is to be preferred, when the retention is caused by an impassable stricture or by injury of the urethra, the perineum, or the neck of the bladder, followed by infiltration of urine. The patient being placed and held, as in the other operation, a moderate-sized catheter is car- ried down to the seat of the obstruction, where it is firmly supported by an assistant, and its point exposed by direct incision, in the raphe^ of the peri- neum. The knife is next conveyed backwards, through the constricted part, and thence by successive touches on through the posterior portion of the urethra as far as the neck of the bladder. As soon as the organ is reached, the urine rushes out in a full stream. A catheter is then passed and retained in the usual manner. Care is taken not to wound the rectum and the arte- ries of the bulb. c The supra-pubic puncture of the bladder has generally been regarded as more objectionable than any other, because of the great danger of the escape of urine into the peritoneal cavity, and the surrounding cellular substance. INCONTINENCE OF URINE. 747 In performing the operation, the patient is placed on his back, the skin is divested of hair, and an incision is made from below upwards, along the median line, from an inch to an inch and a half in length, according to the condition of the part, first through the common integuments, and then through the fibrous struc- ture between the pyramidal muscles, down to the cellular tissue which co- vers the distended organ. Through this opening the bladder is pierced at its lowest part, by means of a long curved trocar, seen in fig. 446, the point of the instrument being in- clined obliquely downwards, and backwards in the direction of the promontory of the sacrum. Trans- fixion being Completed, the trocar Supra-pubic puncture of the bladder. is withdrawn, and the canula gently passed into the bladder, where it is retained by an appropriate bandage, until the obstruction necessitating the operation has been removed. The patient, in the mean time, lies on his side, to promote the escape of the urine. d. The inter-pubic puncture of the bladder is of modern invention ; and, although it has been performed successfully by several surgeons, among others, by Dr. Leasure, of Pennsylvania, it would, perhaps, be premature to express any opinion respecting its relative and absolute merits. As the name implies, the instrument is passed through the centre of the pubic symphysis, and, consequently, only a short distance from the urethra. It has the advan- tage of facility of evacuation, and of freedom from infiltration. INCONTINENCE OF URINE. Incontinence of urine, the reverse of retention, with which it is often asso- ciated, may occur at any period of life, and may be partial or complete, tem- porary or permanent. It may be excited by a great variety of circumstances, the most prominent of which, however, are referable to external injury, or to inflammation, spasm, paralysis, or morbid sensibility of the bladder, or of this organ, and of the urethra. The water may pass off as fast as it is secreted, or it may be retained for a time, and then either dribble away, or be discharged in a full stream. «. The best example of incontinence from external injury is afforded in lithotomy. A kick, blow or fall upon the perineum is occasionally followed by a similar result. Incontinence from this cause often disappears sponta- neously; and, on the other hand, it is occasionally incurable. The treatment must be conducted upon general principles. b. Incontinence from inflammation may depend upon various circum- stances. The escape is usually partial, and is almost constantly associated with severe pain and spasm. The treatment consists in removing the excit- ing cause, and in employing the lancet, the hip-bath, antispasmodics, and anodyne injections. The catheter often affords instant relief. c Paralysis of the bladder, or of this viscus and of the urethra, however induced, is a frequent cause of incontinence. It is particularly liable to supervene upon injury of the brain and spinal cord. It also occasionally follows parturition. Owing to the fact that the sphincter muscle generally retains some contractile power, more or less of the urine is apt to accumulate Fig. 446. 748 DISEASES AND INJURIES OF THE URINARY ORGANS. in the bladder, while the rest gradually passes off, leading thus to a belief on the part of the practitioner that the case is one purely of incontinence, when in fact, it is one both of incontinence and retention. In the treatment of this affection, our remedies raust be addressed chiefly to the invigoration of the nervous system. For this purpose, after having cleared out the bowels and corrected the secretions, the patient is put on the use of strychnia, either alone or combined with some mild tonic, such as the extract of gentian and sulphate of iron. Cantharides may also be advan- tageously given, especially if they be carried to the extent of slight strangury. The diet should be light, and the patient should make frequent use of the cold shower bath, followed by dry frictions. Counter-irritation by blisters is kept up in the sacro-lumbar region. d. Incontinence may arise from a morbid sensibility of the neck of the bladder, or of the entire organ, excited by the acid character of the urine, or by sympathy with the kidney, rectum, anus, vagina, or uterus. Masturba- tion, or inordinate sexual indulgence, may be followed by the same result. In most of these instances, the incontinence is incomplete. To this form of incontinence obviously belongs that variety of the disease which occurs in young delicate subjects, especially in boys. It is most fre- quent before the age of ten, and often begins very early in life. The dis- charge, which may take place several times during the night, is most common towards morning, and is occasionally effected under the influence of the will or of a dream, but, in general, it is strictly involuntary. When it becomes habitual, as it usually does, it may last for years. In most cases, however, it gradually disappears on the approach of adolescence. It is promoted by the use of fluids, by exposure to cold, and by sleeping on the back, a posture which is favorable to the accumulation of urine in the morbidly sensitive portion of the bladder. In boys one of the most common exciting causes of this affection is mas- turbation, and this unnatural habit, if indulged in, will frequently keep up the incontinence until a late period of life. In young children it is often produced by ill health, arising from improper feeding and want of good air and exercise, followed by disorder of the digestive organs; by malarious dis- eases ; by worms in the alimentary canal; by the inordinate use of saccharine drinks; and by the irritating properties of the urine, or by the excessive quantity of this fluid. In the treatment of this form of incontinence, particular inquiry should be made into the nature of the exciting cause, the removal of which is of para- mount importance. In that variety of the affection which is met with in boys and girls, the cure may be greatly expedited by proper attention to the diet, which should always be bland and unirritating. Late suppers are avoided, and the patient must abstain entirely from drinks for several hours before going to bed. During the night, he is to be thoroughly waked two or three times for the purpose of emptying his bladder, and this practice is to be persisted in for weeks and even months, until the disagreeable habit is broken up. During all this time, as well as, indeed, for a long period after- wards, the child should lie upon his side, to prevent the urine frora coming in contact with, and irritating the neck of the bladder. The internal remedies, from which I have derived most benefit in the treatment of this affection, are strychnine and cantharides, given three times a day, in the proportion of the twentieth or thirtieth of a grain of the former, to the twentieth of a grain of the latter, according to the age of the subject. A minute portion of morphia forms a valuable addition; and, in atonic cases, I often combine with these articles some of the preparations of iron. When the strychnine disagrees, or fails to answer the purpose, we may substitute the extract of nux vomica. In either case, it is important to watch the effects of the remedy. I have INCONTINENCE OF URINE. 749 great confidence in the use of cantharides in this affection, having known them to afford relief when everything else seeraed to prove unavailing. I prefer the powder to the tincture, and occasionally continue the exhibition of it until slight strangury is induced. Benzoic acid has also been highly recommended, but the trials I have made of it have disappointed my expec- tations. When the morbid sensibility of the bladder is connected with in- flammation, the balsam of copaiba, in doses of from ten to fifteen drops every eight hours, is sometimes beneficial. In this variety of the affection a full anodyne at night, especially in the form of Dover's powder, often exerts a happy effect in controlling the discharge. Many practitioners have great confidence in the efficacy of belladonna in the treatment of nocturnal incontinence of urine, some regarding it almost as a specific. That the remedy is a valuable one, is certain, but the results of my experience are altogether opposed to such a sweeping conclusion. It should bC administered in small doses, as the fifteenth or twentieth of a grain of the extract, dissolved in distilled water and syrup of ginger, three times in the twenty-four hours, with an occasional intermission for a few days, especially if it causes confusion of sight or redness of the skin. A steady perseverance in the medicine, for several months, will generally be necessary to insure a cure, although in most cases its good effects become almost at once apparent. The cold shower bath should be used twice a day, or cold water poured from a considerable height upon the lower portion of the spine, and blisters applied to the sacro-lumbar region, the perineum and thighs. In obstinate cases, the neck of the bladder is cauterized, as in spermatorrhoea, but much more mildly. In the female the application is made to the orifice of the urethra, and a similar expedient sometimes answers a good purpose in boys, the urine, as it comes in contact with the tender surface, waking them up, so as to induce them to rise and empty the bladder. The application of pressure to the urethra, gentle but steady, and gradu- ally increased, has sometimes been found beneficial in removing the com- plaint. In all cases of nocturnal incontinence, the practitioner must endeavor to secure the co-operation of the patient. The child must be reasoned with, and even threatened with chastisement; of course, he is not beaten, nor does any sensible man ever think, at the present day, of tying up the penis. Some very interesting facts in relation to nocturnal incontinence of urine have recently been published by Dr. Addinell Hewson. In the House of Refuge, of Philadelphia, of which he is surgeon, the disease prevailed as an endemic in 1857, not less than 78 out of 292 boys, the whole number of in- mates, being affected simultaneously. Of the 78, only 63, however, were under observation all the while, and of these 34 were negroes. The ages ranged from seven to eighteen years, the average being thirteen. Many of the boys bore the marks of ill health, especially of disorder of the digestive organs. Twenty-four suffered from ascarides; some had herpes; twenty labored under constipation ; and nearly all were suspected of masturbation, eighteen acknowledging their guilt. The prepuce was discolored and elon- gated, either from frequent scratching or pulling, in not less than 46 cases. A considerable number wet themselves both day and night. The urine de- posited uric acid in nearly one-half of the cases. The use of stimulating food, and sudden atmospheric changes, always produced a marked increase of the disorder. The remedies which proved raost efficacious were the juice of belladonna, prepared according to Bentley's process, magnesia, the cold douche, and a reduced supper of bread, without any drink. Those who had worms were treated with turpentine and bicarbonate of soda. Each boy was compelled to get up and micturate an hour after retiring at night. Under 750 DISEASES AND INJURIES OF THE URINARY ORGANS. this treatment, especially the influence of a restricted diet, enjoined as a punishment, the endemic rapidly disappeared. Finally, when the incontinence is irremediable, the patient should wear a urinal, to prevent the fluid from soiling his clothes. The best contrivance for this purpose is a gum-elastic bottle, shaped somewhat like a Florence flask, and capable of holding about twelve ounces. The subjoined cuts will convey a better idea of the apparatus than any description. Fig. 447 repre- sents the male, and fig. 448 the female urinal. Each instrument is furnished Fig. 447. Fig. 448. Male and female urinals. at its inferior extremity with a screw, for the purpose of evacuating the urine after it has accumulated to some extent in the artificial reservoir. The inte- rior should be frequently washed for the sake of cleanliness, and every patient should be provided with an extra vessel, so that he may not suffer any incon- venience in case of accident. HEMORRHAGE OF THE BLADDER. A discharge of blood from the bladder, technically denominated hematuria, although not of frequent occurrence, is generally a source of disquietude to the patient, from a belief, not altogether unfounded, that it is a symptom of evil import. The bleeding occurs in both sexes, and at all periods of life. Men, however, are more prone to it than women; and it is likewise more common in old and middle-aged subjects than in children and adolescents. Vesical hemorrhage presents itself under two varieties of form, the idio- pathic and the traumatic. The idiopathic variety is infrequent, and is met with chiefly in elderly persons of a weak, lax habit of body, or in such as are affected with scurvy or an anemic condition of system. It sometimes occurs in association with, or in consequence of, rubeola, smallpox, plague, and typhoid fever. The traumatic form is usually the result of a wound of the bladder, or of the rude and forcible use of instruments. Persons affected with stone are very liable to suffer from hemorrhage of the bladder, especially after any rough exercise. Worms in the bladder have been known to cause profuse and even fatal hemorrhage of this organ, vio- lent concussion of the body, severe exercise on horseback, and venereal ex- cesses, may be enumerated as among the more common causes of the affection. HEMORRHAGE OF THE BLADDER—SYMPTOMS. 751 A considerable hemorrhage of the bladder occasionally results from the use of drastic cathartics and irritating diuretics. Ulceration of the raucous and submucons cellular tissue of the organ is nearly always accompanied by bleeding, and one of the most characteristic signs of fungous, encephaloid, and erectile tumors, is a considerable flow of blood. Finally, vesical hemor- rhage is sometimes vicarious of the menstrual flux, and of suppressed hemor- rhoidal discharges. It also, though rarely, marks the crisis of other diseases. When recently effused into the empty bladder, the blood is of a natural appearance; but if it has been retained for some time, or been mixed with the urine, it assumes a dark-brownish, turbid, or muddy hue. In its con- sistence, the blood may be liquid, semi-fluid, or completely solid. The symptoms of vesical hemorrhage are a discharge of blood from the urethra, either alone or in combination with the urine, and accompanied, if the quantity be at all considerable, by a frequent desire to micturate, spasm at the neck of the bladder, and a burning sensation along the course of the arethra. When the blood coagulates nearly as fast as it is poured out by the bladder, it may lead to retention of urine. Copious effusions of this kind may be followed, sooner or later, by all the symptoms of exhaustion. As hemorrhage of the bladder is liable to be mistaken for hemorrhage of the kidneys, the ureters, prostate gland and urethra, the diagnosis is some- times extremely difficult, if not impracticable. In case of direct injury of the bladder, there need be no doubt. In the idiopathic form of the hemorrhage, however, great uncertainty must frequently exist. Under such circumstances, the history of the case, and the absence of disease or injury of the associated organs, may assist in clearing up the difficulty, and leading to. a correct diag- nosis. In renal hemorrhage, the disruption is usually dependent upon injury or organic disease of the kidneys, and is, therefore, apt to be preceded and accompanied by symptoms referable to these organs. The blood is commonly of a pale, pink, or claret complexion, and either entirely fluid, or partly fluid and partly coagulated; it is never voided in a pure state, as it often is when it proceeds from the urethra or the neck of the bladder. The microscope • also discovers what are called blood-casts, consisting of blood moulded in the uriniferous tubes, and washed out by the urine. When the bleeding pro- ceeds from the ureters, it is generally produced by the presence of a calculus, which gives rise to the symptoms associated with the passage of concretions along those conduits. Hemorrhage of the urethra is generally produced by external violence, the passage of a calculus, or the venereal orgasm, and the blood commonly passes off in small vermiform pieces, without any material change of color, or any desire to void the urine. In many cases, the blood is discharged in drops, or in a small stream. In the traumatic variety of hemorrhage, the ordinary hemostatics are, of course, indicated, and should be employed without delay. Accessible arte- ries are exposed and tied, or, when this is impracticable, compression and cold applications are used. All offending causes are sought for, and, if pos- sible, removed. When the bleeding proceeds from an encephaloid, fungous, or erectile tumor, palliation alone is attempted. In such cases, our main reliance is upon opium and lead, gallic acid, alnm, and perchloride of iron, with acidulated drinks, rest in the recumbent position, and cold applications to the perineum and hypogastrium. The catheter should be avoided. In cases of vesical hemorrhage dependent upon fungous excrescences of the bladder, I have generally succeeded in affording prompt relief by a good dose of calomel and rhubarb, followed by alum and opium, with sulphuric acid and infusion of roses as a common drink. In idiopathic hemorrhage of the bladder, great attention must be paid to the system. Vascular action is reduced, the bowels and secretions are care- 752 DISEASES AND INJURIES OF THE URINARY ORGANS. fully regulated, the diet must be light and unstimulating, and the drinks should be cooling and acidulated. Absolute rest in the recumbent posture is of primary importance. The most useful remedies are gallic acid, acetate of lead, and alum. These articles ought usually to be combined with opium. Tannic acid, and elixir of vitriol, also prove highly efficacious. If anemia be the cause of the hemorrhage, chalybeate tonics are indicated and the best forms are the tincture of the chloride, the sulphate, and the aromatic wine of iron. In bleeding of the bladder, vicarious of the men- strual flux, emmenagogues, and aloetic purgatives are required. In all cases the action of internal remedies is promoted by refrigerant applications to the perineum, the inside of the thighs, and the hypogastric region. Cold ene- mata are also beneficial, and a lump of ice introduced into the rectum some- times acts like a charm. Leeches, or cupping over the sacrum, may be useful, when pain and spasm exist. Direct medication, by astringent Injections, occasionally proves serviceable. If the blood coagulate so as to distend the bladder, it may sometimes be removed by injections with cold water, or, what is still better, vinegar and water, after the clot has been broken up by a silver catheter. When all other means fail, and the symptoms are so urgent as not to admit of further delay, the only thing to be done is to open the bladder, as in the operation of lithotomy. When practicable, the lateral method should be performed, and the clotted blood be removed with the scoop. POLYPOUS, FUNGOUS, ERECTILE, AND OTHER MORBID GROWTHS. The bladder is liable to polyps, occurring chiefly in young subjects; some- times, indeed, within less than two years after birth. An instructive paper, detailing the particulars of ten cases, including one seen by himself, was lately published by Mr. Birkett, of London. The growth described by this distin- guished surgeon was attached to the upper boundary of the neck of the blad- • der, from which it projected forwards into the urinary meatus; the patient being a girl five years of age. It was composed of lobes and lobules, was of a soft, friable consistence, not unlike certain nasal polyps, and was covered with epithelium, but was not very vascular. Various anomalous growths, known by the terms fatty and steatomatous, are sometimes observed in the bladder, but their occurrence is so rare that it is scarcely necessary to allude to, much less to describe, them. They seldom attain a large bulk, are generally situated in the bas-fond of the organ, and always exhibit the same structure as in other parts of the body. • A peculiar fungous growth, a species of vegetation of the mucous mem- brane of the bladder, is also occasionally met with. Varying in its size from that of a pea to that of a pullet's egg, it is of a soft, spongy consistence, with a rough, fimbriated, or villous surface. It consists of a grayish, cellulo-fibrous tissue, covered by a prolongation of the lining membrane. Small vessels enter it in different directions, and are liable, when ruptured, to pour out a con- siderable quantity of blood. The only evidence of the existence of this dis- ease is the presence in the urine of a portion of the abnormal substance. Finally, tumors of an erectile, vascular character, similar to that of an anastomotic aneurism, or a maternal nevus, sometimes occur in this organ. The annexed drawing, fig. 449, taken frora a preparation in the pathological collection of the New York Hospital, represents a growth of this description. The specimen was deposited by Dr. Cheeseman, to whom I am indebted for the following history of the case :—The patient was .a widow, seventy-two years of age, of a spare habit of body, and the mother of five or six children. Though naturally feeble, her general health was always good until about three years before her death, when she began to complain of uneasiness in BLADDER—HETEROLOGOUS FORMATIONS. 753 her bladder, attended with a frequent inclination to void her urine, which was always mixed with blood. Her symptoms gradually increased in vio- Fig. 449. Erectile tumor of the bladder. lence; she became pale and anemic, and finally died completely exhausted. For some time before her death, she suffered severely from pain in the bladder during micturition, especially immediately after the passage of the last drops of water. She never experienced any retention, and the blood always came away in a dissolved condition. Upon dissection, a tumor was found upon the floor of the bladder, of a soft, spongy character, of a florid color, circular in its form, and about two inches in diameter. It seemed to spring from the mucous membrane, and had a rough, irregular surface, not unlike that of a cauliflower. The parts around were free from inflammation and other dis- ease; but the muscular tunic was somewhat thickened and reticulated. All the other organs were healthy. Of the exciting causes and diagnostic characters of polypous, fungous, steatomatous, and other tumors of the bladder, nothing, unfortunately, is known. * From the constant pains in the pelvic region, with the straining efforts, and the frequent inclination to void the urine, which are almost always present, the existence of stone is apt to be suspected; an apprehension which is not always relieved by sounding, which, however, should never be omitted in cases of a doubtful nature. Whenever their real character can be ascer- tained, the bladder should be laid open as in the common operation of cysto- tomy, and their removal effected with a pair of probe-pointed scissors curved on the flat. No internal remedies exert the slightest influence in arresting these tumors, or in modifying their development. Hence, all that the practitioner can do, when the disease cannot be reached by operation, is to endeavor to palliate the patient's suffering by anodynes, and such other means as his.actual condition may, from time to time, seem to require. HETEROLOGOUS FORMATIONS. The bladder is liable to malignant diseases, as scirrhus and encephaloid, or hard and soft cancer. Of colloid and melanosis, as occurring in this organ, hardly any cases have been published. I have myself seen only one example VOL. ii.—48 754 DISEASES AND INJURIES OF THE URINARY ORGANS. of the latter, the patient being a man, fifty-eight years of age. The disease, which presented itself in the form of five or six little nodules, co-existed with melanosis in nearly all the principal organs of the body. Scirrhus.—Scirrhus of the bladder, properly so called, is extremely uncom- mon. I have met with only two well-marked cases of it. It has hitherto been chiefly observed in men, between the ages of forty-five and sixty, at the neck and bas-fond of the viscus. Il occasionally Fig. 450. coexists with scirrhus in other organs, as the liver, uterus, breast, and prostate gland. During the progress of this dis- ^fe>-'I^k ease> l^e associated structures are apt to ^'""Mi^feb^ become implicated. The minute structure of scirrhus of the bladder, or of the so-called epithelioma of this organ, is illustrated in fig. 450, Microscopical structure of scirrhus of the from Druitt. The drawing was taken bladder. from a granulation, discharged with the urine in a case of this disease; it was in- vested with numerous scales, and was very vascular internally, the vessels being arranged in loops. There are no signs by which scirrhus can be distinguished from other dis- eases of, the bladder. The most reliable evidences are, the peculiar, lanci- nating character of the pain, the progressive emaciation, the wan and sallow state of the countenance, the age of the patient, the excessive burning at the neck of the organ and in the urethra immediately after micturition, and the occasional discharge of small fragments of the heterologous matter. These, when examined with the microscope, will be found to display the usual charac- teristics of such formations, and will, of course, at once remove all doubt respecting the nature of the disease. Negative testimony is afforded by sounding. No positive conclusion can be drawn from the frequent micturi- tion, the condition of the urine, and the presence of mncus, pus, or puriform fluid. The suffering in this disease is generally so excessive as to require enormous doses of morphia, both by the mouth and rectum, for its relief. In one of my cases, the pain was more severe than I have ever witnessed in any other affection. Towards the close of the disease, anodynes produced so little effect that the poor patient, a gentleman, forty-four years of age, was obliged to be kept almost constantly under the influence of chloroform. The dissection showed an ulcerated scirrhus of the bas-fond of the bladder. Encephaloid.—Encephaloid of the bladder, likewise known by the name of fungus hematodes, soft cancer, or medullary sarcoma, usually runs its course with great rapidity, destroying life in from nine to twelve months. Any portion of the organ may be affected with it, but its most common situation is just behind the neck, between the mouth of the urethra and the outlets of the ureters. It may occur as a solitary tumor, projecting into, and almost filling up, the bladder, or in the form of small nodules, from the volume of a pea up to that of a walnut. The starting-point of the disease is always the submucous cellular tissue. Tumors of this kind are often associated with calculi, which are either partially imbedded in their substance, or else lie loose in the bladder. W hen of large size, they encroach so much upon the organ as to leave hardly any room for the urine. In most cases of encephaloid, the intermediate substance of the bladder is perfectly healthy ; in others, it is diseased and hypertro- phied. Sometimes the organ is very much contracted, while occasionally, though rarely, it is greatly enlarged. The symptoms which are most characteristic of the existence of this disease TUBERCULOSIS AND HERNIA OF THE BLADDER. 755 are, uneasiness about the neck of the bladder, frequent micturition, a bloody state of the urine, a discharge of cerebriform matter, and a peculiar cachectic state of the countenance. When all these phenomena are present, no reason- able doubt can be entertained respecting the nature of the case. Still, as error may possibly arise, the practitioner should never rest satisfied until the bladder has been thoroughly explored by the sound. Should no calculus be detected, it will afford additional proof of the existence of encephaloid. The operation, it may also be stated, is generally attended, in the latter case, with considerable hemorrhage. 'The tumor can often be perceived by the finger in the rectum. A microscopic examination of the suspected matter frequently affords useful information. Mitigation of suffering is all that can be aimed at in this disease. The proper remedies, of course, are anodynes, in full and sustained doses. To check the hemorrhage which always attends the ulcerative stage, it will be necessary to make free use of perchloride of iron and opium, acetate of lead, alum, tannin, creasote, and similar articles. When the discharge is obstinate, or unusually copious, astringents may be thrown into the bladder. TUBERCULOSIS. The bladder is sometimes the seat of tubercular disease. The deposit is commonly met with in the form of minute granulations, similar to those which occur in the bowels and lungs. Their number is generally small. It is pro- bable that they may occur in any part of the bladder, but they are by far raost common in the neck and bas-fond of the organ. The seat of this deposit is in the mucous follicles, in the substance of the raucous membrane, and in the submucous cellular tissue. After it has existed for an indefinite period, it begins to soften, and is finally entirely broken down and expelled, leaving each, in its stead, a small, roundish ulcer, with thin, ragged, and undermined edges. Tubercular disease of the bladder is generally, if not invariably, associated with the same deposit in other parts of the body, especially the kidney and the prostate gland. Its coexistence with tubercular disease of the lungs is uncommon. There are, unfortunately, no symptoms by which we can, with any certainty, determine the existence of tubercular disease of the bladder. As long as the deposit remains in a state of crudity, there is, in general, merely a slight degree of irritability of the mucous membrane, with increased frequency of micturi- tion. When the softening process has commenced, the peculiar matter of tubercle is discharged along with the urine, in which it can often be detected by the naked eye. Where any doubt exists, a small quantity should be placed under the microscope. The ulceration attending this disease occasionally spreads over the whole mucous surface, which is removed in as clean and perfect a manner as if it had been dissected off with the knife. Several specimens, illustrative of this condition, are contained in my private collection. When the case has reached this point, the suffering is most excruciating, there being a constant desire to pass water, and the patient being rapidly worn out by the conjoint influence of pain and want of appetite and sleep. Palliation by anodynes, in full and sustained doses, is all that the disease admits of. HERNIA OF THE BLADDER. The bladder, like the other abdominal viscera, is liable to protrude from the pelvic cavity, constituting what is denominated cystocele. A hernia of this description is sometimes complicated with a bubonocele or rupture of 756 DISEASES AND INJURIES OF THE URINARY ORGANS. the groin, which it may either precede or follow. Occasionally stone co-exists in the protruded organ. The cystic hernia is destitute of a proper sac. The only exception to this rule is where the rupture is of long standing, or of great bulk, in which case the fundus of the bladder may drag the peritoneum down into the scrotum. The swelling is always formed, in great measure, by the superior portion of the viscus, and is generally of small size, though occasionally it has been known to attain the magnitude of a fist. A cystocele is a soft, elastic, and fluctuating tumor, which varies in its size according to the amount of urine contained in the protruded part. When examined in a dark room, with the aid of a candle, it appears translucent, very much like a hydrocele. The diagnosis of cystocele is a matter of importance, as a tumor of this kind has occasionally been cut into by mistake. The most decisive symptom is the change which the swelling undergoes in its volume during micturition. As the water flows off the tumor decreases, or entirely disappears, to recur again, however, as soon as the urine has reaccuranlated, to some extent, in the protruded part. A cystocele has not the doughy, inelastic feel of an omental hernia, nor the soft, gaseous feel of an intestinal one, nor does it return with that peculiar gurgling noise which accompanies the ascent of the latter. The treatment of cystocele, seated in the groin or scrotum, does not differ from that of intestinal hernia. When the tumor is reducible, it should be kept up by means of an appropriate truss ; but when the viscus has contracted adhesions, and no longer admits of reposition, the patient must be contented with a suspensory bag. The urine which accumulates in the lower part of the sac must be discharged by raising and compressing the tumor during micturition. If retention should take place, and relief cannot be afforded by the catheter, the part should be punctured. If calculi collect, and become a source of great suffering, they may be extracted by incision of the sac. URINARY DEPOSITS. The only deposit in perfectly normal urine is a slight amount of mucus and epithelial debris, which gradually subside as a delicate cloud as the fluid cools; but in various abnormal conditions of this excretion, either from excess of its constituents, from a hyperacid condition, or, again, from an alkaline state, Fig. 451. Urinary deposits grouped together. owing either to the fixed or volatile alkalies, we find other precipitates. The most common of these are, first, uric acid, either pure or combined with some URINARY DEPOSITS — TREATMENT. 757 bases; secondly, phosphatic acid, as the phosphate of lime, the phosphate of magnesia, or what is called the triple phosphate, consisting of a combination of phosphoric acid with magnesia and ammonia; thirdly, oxalic acid, in com- bination with lime; fourthly, cystine and xanthine. The latter two sub- stances, however, are very infrequent. The different urinary deposits, including renal casts, are beautifully illus- trated in fig. 451. The grouping is so arranged as to afford, at a single glance, the characteristic features of every substance found in the urine, ex- cept what may result from the admixture of certain abnormal growths, benign and malignant. At 1 are seen small globules, consisting of blood, nuclei, delicate epithelial cells, and spherules of oxalate of lime ; at 2, pus globules; at 3, typical epithelial cells from the bladder, pointed at each extremity, with a central nucleus, the younger being rounded and pellucid, the older flattened, and often full of oil or granules; at 4, fibrinous casts from the kidney, en- tangling a few epithelial cells ; and at 5, triple phosphate. 1. Uric acid appears as a deposit in crystals, under varied forms, some of which are a modification of the rhomboids. The urates present themselves as an amorphous sediment, of which there are two, the yellow and the red. The color, in the former, is probably owing to hematine ; and, in the latter, to a peculiar pigment, termed purpurine. Both uric acid and the urates are distinguished frora all other deposits by their behavior with nitric acid, on the addition of a drop of the concentrated fluid to a small quantity of the secretion. The first perceptible effect is an effervescence, followed by solution ; and on drying the mass carefully over a spirit lamp, a beautiful crimson tint is produced, termed murexid. The color is much heightened by subjecting the residue to the fumes of ammonia. The two deposits are also readily distinguished from each other. The crystallized sediments, red sand, or gravel, consist of lithic acid, nearly in a pure state. They appear in the form of minute particles, resembling very much, in shape, size, and color, the particles of Cayenne pepper. Heat does not dissolve thera, as it does lithate of ammonia. Under the microscope, they are found to consist of exceedingly deli- cate crystals, most of which have the appearance of rhombic prisms, which may, therefore, be assumed as their normal form. The most perfect specimens are generally contained in the de- posits of yellow sand in the urine of young infants. The crys- tals are sometimes nearly square; or they are very thin, and longer than broad, so as to represent square tables ; or, finally, they are so thin as to appear merely like pale, lozenge-shaped lamellae. Occasionally they lie across each other, and are firmly coherent. The urates appear as a colored, amorphous deposit, and are redissolved on heating the urine, which is not the case with uric acid. An excess of the yellow deposit may generally be m.io regarded as denotive of disturbance of the digestive functions, or disorder of the cutaneous transpiration. The urine de- positing this substance is of a pale amber tint, more or less acid, and clear when voided. Its quantity is commonly confined within the natural limits, its specific gravity ranging from 1.015 to 1.025. The red deposits are always present in those states of the system which are attended with imperfect assimilation, or a want of proper aeration of the blood. The pink sediment, described by Prout, is merely a variety of this; ]t is exceedingly rare, aud is generally expressive of organic disease of the lungs, liver, or spleen. The crystallized sediments are generally produced under the influence of a 758 DISEASES AND INJURIES OF THE URINARY ORGANS. luxurious, indolent life, attended with dyspepsia, flatulence, acidity, and con- stipation of the bowels, with disorder of the cutaneous secretion. In the treatment of this affection, it is important to ascertain, if possible the causes by which it has been induced. It may be assumed, from what has been stated previously, that these deposits are all dependent upon the reten- tion in the system of nitrogenous principles, which, in consequence of derange- ment of the cutaneous and other emunctories, are obliged to pass off by the kidneys. The causes which may conduce to this result are—1st. Imperfect assimilative action; 2dly. The use of unwholesome food and drink; odly. Defective oxygenation of the blood frora disorder of the lungs and skin; and, 4thly, Congestion, irritation, or inflammation of the urinary apparatus. The first indication is to improve and invigorate the state of the digestive organs; 1st, by attention to the patient's diet, and, 2dly, by a proper regu- lation of his bowels. As a general rule, no articles of food should be per- mitted that are known to disagree. All kinds of pastry, fresh bread, and oily, fatty, and saccharine substances, should be interdicted. Boiled fish, raw oysters, and the white meats, may be used in moderation once a day. For breakfast and supper, which latter should always be very light, brown bread, dry toast, and soda biscuit, with a small quantity of butter, and a cup of black tea, will generally be sufficient. At dinner, green vegetables and ripe fruits may be indulged in, provided they do not impede the digestive process, or create flatulence and acidity. They promote the peristaltic action of the bowels, and furnish the urine with alkaline matter, thus preventing the deposit of gravel or lithic acid. Beef, pork, and mutton, if used at all, should be taken very sparingly. An important rule is to masticate as thoroughly as possible, to eat slowly, and not to overload the stomach, or overtask the powers of this organ. Coffee, beer, and alcohol should be avoided. If the patient has been accustomed to the use of wine, he should either be obliged to discontinue it entirely, or limit himself to a little dry sherry or Madeira at dinner, though brandy and gin are far preferable. Hard water must be avoided. Some mild aperient should occasionally be given to regulate the bowels, such as blue mass and rhubarb. Active purgation is rarely required, or proper, while there is much acid in the stomach and bowels. Castile soap raay be advantageously united with the cathartic medicines. Exercise should be taken at stated periods, in the open air, on foot, on horseback, or in a carriage. A valuable rule is never to carry the exercise to fatigue, or to take it immediately after a meal. It is a matter of primary importance to maintain the skin habitually clean and pure. In warm weather, sponging with cold water, either simple, or impregnated with salt, mustard, or red pepper, followed by frictions, should be used, and provided there is no contraindication, the same plan may be pursued in winter. Cold ablutions are more invigorating than warm. They are, in fact, to the external surface what cold air is to the lungs. Neverthe- less, a warm bath is occasionally highly beneficial, especially during a fit of the gravel. The body and bedclothes should be frequently changed and aired, the skin should be protected both summer and winter with flannel, and the patient should avoid exposure to cold. When the lithic deposit is connected with a gouty or rheumatic diathesis, recourse must be had to colchicum, preceded and accompanied by mercurial cathartics. Not unfrequently it is necessary to administer mercury in altera- tive doses until slight ptyalism is produced. When tonics are required, the best articles are quinine, iron, and the mineral acids, particularly the nitric and nitromuriatic. The vegetable acids are also beneficial. Both kinds may be exhibited, either alone or in combination, with some of the vegetable bitters. URINARY DEPOSITS — TREATMENT. 759 The bicarbonate of soda and of potassa, either alone or together, may be {riven to relieve acidity. The best time of exhibition is about an hour after meals. Phosphate of soda, liquor potassae, and benzoic acid, are also valu- able remedies. Irritation of the urinary organs, especially if inflammatory, may be relieved by the application of leeches, cups, and blisters to the lumbar region, sacrum, or perineum. The warm bath will also be useful, and anodyne injections rarely fail to afford prompt relief. Opiates have a happy effect in controlling the excretions'in question, often curing the milder, and mitigating the distress in the more severe forms. Morphia, lupulin, and hyoscyamus, are the best of this class. When the skin is disordered, Dover's powder may be administered. 2. The oxalic deposit holds, in point of frequency, an intermediate rank between the lithic and phosphatic. It occurs in the form of a white, glisten- ing powder, which is suspended in the urine, and manifests no disposition to precipitate itself, unless it can attach itself to F]'§- 453- some substance capable of constituting a nucleus. Examined ^a with the microscope, this powder is found to consist of beau- '*% tiful, transparent crystals, of an octohedral figure, with sharp and well-defined edges and angles. Occasionally, though rarely, ^ ^ they are shaped like dumb-bells, or like two kidneys united at ^ u their concavities, and so closely approximated as to appear almost circular, as in fig. 453. They vary much in their size, <^j but, in general, they are exceedingly minute. If they are sub- <$3 a"| jected to ignition on platinum foil, the oxalic acid is decom- fj posed, and a small quantity of carbonate of lime is left, which ^% is readily dissolved with effervescence on the addition of dilute „ ... • j /-» i • -i .• t...t . Oxalate of lime nitric acid. Oxalic acid sometimes occurs as a distinct deposit, „„„,„,, , . i ' ciysitiis. in the form of a small concretion resembling a hemp-seed, which raay be retained in the bladder, and go on gradually increasing until it con- stitutes a mulberry calculus. The formation of oxalic acid is favored by whatever has a tendency to im- pair the assimilative powers and to exhaust the vital energies. Hence, it is most commonly induced by errors of diet, or the use of unwholesome food and drink, excessive mental exertion, inordinate venery, exposure to cold, long-continued suppression of the cutaneous perspiration, and injury of the spinal cord, brain, or sacro-lumbar nerves. The immediate agency in its production is not yet entirely settled, but the experiments of Wohler, Liebig, and Frerich, render it raore than probable that it is due to the oxidation of the uric acid. Certain articles of food, such as rhubarb, sorrel, and tomato, also promote its appearance in the urine. The symptoms of this affection are such as generally indicate the presence of derangement of the digestive, but more especially of the nervous, functions. Dyspepsia often exists in a marked degree ; flatulence is a common occur- rence; the mind is often gloomy and despondent; the temper is fretful; the surface is exceedingly susceptible to external impressions; the extremities are almost constantly cold ; the sleep is disturbed by disagreeable dreams ; and the patient continually broods over his disease, having a thousand mis- givings, and the most horrible forebodings; pain in the loins is a frequent symptom; the sexual power is usually much impaired; and the urine is often voided with uncommon frequency, as well as with more or less heat and smart- IDg- As the disorder advances, the patient becomes excessively emaciated, and ultimately falls into a state of confirmed hypochondriasis. Serious pul- monary suffering is sometimes present, and in many cases the skin is covered with boils and scaly eruptions. In the treatment of this disorder, the first thing to be done is to improve 760 DISEASES AND INJURIES OF THE URINARY ORGANS. the general health. The diet should be regulated, and those articles which produce acidity and flatulence should be carefully avoided. The body should be well protected with clothing, and the skin should be rubbed daily with tepid salt water or some other stimulating fluid, and thoroughly rubbed with a coarse, dry towel, or a flesh brush. In warm weather cold ablutions may be used. If there is much debility, tonics are indicated, such as quinine and sulphate of iron, in combination with capsicum and hyoscyamus. Sulphate of zinc in the dose of one grain, two or three times a day, occasionally answers an excellent purpose. The mineral acids, as the dilute nitric and nitrorau- riatic, also possess valuable tonic properties. 3. The phosphatic deposit is characterized by its whitish color, by its pul- verulent arrangement, by its solubility in dilute hydrochloric acid, and by its insolubility in ammonia and solution of potassa. It presents itself under three distinct varieties of form, the triple, the calcareous, and the mixed, each of which demands succinct notice. a. The triple phosphate consists of phosphate of ammonia and magnesia, on which account it is generally called the amraoniaco-raagnesian phosphate. It commonly occurs in minute white crystals of a beautifully Fig. 454. brilliant aspect, transparent or opaque, and remarkable for m^-v their sharp angles and edges. In their form, these crystals t? exhibit great diversity, but in most cases they are prismatic. ^ Occasionally they have a stellar, penniform, or foliaceous ar- rangement, as in fig. 454. They often float on the surface of the urine, especially if it is partially decomposed, and look like an iridescent film of grease. The urine which accompa- nies this deposit is preternaturally copious, pale, or whitish, and of low specific gravity, ranging from 1.005 to 1.014. It has a faint, sickening smell, which soon becomes ammoniacal and offensive. In some instances of the affection the fluid is Phosphates. unnaturally dark, brownish or greenish-brown, decidedly alka- line, and loaded with dense, ropy mucus. The triple phosphatic deposit very often alternates with the yellow lithic or calcareous. Old persons are more subject to it than children and adoles- cents, and it is always associated with great disorder of the digestive organs. The patient is weak, irritable, and bloodless; the slightest exercise fatigues him, and he complains constantly of a dull, heavy, aching pain in the lumbar region. Over-exertion, errors of diet, dyspepsia, severe courses of mercury, and excessive venery, are its most common exciting causes. b. The calcareous deposit is composed of phosphate of lime, and occurs in the form of an impalpable powder, of a whitish, grayish, or drab color. The urine, as in the triple variety, is pale, copious, and of low specific gravity, and is readily decomposed by exposure to the atmosphere. The deposit is often accompanied by an inordinate secretion of mucus. c The mixed deposit, consisting of a combination of the two preceding, is very common. It is usually combined with mucus, which is often secreted in large quantity, and of a ropy, viscid character. The urine is fetid, pale, and abundant, depositing a thick mortar-like sediment upon standing. The most common causes of this condition are, injury of the lower part of the spine, organic disease of the kidney and bladder, dyspepsia, long-continued bodily fatigue, mental anxiety, night watching, unwholesome food, and de- bilitating medicines. Patients thus affected are weak, flatulent, irritable, nervous, easily affected by cold, emaciated, and of a gloomy, desponding dis- position. The urine is voided more frequently than iu health and with more or less pain and scalding along the urethra. Pain in the loins is seldom wanting. In the treatment of this affection, the principal indications are, first, toim- STONE IN THE BLADDER. 761 prove the condition of the digestive organs ; secondly, to acidify the urine ; nnd, thirdly, to strengthen the system. To accomplish the first of these ob- jects, it is necessary to regulate the diet, and administer mild aperients. Hard water should be avoided. Exercise should be taken daily in the open air, but it must never be carried so far as to induce fatigue. The skin should be frequently bathed. To fulfil the second indication, acids are required, of which the dilute nitric is the best. It may be administered by itself, in a large quantity of water, or, what is generally preferable, in union with hyoscyamus, black drop, pare- goric, or infusion of opium. Anodynes can rarely be dispensed with, and are often of immense benefit, from the manner in which they allay pain aud ner- vous irritation. In some instances the tincture of the chloride of iron proves useful. When the urine is rendered preternaturally acid, or when there is marked pyrosis, recourse must be had to soda, or soda and potassa, along with uva ursi and hop-tea. All diuretics, properly so called, are injurious. The third indication is fulfilled by the use of tonics, such as quinine, bark, and steel, a plain, but generous, diet, exercise in the open air, and change of residence. A sea voyage is sometimes highly beneficial. Exposure to cold, irregularities of diet, and indiscretions of every kind, should be avoided, both during the actual existence of this diathesis, and for a long time afterwards, on account of the great tendency to relapse. When the deposit depends upon lesion of the spinal cord, the internal use of strychnine and counter-irritation, in the form of blister, issue, or the hot iron, will be of benefit. If inflammation of the bladder or kidney exists, it must be combated by the ordinary means. STONE IN THE BLADDER. Most urinary calculi originate in the kidneys, from which they descend into the bladder, where, if they are retained for any length of time, they gradually increase in size, and ultimately produce more or less obstruction. Their progress along the ureter is sometimes slow and painful; at other times rapid and almost free from suffering. The amount of the local distress is greatly influenced by the nature of the concretion, and by the degree of resistance afforded by the ureter. A small, smooth calculus usually causes little incon- venience ; while a large or rough one often occasions exquisite torture. The process of descent, which generally occupies from twelve to forty-eight hours, is characterized by excessive nausea and vomiting, great restlessness and jac- titation, pain in the back, groin, and thigh, retraction of the testicles, numb- ness along the spermatic cord, a sense of constriction at the umbilicus, and tenderness of the hypogastrium, with coldness of the extremities, rigors, and a feeling of excessive prostration. The urine gradually accumulating behind the calculus, the ureter is slowly dilated, and the concretion at length reaches the bladder, from which it is either ejected, or it remains there until removed by operation. As soon as the,passage is completed, the pain and sympathetic irritation subside, the patient frequently falling into a tranquil and refreshing sleep. The descent of the calculus may be expedited, and rendered less pain- ful, by the abstraction of blood from the arm, the loins, or hypogastric regions, large doses of morphia, along with castor oil and turpentine, the hot bath, fomentations, and auodyne injections. The free use of chloroform, by inhala- tion, will also prove highly beneficial. Stone occurs at all ages. I have met with several examples of it in very young infants, and cases have been related which render it highly probable that it is occasionally an intra-uterine affection. In my Treatise on the Urinary Organs are given the ages of 6,042 cases of stone in the bladder, as occurring in England, France, and Russia, of which 2,334 were observed 762 DISEASES AND INJURIES OF THE URINARY ORGANS. from the first to the tenth year, 1,079 frora the tenth to the twentieth, 513 from the twentieth to the thirtieth, 353 from the thirtieth to the fortieth, 422 from the fortieth to the fiftieth, 536 from the fiftieth to the sixtieth, 587 from the sixtieth to the seventieth, 201 from the seventieth to the eightieth and 17 from the eightieth to the ninetieth. Thus, it will be seen that more cases occur prior to the age of twenty than at all other periods together. In attempting to forra a correct estimate of the relative frequency of cal- culous complaints in children, adults, and old persons, we must not lose sight of the fact that many of the cases which fall into the hands of the surgeon are examples of long standing, extending, perhaps, through a period of many years. Thus, a man at forty raay have contracted the disease at ten or fifteen. Moreover, it should be borne in mind that calculous diseases arc more frequent, in certain countries, among children than among adults, and conversely. It is not satisfactorily ascertained whether this affection is ever hereditary. Cases related by Civiale and Prout seem to warrant the inference that it is; • but I have myself not met With any confirmatory evidence. Stone in the bladder is very uncommon in females, owing, mainly, to their having a much shorter and more capacious urethra, which thus favors the excretion of any deposits that might otherwise form in the bladder. It has been alleged that this immunity is due to the fact that women are much less exposed to the exciting causes of the disease than men; but this conclusion is invalidated by the circumstance that at least one-third of all the cases of stone that are met with occur in boys before the tenth year, and, consequently, before they are subjected to any particular hardships. The different varieties of the negro race of this country are much less sub- ject to calculous diseases than the whites. I have ascertained from reliable statistics, founded upon 443 cases of stone in the bladder occurring in Ken- tucky, Virginia, Tennessee, Georgia, Alabama, Louisiana, and Missouri, that the latter suffer three times as frequently as the former. The same fact dis- proves the idea, so much insisted upon by certain writers, that the nse of com bread and bacon, which constitute a large proportion of the daily food of the colored population, in the above regions, is favorable to the production of urinary calculi. Stone in the bladder occurs in all parts of the world, though by no means with equal frequency. In the United States it is more common in Kentucky, Virginia, Tennessee, and Ohio than in any other parts of the country. New England is remarkably exempt from it. The disease is sufficiently common in France, Austria, Hungary, Russia, and England. The inhabitants of Ireland, Spain, and Switzerland, on the contrary, suffer from it comparatively seldom. In Holland, calculus of the bladder is much less frequent now than it was a hundred years ago. The causes of these topographical differences in regard to the occurrence of stone in the bladder have not been determined. The great prevalence of the disease in limestone regions has long been familiar to observers, but whether the use of limestone water has really any agency in its production, is still a mooted question. It is certain that it frequently occurs in freestone regions. It has long been known that calculous diseases are much more common among the poor than the rich. Upon what this difference depends, is not posi- tively ascertained; but the probability is that it is mainly due to derangement of the digestive organs, engendered by the use of unwholesome food, by irregular habits, want of cleanliness, intemperance, and deficient clothing. Occupation, no doubt, exerts an important influence upon the production of this disorder, but in what manner, or to what extent, is unknown. In Ohio, and the Southwestern States, especially Kentucky, Tennessee, and STONE IN THE BLADDER—PHYSICAL PROPERTIES. 763 Alabama, the great majority of calculous subjects are common laborers, farmers, and mechanics, or the sons of persons of this description. Seafaring people are remarkably exempt from urinary calculi, and a similar immunity seems to be enjoyed by soldiers. Climate, also, exercises no little influence in the formation of urinary con- cretions. Thus, it is well known that the disease is most common in those parts of the world w^hich are subject to frequent, great, and sudden atmo- spheric vicissitudes. In very cold and tropical regions, on the contrary, it is exceedingly rare. Certain kinds of food predispose to the formation of calculous disease. All articles which have a tendency to create acidity and flatulence exert a deleterious influence upon the renal secretion, changing its properties, and promoting the deposition of earthy matter. Hot bread, in its various forms, frequently only half-baked, and generally very imperfectly masticated, is suf- ficient, if used for any length of time, to wear out the strongest stomach, and to break down the most vigorous frame. A weakened digestion, with a sour and flatulent state of the stomach, constipation of the bowels, and an irritable condition of the brain, cannot by any possibility produce a healthy blood, any more than a morbid state of the blood can produce a healthy urine. Various kinds of drinks exert an influence favorable to the formation of stone in the bladder. It has long been remarked in England that those dis- tricts in which cider is much employed are remarkably prone to calculous disorders. On the other hand, it is alleged that the use of Rhenish wine and of frin acts as a preventive. The formation of stone in the bladder is remarkably favored by certain kinds of diseases, especially stricture of the urethra, chronic enlargement of the prostate gland, and organic affections of the bladder, ureters, and kid- neys. Injury of the spinal cord, particularly when it involves the dorso- lumbar portion of that structure, or the nerves detached from it, is extremely prone to be followed by phosphatic deposits; and it has long been known that gout and rheumatism are eminently conducive to the formation of uric acid calculi. Physical Properties.—Most calculi have a distinct nucleus, round which the earthy matter accumulates and crystallizes. The nucleus may be formed of any substance, either solid or semi-solid, whether generated in the urinary organs, or introduced from without. In general, it consists of some saline matter of the urine, as uric acid, oxalate of lime, or phosphate of lime and magnesia. Inspissated mucus, lymph, hair, or clotted blood, may serve a similar pur- pose. In my private collection are speci- mens in which the concretions were formed round the tail-bones of a squirrel, an elm bougie, a piece of lead pencil, and a bullet, the latter having been kindly presented to me by Dr. Robinson, of Warfordsbury, Pennsylvania. In fig. 455, from a prepara- tion in the cabinet of Dr. Sabine, of New lork, the nucleus consists of a piece of cork. Professor Van Buren informs me that he has a calculus which was formed round an ear of wheat. Finally, the nucleus varies much in size, color, shape, and consistence; and, although generally single, it is sometimes double, triple, and even quadruple. The number of concretions is variable. In general, there is only one, but there may be several dozen, if not several hundred. The largest number I Fig. 455. Calculus with a cork for a nucleus. 764 DISEASES AND INJURIES OF THE URINARY ORGANS. have ever found was fifty-four. Dr. Physick, in one case, met with upwards of one thousand, from the size of a partridge shot to that of a bean. The mulberry calculus is almost always solitary ; and the same is true, but not to the same extent, of the uric calculus. The phosphatic calculus, on the contrary, is not unfrequently multiple. When the concretions are nu- merous, they are generally proportionately small and smooth on the surface. When, on the coutrary, they are solitary, they are generally rough and com- paratively large. The volume of urinary concretions ranges from a hemp-seed to a goose's egg. In young subjects, and in recent cases generally, it is usually incon- siderable. The size of a urinary concretion, however, does not necessarily depend upon the period of its sojourn in the bladder, or the age of the patient. Occasionally, it increases very rapidly, so as to attain a large bulk in a very few months; and, on the other hand, it may remain small for many years. The ammoniaco-magnesian and the fusible calculi are capable of attaining a very large size, while the uric, oxalic, cystic, xanthic, and fibrinous are almost always comparatively small, no matter what may be their age, or the age of the patient. This fact is interesting in a practical point of view; because, by ascertaining the calculous diathesis of the sufferer, we shall be able to form a tolerably correct idea of the volume of the stone under which he is laboring. The toeight of urinary concretions does not, in general, exceed a few drachms or ounces. Many examples, however, are recorded of four, six, eight, ten, twelve, fifteen, and even sixteen ounces. Deschamps gives a case of fifty-one ounces. The consistence of vesical concretions, as a general rule, varies from that of semi-concrete mortar, chalk, or wax, to that of stone. The hardest calculi are the oxalic and uric, which commonly emit a clear sound when struck with steel, aud cannot be fractured without a considerable degree of force. 'Cal- culi, on the other hand, composed of ammoniaco-magnesian phosphate and phosphate of lime, are friable, and easily reduced to powder. The cystic and fibrinous calculi are quite soft, the latter scarcely equalling that of yel- low wax. In what are termed alternating calculi, one part of the stone will commonly be hard and compact, while another is soft and friable, if not pul- verulent. Stones are occasionally composed of a mixture of sabulous matter and hair. Their formation is of rare occurrence, and they appear to consist, principally, of phosphate of lime and magnesia. The color of these bodies is variable. The cystic and fibrinous calculi are of a yellow hue ; the phosphatic, whitish or grayish; the oxalic, dark or blackish; the uric, rose, reddish or brown. Vesical calculi assume a great variety of forms. The circumstances which are chiefly concerned in producing this result are the action of the bladder, the friction which the concretions, when multiple, exert upon each other, and the nature of the nucleus. Finally, it is not unlikely that Fig. 456. the chemical constitution exerts more or less influence upon the form of the stone. Vesical calculi ace generally of an oval form, but they may be round, or even angular, or cylindrical. Sometimes several are matted together, so as to form what, geologically, is termed a pudding-stone. Dr. Mussey showed me, some years ago, a very curious calculus, depicted in fig. 456, Thomy calculus, which had been removed after death from the bladder of a man who had long labored under disease of that organ, it is of a light-brownish color, and consists of a central portion and a number of distinct processes, each of which has a small cavity containing animal STONE IN THE BLADDER—CHEMICAL PROPERTIES. 765 Fig. 457. matter. The processes are remarkably rough, and several of them are nearly half an inch in length. Its composition is supposed to be oxalate of lime. Occasionally the concretion consists, ap- parently, of two parts, one corresponding with the bladder, and the other with the urethra, as is seen in fig. 457. The surface of these concretions may be smooth or rough. The oxalic calculus derives its common name from the irre- gularity of its surface, which resembles that of a mulberry. The uric acid calcu- lus is usually finely tuberculated. Chemical Properties.—The composition of urinary calculi has deservedly engaged much attention. The subjoined account includes the most important species that have yet been described. The uric calculus, called also the lithic calculus, the most common species of all, is of a brownish color, inclining to that of mahogany, of a flattened, oval Bhape, occasionally finely tuberculated on the surface, but most generally smooth, though not polished, unless there are several concretions at the same time, and from the size of a currant to that of a hen's egg. If it be sawed, it will be found to consist of several layers arranged concentrically around a common nucleus, the laminae being frequently distinguishable from each other by a slight difference in color, and sometimes by the interposition of other ingredients. Water has but little action upon it; it is perfectly dissolved by caustic potassa, and disappears with effervescence in hot nitric acid, the solu- tion affording, on evaporation to dryness, a bright carmine-colored residue. Before the blowpipe, it becomes black, emits a peculiar animal odor, and is Urinary calculus; a showing the vesical, and 6 the urethral portion. Fig. 458. Fig. 459. Uric calculus. gradually consumed, leaving a minute quantity of white, alkaline ashes. Fig. «S shows the oval shape and finely tuberculated surface of the calculus; no' 459, the internal concentric layers. 766 DISEASES AND INJURIES OF THE URINARY ORGANS. The uro-ammoniac calculus is a variety of the preceding. It is princi- pally observed in children, and is extremely rare. It is generally of small size, with a smooth surface, of a clay color, and composed of concentric rincs which present a very fine earthy appearance when fractured. Much more soluble in water than the uric calculus, it gives out a strong ammoniacal smell when heated with caustic potassa, and deflagrates remarkably under the blowpipe. Next to the uric calculus, in point of frequency, is the oxalic, which is generally of a dark brown color, rough and tuberculated on the surface, very hard, compact, and imperfectly laminated, seldom larger than a walnut spherical, and always single. Under the blowpipe, it expands and effloresces into a white powder, while it dissolves slowly in nitric and hydrochloric acid provided it be previously well broken up. In the alkalies, it is perfectly insoluble. This species of urinary concretion, called by many the mulberry calculus, from its resemblance to the fruit of the mulberry, consists essentially Fig. 460. Fig. 461. Fig. 462. Oxalic calculus,. of oxalate of lime. Figs. 460 and 461 show the external appearance and internal structure of this concretion. A variety of this species of calculus, seen in fig. 462, has been described by the term hemp-seed, from some resemblance which it bears in color and lustre to that substance. It is always of small size, remarkably smooth, and generally exists in considerable numbers, being rarely, if ever, found alone. The phosphatic calculus, exhibited in fig. 463, is of a pale brownish color, and of a loosely laminated structure, with a smooth, polished surface, like porcelain. The shape is mostly oval, and the size, though generally small, is sometimes very considerable. It whitens when exposed to the blowpipe, but does not fuse; and Fig. 463. readily dissolves in hydrochloric acid, without efferves- cence. This calculus, composed essentially of phosphate ^sm¥^ of lime, is extremely rare, as forming entire concretions, Phosphatic calculus, hut frequently constitutes alternate layers with other mat- ters. It is sometimes called the bone-earth calculus, and occasionally contains small quantities of carbonate of lime. The next species, represented in fig. 464, is the ammoniaco-magnesian, so called from its being composed of phosphate of ammonia and magnesia. This mixed calculus is of a white color, friable, and crystallized on the sur- face, looking a good deal like a mass of chalk, its texture being never lami- nated ; it easily dissolves in dilute acids, but is insoluble in caustic potassa; before the blowpipe, it exhales an ammoniacal odor, and at length melts into STONE IN THE BLADDER — CHEMICAL PROPERTIES. 767 Fig. 464. a vitreous substance. This species of concretion sometimes attain mense size. The fusible calculus consists of a combination of the last two. It is of a white color, extremely brit- tle, leaves a soft dust on the fingers, and is easily separated into layers; when broken it presents a ragged, uneven surface. It is insoluble in caustic potassa, but gives off ammonia; and, under the blow- pipe, it is readily converted into a transparent, pearly-looking glass. This concretion is very com- mon, and sometimes attains a very large size. It is frequently met with as an incrustation of foreign s an nn- Ammoniaco-magnesian cal- culus. Fig. 465. Fig. 466. Fusible calculus. bodies. Figs. 465 and 466 exhibit the outer appearance and internal struc- ture of this concretion. The cystic calculus is a very rare species of concretion, so called from an erroneous supposition that it was peculiar to the bladder. It consists of a confused crystallized mass, of a yellowish-white color, with a smooth surface. The structure is compact, and the fracture exhibits a peculiar glistening lustre, Fig. 467. Fig. 468. Cystic calculus. ike that of a body having a high refractive density. It exhales a strong cnaractenstic odor under the blowpipe, aud is very abundantly dissolved in 768 DISEASES AND INJURIES OF THE URINARY ORGANS. acids and alkalies, with both of which it crystallizes. This species is com- monly of an irregular spherical shape, and seldom attains a large volume. The external and internal appearances of the cystic calculus are shown in figs. 467 and 468. The xanthic calculus is extremely rare. Its texture is compact, hard, and laminated; its color is of a cinnamon brown, its surface smooth, and its volume small. It dissolves very readily in acids and alkalies, and is gradu- ally consumed before the blowpipe, leaving a minute quantity of white ashes. There is, lastly, what is called the fibrinous calculus. Like the preceding species, this is also extremely rare, and appears to be composed principally of the fibrin of the blood, a property to which it owes its name, and by which it is characterized. It is of small size, of a spherical or oval shape, and of a brownish color. When dried, it shrinks, and loses some of its weight. Situation.—Calculi lie generally loose within the cavity of the bladder, and are, consequently, liable to shift their position, not only with that of the viscus in which they are contained, but also with that of the body. Hence at one moment they raay be at the bas-fond of the organ, at another at the neck, at another at its superior portion or base, at another at its sides, and at another, perhaps, at its anterior part, just above or behind the pubes. A knowledge of this variation in the position of these foreign substances is of no little importance in regard to the operation of sounding. Their most common situation is, undoubtedly, the bas-fond of the bladder, from the fact that this is the most dependent portion of the reservoir. In old subjects, affected with enlargement of the prostate, the concretion generally lies just Fig. 469. behind this body, in a sort of pouch, hollow, or cul-de-sac. When this is the case, and the calculus is of large size, it may often be easily felt by the STONE IN THE BLADDER — SYMPTOMS — DIAGNOSIS. 769 finger in the rectum. When the bladder is perfectly sound, the concretion, especially when the patient is in the erect position, and the urine evacuated, rests against the neck of the organ, and sometimes even projects into the orifice of the urethra. Cases occur in which the concretion is alternately loose and fixed. This may be owing to the existence of an abnormal pouch. The foreign body may also be arrested in the folds of the mucous membrane, in a depression behind the prostate, in the substance of this gland, in the orifice of the ureter, or in the mouth of the urethra. Tesical calculi may become permanently adherent, attached, or fixed, as exhibited in fig. 469, frora a specimen in the cabinet of Dr. Petticolas, of Richmond, Virginia. This may take place in different ways, and under a variety of circumstances, of which the following may be mentioned as the most important: 1. An effusion of coagulating lymph. 2. The formation of an abnormal pouch. 3. The existence of a fungous tumor or excrescence. 4. A bilobed state of the bladder. 5. The projection of the concretion into the ureter, or some other passage. 6. Its lodgment in the wall of the bladder. Finally, the calculous matter, instead of being collected into a distinct concretion, is sometimes spread out in the form of a layer upon the bas-fond of the bladder. A layer of this kind, of considerable thickness, now and then forms around a spongy, erectile, or fibrous tumor of this organ. When the calculous matter presents this peculiar arrangement, it grates under the in- strument, and can be distinctly felt through the rectum. When struck with the sound it emits a peculiar noise, not unlike that of a cracked pot. I have seen several specimens in which this lamelliform arrangement co-existed with separate calculi. Symptoms.—The symptoms of stone in the bladder may be conveniently divided into the rational and physical. They may be divided, also, into local and general, as they affect the urinary apparatus or the system at large. The rational symptoms are : 1. Pain in making water, especially when the last drops are being expelled, felt both in the bladder and the adjacent parts. 2. A sense of weight and uneasiness in the pelvis, anus, and perineum. 3. Frequent micturition. 4. An occasional interruption of the stream of urine. 5. Pain and itching in the head of the penis, with smarting and pricking sensations in the urethra, particularly at its orifice. 6. Enlargement of the penis and elongation of the prepuce. 7. Occasional priapism, with or with- out sexual desire. 8. An increased secretion of mucus from the lining mem- brane of the bladder. 9. A bloody state of the urine. 10. Incontinence of urine. 11. Prolapse of the anus. 12. Sympathetic suffering. 13. Noise furnished by the calculi knocking against each other in the bladder. The above symptoms usually come on gradually, and a considerable period often elapses before the patient is led to suspect the real nature of his con- dition. This is especially the case when the general health is good, and the bladder perfectly sound. Indeed, under such circumstances, the organ may, for a long time, take no cognizance of the presence of the foreign body. , Physical Signs—Sounding—Diagnosis.—When the symptoms above de- scribed are all present, or even when several of them are absent, there is a strong probability that the patient is laboring under stone of the bladder and this probability is converted into certainty when the surgeon is able to feel and hear the foreign body. Nevertheless, cases occasionally occur, in which, notwithstanding the existence of both rational and physical signs, no concretion is to be discovered. Sounding consists in introducing into the bladder an instrument shaped like a catheter, either solid or hollow, with which the cavity of the organ is explored. The instrument itself is called a sound. vol. n.—49 770 DISEASES AND INJURIES OF THE URINARY ORGANS. Fig. 470. Ordinary sound. Sounds vary in their construction, in their size, and in the materials of which they are composed. The best are solid, well polished, and made of steel, with varying degrees of curvature, as in figs. 470 and 471. For an adult, the length from one extremity to the other should be about twelve inches, of which two '^i inches and a half should be allowed for the / handle. Children, of course, require a shorter instrument. Generally speaking, a sound of moderate diameter is preferable to one of large size, as it is more easily moved about in the bladder. The vesical extremity or beak should be rounded off, not conical or pointed, so that it may not be liable to be arrested by the irregularities of the ure- thra. The curved portion should not, as a general rule, exceed three inches, and should form an angle of about 45° with the straight portion. The handle of an adult sound should not be less than two inches in length, by one inch and an eighth in width; it should taper somewhat towards the stem of the instrument, be about a line in thickness, rounded off at the corners, and well polished. Every lithotomist should be provided with several sounds, of various sizes and curva- tures. Previously to sounding, the bowels should always be well cleared out with castor oil, or a purgative enema. The bladder, at the time of the exploration, should contain from three to five ounces of urine, or, if it be too irritable to retain that quantity, or if the patient has urinated inadvert- ently, the requisite distension should be produced by the injec- tion of tepid water, through a silver catheter, which may then be used as a sound, care being taken to stop up its orifice, to prevent the regurgitation of the fluid. During sounding, the patient should lie upon his back, with his head and shoulders somewhat elevated, and the lower ex- tremities slightly fixed and separated, to relax the abdominal muscles. Adults are sometimes sounded in the erect posture; children never, except under particular circumstances. The surgeon comports himself precisely as in catheterism. Frequently the sound encounters the stone the moment it enters the neck of the bladder ; but should this not happen, it must be passed further in, and moved about in different directions until the object is accomplished. . The pubic surface of the bladder can be reached only by an instrument with a very long curve, not unlike that of the English S. Very frequently the stone cannot be felt, in consequence of its lying in a pouch, in the bas- fond of the organ, just behind the prostate. When this is the case, the index-finger of the left hand, properly oiled, is introduced into the rectum, and the foreign body pushed forwards against the sound. When the diffi- culty is very great, an instrument with a short, abrupt curve, as in fig. 471, may be used. Sometimes it is necessary to change the position of the patient, making him lie on his side, sit or stand, bend forwards, or raise his buttocks. The crying and struggling of children may be quieted by the use of chlo- Abruptly-curved sound. STONE IN THE BLADDER—SOUNDING. 771 roform, which I am in the habit of employing in nearly all cases of the kind, both for the purpose of preventing pain, calming the patient's mind, and quieting the bladder. The noise and sensation communicated by sounding are peculiar. The noise is a sort of click, clink, or clear metallic resonance. It is in the highest degree valuable as a diagnostic sign. It may often be perceived at a distance of several yards frora the patient. A grating, rubbing, or friction sensation is sometimes distinguished, but this is rather indicative of a fasci- culated state of the bladder, a morbid growth, or an incrusted condition of the mucous membrane than of the existence of stone. Patients are often brought to the surgeon from a distance to be lithoto- mized. When this is the case, they should not be sounded until they have recovered from their fatigue ; nor should the operation be performed during or immediately after a " fit of the stone." The system should be prepared for the operation. From neglect of this precaution, patients are often sub- jected to much suffering, and I believe that life has been repeatedly sacrificed in this way. The sounding should be conducted with the utmost gentleness, and should never be continued beyond a few minutes at a time. When the stone is very small, or the feel and noise elicited are very feeble, recourse maybe had to auscultation. This maybe done by applying the stethoscope either to the pubic region, to the sacrum, or to the perineum; at the same time that the sound is moved about in the bladder. Sounding enables us not only to detect the presence of a calculus in the bladder, but it frequently furnishes important data in regard to its bulk, situa- tion, and consistence, and as to whether it is single or multiple, rough or smooth, loose or attached. Another object in sounding is to ascertain the condition of the urinary apparatus. This can frequently be accomplished in no other manner. The capacity of the organ, and the amount of its sensibility or tolerance can thus be discovered. Moreover, we can generally determine, with considerable accuracy, by such a mode of exploration, whether the inner surface of the bladder is smooth or rough, ulcerated or fasciculated, incrusted with lymph or sabulous matter, or studded with fungous, fibrous, or other morbid growths. The passage of the sound along the urethra enables us to judge whether this tube is healthy or diseased, contracted, changed in its direction, or obstructed by the presence of a foreign body. The condition of the prostate gland is best determined by the finger in the bowel. The anus and rectum should also be carefully examined. Although sounding is the only certain way of detecting the presence of stone, it is by no means free from error, as is proved by the fact that many a poor patient has been subjected to all the pains and penalties of lithotomy, when the bladder was perfectly free from everything of the kind. I am cog- nizant of at least half a dozen cases in which this mistake was committed. Ihe circumstances which may give rise to it differ very much in their cha- racter, some being dependent upon the bladder itself, others upon the neigh- boring parts, as the prostate gland, rectum, uterus, vagina, and pelvic bones. Mere irritability of the bladder, attended with a frequent desire to void the urine, may lead to the supposition of the existence of stone, and if the sur- geon, anxious for the eclat of an operation, should, in such an event, strike nis sound against a mass of impacted feces, a projecting sacrum, or a morbid growth in the bladder or pelvis, he would be very apt to deceive himself. Ihe greatest possible circumspection should, therefore, always be used in sounding; the operation, if necessary, being performed again and again, until the surgeon is perfectly certain that a stone really exists. 772 DISEASES AND INJURIES OF THE URINARY ORGANS. ' On the other hand, it is well known that there may be a stone in the bladder and yet the surgeon be unable to detect it by sounding, aided, perhaps, by all the auxiliary means he can command. This failure has frequently occurred even where the concretion has been uncommonly large, and where the opera- tion has been repeatedly performed with the greatest care and skill, and varied in every possible manner. Want of success has sometimes attended, even where the calculi were multiple, or where a considerable number coexisted. Again, it has happened that a stone has been promptly detected in a first sounding, and, perhaps, not at all, or only after much trouble, in a subsequent one. Or the reverse of this may occur, that is, the concretion may elude the instrument in a first and second sounding, but be always readily detected afterwards. It is with sounding as with everything else; to perform it well requires great tact in the use of instruments, a perfect knowledge of the anatomy of the urinary apparatus, and a degree of experience which multi- plied observation alone can supply. But the want of success, in this opera- tion, is not confined exclusively to the young, the ignorant, or the unskilful. Men of the most consummate dexterity have occasionally failed in detecting a stone, when a stone really existed. Of the various circumstances which may prevent the detection of urinary calculi, some relate to the stone itself, some to the bladder, and some to the Fig. 472. Sounding for stone in sacculated bladder. neighboring and associated organs. Thus, the foreign body may be very small, or there may be too much or too little water in the bladder during Fig. 473. Sounding for stone in enlarged prostate. sounding; or it may be encysted, as in fig. 462, or lodged in a cul-de-sac, i the bas-fond of the bladder, just behind the prostate gland, as seen in fig. 41 STONE IN THE BLADDER—PATHOLOGICAL EFFECTS. 773 Sometimes, again, the concretion lies in a dilated ureter, or in a pouch in the prostate gland itself. Pathological Effects.—Although the formation of vesical calculus is the immediate result of a morbid condition of the urinary secretion, the bladder aud its associate organs are generally diseased, to a greater or less extent, in the progress of the affection. The primary impression is probably always made upon the viscus in which the concretion is confined ; but the irritation which its protracted presence there induces is gradually reflected upon the other portions of the apparatus, awakening in them, in the first instance, im- portant sympathetic actions, and, ultimately, serious structural lesions. One of the first effects to which the foreign body gives rise, is inflammation of the mucous coat of the bladder, as indicated by a frequent desire to make water, spasmodic pains in the lower part of the pelvis, and an increased secretion of mucus. Thickening of the lining membrane with increased vas- cularity, and the development of granulations, is another effect; and the irri- tation extending to the different coats of the bladder, hypertrophy of the organ may take place. A diminution in the size of the bladder is not infre- quent even in young subjects, but is much more common in old persons, who have labored for years under the continued irritation of a calculus. Ulcera- tion of the mucous coat is another effect of stone in the bladder. It is most frequently observed at the neck and bas-fond of the organ. One of the most distressing accidents which take place, during the progress of this disease, is perforation of the bladder, followed by a partial or complete escape of the stone, and the formation of a fistule. When it is accompanied by extravasation of urine into the surrounding cellular tissue, it may ter- minate fatally in a few days, or lead to violent inflamraation and suppuration, inducing death at a more distant period. The urethra rarely suffers except in its prostatic portion, which may be unnaturally red, inflamed, hypertrophied or attenuated. The prostate gland soon becomes diseased. It gradually increases in volume and density, some- times enlarging in every direction, impeding the flow of urine, augmenting the pain and spasm of the bladder, and even producing serious pressure upon the rectum. Ulceration, abscess, and sloughing may follow from the constant and excessive irritation. In some instances the prostate is converted into a cavity, nearly equal to that of the contracted bladder itself, and capable of lodging a calculus of considerable size. The ureters are frequently reddened and thickened, sometimes ulcerated, and now and then enlarged, or enlarged at one place, and contracted at another. The kidneys rarely entirely escape in this disease. In the worst form of the malady, it is not unusual to see one of thera converted into a large pouch filled with purulent matter, or turbid urine. Abscesses and fistules occasionally form in the perineum. Prolapse of the anus may take place, attended with relaxation of the sphincter muscles, in- flammation and thickening of the mucous membrane, and hemorrhoidal tumors. The orifices of the seminal ducts are, in many cases, dilated, or otherwise affected, and the ducts themselves raay be variously altered. The seminal vesicles are sometimes atrophied, or diminished in volume and changed in structure. It may be mentioned here that a calculus of the bladder has sometimes obstructed parturition, and required extraction before the labor could be completed. Finally, another effect which occasionally occurs is the spontaneous frac- ture of the calculus, succeeded by violent irritation of the bladder, and some- times even the death of the patient. The immediate cause of fracture of "Hnary calculi within the bladder is, no doubt, the inordinate contraction of the muscular fibres of this organ. 774 DISEASES AND INJURIES OF THE URINARY ORGANS. TREATMENT OF STONE IN THE BLADDER. The treatment of stone in the bladder necessarily divides itself into medical and surgical, of which the former is, in general, merely palliative, though fre- quently of paramount importance, whether it be considered only in reference to the temporary comfort of the sufferer, or as a means of improving his health, with a view to his relief by an operation. 1. MEDICAL MEANS. Persons affected with stone in the bladder do not always find it convenient to submit to the operation of lithotomy, and it, therefore, becomes a matter of great importance to render thera as comfortable as their circumstances may admit of. By attention to the general health, as regulated by food, drink, and exercise, much may be done to allay local suffering, and make the patient almost forget his disease. A concretion, which may have been a source of great distress for years, may, by appropriate and well-directed treatment, become a comparatively harmless tenant of the bladder, and thus convert a state of torture into one of elysium. The improvement thus produced has sometimes lasted many years, though, in general, it is comparatively short. A consideration of these circumstances has led to a belief, not altogether unfounded, that urinary concretions are sometimes dissolved in the bladder, and voided along with the urine. Hence certain remedies, supposed to be endowed with this property, have received the name of lithontriptics or sol- vents and disintegrators of stone. Much of what might be said under this head has been anticipated in the article on the different calculous deposits. It is hardly necessary to remark that a due regulation of the diet is of para- mount importance in the treatment of stone in the bladder. Without enter- ing into details, it may be observed, in general terms, that the diet should be simple, easy of digestion, and yet sufficiently nutritious. Plainly roasted meats, boiled fish, mealy Irish and dry sweet potatoes, well boiled rice and hominy, soda biscuit, and stale wheat bread, with weak tea, or milk and water, are, ordinarily, the most suitable articles. Coffee, wine, fermented liquors, cider, and subacid fruits, with pastry, and the coarser kinds of vegetables, are to be eschewed. If the patient be feeble, or has been in the habit of using liquor, a little French brandy, or, what is better, Holland gin, may be allowed at dinner and after exercise. Gin has a specific tendency to the urinary organs, and its exhibition is occasionally attended with good effects. Some persons are greatly benefited by hop-tea, beer, or malt liquors. Generally speaking, however, these articles produce more harm than good. All kinds of water impregnated with lime must be abstained from. The patient should be well clad, avoid exposure to wet and cold, and refrain from rough exercise of every description. In the winter, he should keep himself well housed, or reside, if possible, in a warm and genial climate. Sexual excitement must be carefully guarded against, for any indulgence of the kind is always sure o be followed by an aggravation of the complaint. The urine must, in all cases, be kept in as neutral a condition as possible. If it be acid, alkalies are indicated, whereas, if it be alkaline, acids are re- quired. Frequent examinations of the fluid are, therefore, necessary, in order that the remedies may be varied as the circumstances of each particular case may render it proper. It should be remarked here that some patients are most benefited by alkalies, others by acids, even when the urine and the stone are both apparently of the same character. In ray own practice, 1 have generally derived most benefit from the use of alkaline remedies, what- ever may have been the nature of the diathesis, or of the concretion. EXTRACTION OF CALCULI THROUGH THE URETHRA. 775 The best alkalies in the treatment of vesical calculi are soda and potassa, in the form of bicarbonate, either alone, or variously combined with each other. I usually give the preference to the soda, for the reason that it seems to me to exert a more obtunding effect upon the mucous surfaces of the uri- nary passages. The best form of exhibition is in solution in a strong in- fusion of hops and uva ursi, in the proportion of thirty grains to the ounce, three or four times a day. The best period for using the medicine is about one hour after meals and at bedtime. Administered in this way, it readily mixes with the ingesta, prevents the evolution of acidity and flatulence, and exerts a more controlling influence over the urinary secretion. The quantity of the salt raay be gradually increased to forty, fifty, and even sixty grains, according to the tolerance of the stomach ; and a good plan is to pretermit the use of it occasionally for a few days. Carbonate of potassa is sometimes employed alone, but its beneficial influence is always greatly enhanced by giving it in union with soda. The liquor potassse now and then answers an excellent purpose in these cases, particularly in persons of a dyspeptic habit. It should be administered, largely diluted with water, in doses varying from twenty to forty drops, three times daily, or, what is better, under such cir- cumstances, in combination with some of the simple bitters, as tincture of gentian, quassia, or cinchona. Some patients derive much relief from the free use of lime-water, castile soap, magnesia, and lye. Marked benefit, sometimes of a permanent character, springs from the long- continued use of certain mineral waters. Of the various waters celebrated for their virtue of solving calculi and soothing the bladder, those of Vichy, in France, are the raost remarkable, on account of the numerous cases that have been relieved by their use. The Vichy waters contain a large quantity of free carbonic acid, and very nearly a drachm and a half of bicarbonate of soda in every thousand drachms of the menstruum, upon the presence of which their good effects, no doubt, depend. When the urine is decidedly alkaline in its character, acids are indicated. Those usually employed are the nitric and hydrochloric, of which the former is preferable. The best form of exhibition is the dilute nitric acid of the shops, in doses of from twenty to thirty drops, three times daily, in nearly half a tumblerful of cold water, sweetened with a little sugar. Attempts have been made, from time to time, to dissolve urinary calculi in the bladder by means of injections of acid and other fluids, but the results have not been such as to encourage a repetition of the operation, now that the subject is so well understood. The same remark is true in regard to the effects of galvanic electricity, proposed by some French surgeon. 2. EXTRACTION OF CALCULI THROUGH THE URETHRA. The fact that small calculi sometimes escape during micturition was long ago noticed by practitioners, and has been turned to good account by modern surgeons. When it is known, for example, that a concretion has recently descended from the kidney, its expulsion from the bladder may occasionally be effected by making the patient grasp the head of the penis, while he dis- tends the urethra with urine ; then, letting go his hold, he empties his bladder with all the force he can direct upon it by the action of the diaphragm and abdominal muscles. The water should be previously accumulated to the greatest possible extent, and, during its evacuation, the patient should lie upon his belly, or bend his body forward, to place the stone in the most favorable position for reaching the urethra. These attempts at extrusion are much facilitated by the prior dilatation of the tube by means of the bougie or catheter. Efforts have been made, especially in recent times, to remove calculi entire 776 DISEASES AND INJURIES OF THE URINARY ORGANS. from the bladder, through the urethra, by means of forceps. It was observed long ago, that, during catheterism, small concretions became occasionally im- pacted in the eyelets of the instrument, which they followed upon its with- drawal. A circumstance so interesting and important was calculated to arrest the attention of surgeons, and we accordingly find that they have taken full advantage of it. It was in this way that the late Mr. George Bell, of Edin- burgh, had the good fortune to rid a patient of one hundred and fifty con- cretions. In performing such an operation, a full-sized catheter, with two large eyelets, should be selected, and the bladder should be previously dis- tended with water, so that, as the fluid runs off, the calculi may have a better chance of being forced into the tube. Instruments have been constructed for the special purpose of seizing the stone, and removing it entire. Sanctorius, if not the first, was one of the earliest surgeons who busied themselves in this manner. He has described the operation with some minuteness, and has figured a pair of forceps which he contrived for performing it. Hales, Hunter and others also invented instruments which have been greatly improved in modern times by Sir Astley Cooper, and some of the French lithotoraists. The forceps of the English surgeon, which are represented in fig. 474, and with which he extracted Fig. 474. Cooper's stone forceps. upwards of eighty small calculi from one individual, consists of two movable blades, shaped, when closed, like a curved catheter. They are introduced in the ordinary manner, and are used at first as a searcher. When the stone is found, the blades are gently separated and expanded over it, when, being again shut, the instrument is carefully withdrawn. An index upon the sur- face of the instrument serves to show the size of the calculus, or, what is the same thing, the possibility of removing it entire. When the concretion can- not be extracted in this manner, it may, if not too hard or large, be crushed, and disposed of piecemeal. In performing this operation, it is important that the bladder should be perfectly free frora irritation, that the urethra be previously dilated by the catheter or bougie, and that the forceps do not pinch the mucous membrane. If these precautions are neglected, serious mischief may follow. At least one instance is on record where death ensued, although the operation was performed by a competent surgeon, and the forceps were introduced only twice. A small calculus has sometimes been entrapped and removed by a very simple procedure. Many years ago, an American practitioner, Dr. Calvin Conant, relieved a youth, aged fifteen, by means of a silver wire, passed through a catheter, the vesical extremity of which was pierced by two holes, about a line and a half apart. The wire, which was very fine, elastic, and twenty inches long, was formed, upon its arrival in the bladder, into a loop, which was then moved about until the concretion was found and ensnared; the ends were next secured to the shoulders of the catheter, when both the instrument and stone were withdrawn. %_ LITHOTRIPSY. 777 3. LITHOTRIPSY. It is not my intention in this place to enter into the history of lithotripsy, or an account of the different steps by which, from humble and unsatisfactory beginnings, the operation has attained its present extraordinary degree of perfection. To Civiale is, undoubtedly, due the credit of the invention, which threatened, at one time, to supersede lithotomy, and struck terror into the minds of the knivesmen. His first successful operation was performed in 1824, at two sittings. The procedure, as originally executed by Civiale and others, was denomi- nated lithotrity, as it consisted in seizing, boring, perforating, or piercing the calculus. This name is still retained by him, and likewise by some of the English surgeons, although the operation has been essentially modified. As performed at the present day, at least by most practitioners, it consists in breaking, crushing, or grinding the foreign body, and is, therefore, more appropriately termed lithotripsy. Instruments.—The instrument employed by Civiale, in his earlier opera- tions, was a silver canula, containing a steel tube, furnished with three branches, claws or pincers. Within the steel tube, again, was a cylindrical rod, called the perforator, one end of which was fashioned into a sort of crown with sharp teeth, to bore and break the stone into fragments. The perforator was moved during the operation by a steel drill bow. Although great improvements have been effected in this instrument, there are comparatively few surgeons who do not now altogether prefer the opera- tion of lithotripsy, not only because it is equally efficient, but because it is much more simple and easy of execution. The merit of the discovery of this operation is usually, at least in this country, ascribed to Baron Heurteloup, of Paris; but there is no doubt that much credit is also due to Mr. Weiss, the celebrated London cutler. As early as 1824, this gentleman contrived an instrument for this purpose ; which, after having been variously modified by different lithotriptists, among others by Mr. L'Estrange, of Dublin, and Fig. 475. Heurteloup's instrument. by Heurteloup himself, was subsequently remodelled and greatly improved by the inventor. The instrument, as now constructed, is remarkable for its Fig. 476. Screw of the lithotriptor. Mode of turning the screw. simplicity, its strength, and its adaptation to the end proposed. It is com- posed of two blades, as seen in fig. 475, curved at the extremity at an angle 778 DISEASES AND INJURIES OF THE URINARY ORGAN'S. of about 55 degrees, twelve inches in length, and about the size of an ordi- nary catheter; the one sliding within the other, and propelled by means of a screw. Near the upper end of the male rod is a graduated scale, intended to indicate the size of the stone. The extremities of the beak, on their inside, are serrated or notched, the better to Fig. 478. seize, retain, and crush the concretion. The curved portion of the fixed blade is hollow, to prevent impaction of the fragments. Fig. 476 represents the screw or handle, by turning which, in the manner indicated in fig. 4h, the male blade is propelled onwards, by short and sudden, but gentle, jerks, so as to imitate slight percussions, until the concretion is shattered. Fig. 478 exhibits the calculus in the jaws of the instrument, and fig. 479 the instrument in the bladder, the stone being grasped in a position suitable for crushing. Every operator should be provided with a number of these instruments, of different forms and sizes, that he may be able, without difficulty, to adapt Fig. 479. Lithotriptor grasping the stone. Seizure of the stone in the bladder. them to the varying circumstances of his patients. When the concretion is small, or uncommonly soft, the lithotriptor sketched at fig. 480 will generally 480. s Another form of lithotriptor. be found to answer every purpose, as it is of simple construction, very light, and of easy management. For the removal of little fragments, or diminutive calculi, an instrument with a short, broad, and rather abrupt curve, the female blade of which is moulded into a kind of cup, to receive and retain the detritus, may advantageously be used. LITHOTRIPSY — SELECTION OF CASES. 779 In the ordinary lithotriptor, the female blade has a large fissure, to allow the fragments, in the act of crushing, to fall away into the bladder,' and thus enable the operator to withdraw the instrument without the risk of lacerating the lining membrane of the urethra. These features are well seen in the accompanying cuts, figs. 481 and 482. Fig. 481. Fig. 483. Lithotriptic instruments. Another meritorious instrument is that of Dr. Jacobson, of Copenhagen. It consists of a silver canula, almost ten inches long, by three lines in diameter, the upper extrem- ity of which is furnished with a circular steel rim, an inch in width, while the lower is slightly curved for about two inches, and terminates in a blunt point. Within this tube is a steel rod, designed to move backwards and forwards at pleasure, and connected inferiorly, with the one just described, by means of an articulated chain consisting of three links. The superior extremity projects beyond the horizontal rim of the canula, and is furnished with a stout screw, which is intended to work the chain backwards and forwards, during the seizure and comminution of the stone. A graduated scale ex- ists upon the instrument for measuring the volume of the stone. Fig. 483 represents Jacobson's crusher as modified by Velpeau. In addition to the above instruments, the operator should be provided with a large syringe, fitted with rings, and in good working order, the nozzle being small and easily adapted to a silver catheter. When there is serious hypertrophy of the prostate gland, it may be well also to have at hand Crampton's appa- ratus, consisting of a gum-elastic bottle and a cathe- ter, the former being furnished with a stop-cock. The catheter being introduced into the bladder, and the air exhausted from the bottle, the urine and grit are forcibly expelled by the pressure of the atmosphere. Selection of Cases for Operation.—A proper selection of cases is a matter of great importance in this operation, for it is not every calculus that admits of being crushed. The circumstances which are favorable to the operation are chiefly a sound condition of the genito-urinary organs, the existence of a small ana comparatively soft calculus, and a good state of the general health. There must be no stricture of the urethra, enlargement of the prostate gland, or disease of the bladder, ureters, or kidneys. Even an excess of morbid sensi- h ilk the urinar-v Passages is incompatible with the operation. The stone snould be small, soft, and loose. A large concretion cannot be easily grasped an< retained by the instrument; a very hard one would be crushed with diffi- culty, and an adherent or encysted one could not be seized. The mulberry calculus is generally so firm and dense as to resist any amount of pressure Jacobson's lithotriptor. 780 DISEASES AND INJURIES OF THE URINARY ORGANS. that may be safely employed against it; and the uric acid concretion is fre- quently so large as to render it impossible to seize it. The operation is also inadmissible when there are a number of calculi. Preparatory Treatment.—Before operating, the system and the parts more immediately concerned should be subjected to a course of preliminarv treat- ment. If the general health is good, and the bladder is laboring merely under the mechanical inconvenience produced by the stone, little, if anything will be required beyond a few closes of aperient medicine, rest in the recumb- ent posture for five or six days, light diet, and the free use of diluent drinks. Should the reverse be the case, a more thorough preparation must be insti- tuted. Under such circumstances, in addition to the ordinary means adverted to, it may be necessary to take blood from the arm, or by leeches from the perineum and the hypogastric region, especially if the patient is young and robust, and to employ the warm bath, bicarbonate of soda with hop and uva ursi tea, and anodynes by the rectum. The next step is to dilate the urethra. This usually requires but a few days, and is best accomplished with a series of silver catheters, used two or three times in the twenty-four hours. Chloroform ought generally to be avoided, except in the case of children, as this operation is unattended with much pain. The patient's mind should be clear, in order that he may promptly inform the surgeon of his suffering, should any arise. Operation.—During the operation, the patient may lie on his back, near the edge of the bed, or he may sit in an easy chair with a movable back, as may be most convenient. If the patient is recumbent, the head and shoulders should be moderately elevated, the breech should be raised by a pillow, and the thighs should be separated and held up by assistants. If the meatus is unusually small, as it often is in very young children, it should be enlarged with the bistoury, as this will afford more room for the requisite manipulation. The bladder should contain frora six to eight ounces of urine, or a suitable quantity of tepid water should be gently injected through a silver catheter. The lithotriptor, warmed and well oiled, is now carried into the bladder, in the same manner as a common catheter. Upon reaching the organ, the stone, if not felt, is to be searched for. The instrument is next planted against the inferior wall of the bladder, the sliding blade is carefully retracted, and then, by a wriggling movement of the wrist, or a sort of sleight of hand, the con- cretion is engaged in the jaws of the forceps, which are at once closed upon it. Satisfying himself that the lithotriptor does not embrace the mucous membrane, as he may by moving its point from side to side, or turning it round, he holds it as firmly and steadily as possible with his left hand, while with the other he propels the screw at the handle of the instrument, thus slowly crushing the calculus. If the concretion is small and friable, one effort of this kind will probably be sufficient; but in general, several will be neces- sary before this object is fully attained ; for even if the foreign body has been pretty thoroughly broken in the first instance, there are almost always some coarse fragments, which require separate seizure and grinding before they can be expelled. The stone being broken, and a portion of it, if possible, comminuted, #the instrument is closed and withdrawn, care being taken that no large fragments remain impacted in its jaws, lest serious injury be thereby inflicted upon the urinary passages. The patient should now be desired to void his urine, which will usually be found to be a little bloody, in order to afford an opportunity to'the smaller fragments to escape, the passage of any that remain behind being favored immediately after by injecting the bladder freely and repeatedly with tepid water, through a short, large eyed catheter. The operation, how- ever, should be performed with all possible gentleness, and should be desisted LITHOTRIPSY — ILL EFFECTS. 781 from the moment it becomes a source of much uneasiness or pain. The patient is now put to bed, and kept upon light diet, using, however, large quantities of diluent drinks, such as gum Arabic water, or linseed tea. If much pain or spasm ensue, with a frequent desire to empty the bladder, a large anodyne is given by the mouth or rectum, and recourse is had to the warm bath, with medicated fomentations to the abdomen and perineum. Re- tention of urine is relieved with the catheter. If peritonitis threaten, the antiphlogistic treatment must be carried to its fullest extent, aided by the liberal use of opium. If no untoward symptoms arise, the operation may be repeated in five or six days. To make sure that the bladder is thoroughly free of foreign mat- ter, frequent recourse must be had to the sound, for the smallest remaining particle will certainly become the nucleus of a new concretion. The length of each sitting should generally not exceed six, eight, or ten minutes; when the operation is productive of pain, it should be much shorter. It is a safe rule to be governed by the feelings of the patient. /// Effects.—The ill effects of this operation are—1. Hemorrhage. 2. Rigors and fever. 3. Retention of urine. 4. Contusion and laceration of the prostate and urethra. 5. Cystitis. 6. Perforation of the bladder. 7. Impaction of the fragments of the stone in the urethra. 8. Peritonitis. 9. Purulent infection. 10. Atony of the bladder. 11. Renal irritation. 12. Bending and fracture of the lithotriptor. Some of these accidents are unim- portant, others serious, if not fatal. Hemorrhage, rigors, retention of urine, and cystitis, should be treated upon general principles. Perforation of the bladder is uncommon, but has sometimes happened in the hands of the most skilful operators. The accident, which is a most serious one, may be caused either by the instrument itself, or by a fragment of the calculus, a sharp corner of which may perhaps be pressed into the coats of the bladder as the lithotriptor is withdrawn. However induced, the lesion is generally rapidly followed by infiltration of urine, and death. A fragment of the broken calculus may be arrested in the urethra, and, if sharp and angular, serious mischief may ensue. If it is situated far back, an attempt should be made to push it into the bladder; but, if it has ad- vanced considerably forward, it may be removed with the forceps. Purulent infection occasionally occurs, chiefly in old, enfeebled subjects. It is usually very stealthy in its character, and is nearly always fatal. Our principal reliance must be upon mercury and opium, with tonics and stimu- lants, and free incisions to give vent to effused and pent-up fluids. Atony of the bladder, as an effect of lithotripsy, occurs chiefly in old sub- jects, in consequence of the rude and protracted efforts at crushing. The irri- tation thus occasioned rapidly extends \o the muscular fibres of the organ, which, crippled, if not completly paralyzed, is unable to expel either the urine or the fragments of stone, the retention of which thus becomes an ad- ditional source of suffering, both to the part and system, the great danger being from cystitis, accompanied with a low forra of fever and excessive prostration. The proper remedy for this affection is riddance of the fragments. Some- times this may be effected with the lithotriptor, aided by the injection of large quantities of water by means of a large-eyed catheter. When these efforts fail, relief must be sought by lithotomy. Renal irritation, followed by suppression of urine, is a rare, but commonly a fatal, accident after lithotripsy. It is most frequent in elderly, irritable Persons, and is characterized by pain in the back, a quick, frequent pulse, mtense thirst, and other evidences of prostration, along with typhomania. The treatment must be supporting, the chief remedies being quinine, opium, ftid milk punch, with cupping of the loins, and the use of the warm bath. 782 DISEASES AND INJURIES OF THE URINARY ORGANS. Fracture of the lithotriptor has occurred, but for such an accident both the surgeon and his cutler should be held personally responsible. Statistics.—Xo statistics of this operation on a large scale have hitherto been published. Of 206 cases, furnished, many years ago, by Civiale, 108 were cured, 80 died, and 18 were unrelieved. Malgaigne estimates the mor- tality frora lithotripsy, in the Parisian hospitals, at 1 in 4, while that of pri- vate practice, in the French metropolis, is as 1 in 8. In the London hos- pitals, the operation has not, according to Mr. Erichsen, been a successful one. In 1856, Dr. Ivanchich, of Vienna, published the particulars of 100 cases of this operation, of which 13 died, and 87 recovered; 81 completely and 6 incompletely. Three of the patients were females. Dr. Swalin, of Stockholm, has lost 7 out of 49 cases. It is impossible, in the existing state of the science, to form anything like a correct estimate of the comparative value of lithotripsy and lithotomy. Excepting in France, crushing is so rarely performed that no means for in- stituting such an estimate have yet been furnished; and, in that country, the only elaborate data are those supplied by Civiale. From these, it appears that relapse followed in 55 cases out of 548, being in the proportion of nearly 1 to 10. This is unquestionably much greater than in lithotomy, and affords a strong argument against the general introduction of the operation, even in the most favorable cases. The cause of the frequent relapse after lithotripsy is no doubt the fact that fragments of the broken stone are more liable to be left in the bladder, which thus become, often in a very short time, the nuclei of new formations. In lithotomy, on the contrary, the concretion is generally removed whole, while any pieces that may be split off are either extracted at the time, or they are washed away subsequently by the urine as it flows through the wound, the patency of which, for a certain time, greatly favors this mode of clearance. The results of lithotripsy, like those of lithotomy, vary, no doubt, mate- rially in the hands of different operators, according to the manner in which they select their subjects, the mode and skill with which they execute their manipulations, and the attention which they bestow upon the after-treatment. There is every reason, too, to believe that the mortality is much greater in hospital than in private practice. All things considered, the conclusion is inevitable that the procedure, in its aggregate results, is decidedly less safe and satisfactory than lithotomy. 4. LITHOTOMY. Lithotomy raay be performed at any period of life, even in early infancy. Experience, however, has shown that the greatest number of recoveries take place in children, and in subjects under thirty years of age. Persons after this time of life are more prone to suffer from inflammation of the urinary apparatus, and perhaps, also, from erysipelas of the wound, and phlebitis of the neck of the bladder and prostate gland. When a patient is about to undergo lithotomy, he should be subjected to a certain degree of preparatory treatment, in order to place him in the best possible condition to bear the shock and other ill effects of the operation. There is no doubt that much of our success depends upon the manner in which this is done. When the patient is in good health, he will seldom re- quire anything more than a dose or two of aperient medicine, and abstinence from animal food, with rest in his room. Four or five days will, in fact. generally suffice to put him in a proper condition for the operation. But it is very different when he is in bad health ; for then a more thorough course of preparatory measures is necessary. The secretions must be rectified, the bowels must be opened by mercurial and other cathartics, the diet must be LITHOTOMY—LATERAL OPERATION. 783 regulated, and, in a word, all sources of excitement, local and constitutional, must be removed. Too much preparation, however, should be avoided. All serious lesions of the lungs, kidneys, ureters, bladder, and prostate, or, in short, of any other of the more importaut viscera, forbid interference. Lateral Operation.—Of the different operations for stone, the lateral, peri- neal, or infra-pubic, as it has been variously termed, is by far the most im- portant, not only on account of its greater frequency, but also on account of the remarkable success which has hitherto attended it. In the description which I am about to give, I shall speak of it as I am myself in the habit of executing it, premising that this does not differ, in any essential particular, from the method devised and so happily practised by Cheselden and his disciples. The design of the lateral operation is to make an opening on the left side of the perineum, extending from the surface of the skin through the neck of the bladder and the prostate gland, and large enough to admit of the easy extraction of the foreign body. It is usually described as consisting of three steps or stages. In the first, the surgeon divides the skin, the cellulo-adipose tissue, and the superficial fascia; in the second, the transverse muscle, the triangular ligament, and the membranous portion of the urethra ; and in the third and last, the prostate gland and the neck of the bladder. The wound made in the operation may be said to represent a truncated cone, the apex of which corresponds with the neck of the bladder, and the base with the surface of the perineum. In the adult, its extent externally varies from three inches to three inches and a half, while internally it does not, as a general rule, exceed fifteen or eighteen lines. Its superior angle is an inch and a quarter above the verge of the anus, and immediately on the left side of the raphe of the perineum ; the inferior, on the contrary, is usually about three-quarters of an inch to an inch below the anus, and a little nearer to the tuberosity of the ischium than to the outlet in question. The inner wall of the wound corresponds with the middle line of the perineum ; the external with the ramus of the ischium and the erector muscle of the penis. The evening before the operation, a brisk purgative is administered, to clear out the alimentary canal. The article which I usually select for this purpose is castor oil; but if there be disorder of the secretions, as indicated by the state of the tongue and stomach, a combination of calomel and rhu- barb, with a few grains of jalap, is to be preferred. If it appears probable that the rectum has not been thoroughly evacuated, a stimulating enema, consisting of tepid salt water, is used a few hours before the operation. I consider it of paramount importance, both as it respects the safety of the lower bowel, and the comfort of the surgeon, that this precept should be faithfully attended to in all cases. Moreover, by opening the bowel freely, immediately before the operation, there will be no necessity, as a general rule, for any purgative medicine for some days after. The patient is requested to retain his urine for several hours before the operation, for a certain degree of distension of the bladder is necessary to prevent injury of its walls, and facilitate the extraction of the foreign body. If he be a child, and cannot hold his water without great difficulty, a piece of tape should be tied loosely around the penis, otherwise he will be sure to disobey an injunction which every lithotomist raust regard as of no little con- sequence. In old subjects, affected with excessive irritability of the bladder, and with a constant desire to micturate, it is necessary to inject the organ with a few ounces of tepid water just before commencing the operation. During the operation the patient lies upon his back, on a narrow breakfast table, about four feet in length, and provided with stout, firm legs, to prevent 't from shaking. It is covered with a folded blanket, over which are spread, first, a piece of soft oil-cloth, and, next, a folded sheet. Several pillows are 784 DISEASES AND INJURIES OF THE URINARY ORGANS. required for the head and shoulders, which, however, should be but slightly raised, otherwise the abdoraen will be doubled up, and thus unduly compress the bladder. The breech is fully exposed to the operator, and is, therefore, brought low down, a little over the edge of the table. His head and trunk are held by assistants, one of whom administers chloroform. If an anaesthetic be used, there will be no necessity for tying the hands and feet; otherwise they should be secured by two stout worsted bands, from six to eight feet in length by two inches and a half in width, Fig. 484. with a hole in the middle to afford greater security against their slipping ; or they raay be arranged as in fig. 484. As a preliminary step, the patient, stripped to his shirt, and placed upon the table, is desired to grasp his feet in such a manner as to apply his fingers to the sole and the thumb to the instep ; in which position they are confined by means of the fillets, passed round them in the form of the figure 8, the ends being tied in a double knot, or fastened with stout pins. This duty is generally confided to the assistants, for which reason it is often discharged so badly as to be fol- lowed by much delay and annoyance ; the patient, perhaps, becoming untied during the operation. A careful super- vision should, therefore, always be exercised in this respect by the surgeon. The limbs, bound as here directed, are given in charge of two assistants, who, one standing on each side of the patient, place one hand upon the top of the knee, and the other beneath the sole of the foot. When the operation is Lithotomy bandage, about to be commenced, the thighs are moderately separated from each other, and held nearly at a right angle with the trunk. It can easily be perceived how important it must be, in reference to the speedy and successful execution of the operation, that the patient's limbs should be thoroughly controlled, and out of the surgeon's way. It is usually recommended that the staff be introduced previously to the ligation of the patient; but to such a procedure I am altogether averse, because it is productive of serious annoyance to the patient, and is almost sure to be followed by a premature escape of the urine. Besides, it is a source of inconvenience to the persons who have charge of the limbs. My rule, there- fore, always is to tie the patient first, and immediately after to introduce the staff; taking care to confide it to a good, intelligent assistant, one who is thoroughly acquainted with the anatomy of the pelvis, and the different steps of the operation. A poor staff-holder is a great nuisance ; for he often exces- sively embarrasses the surgeon, and makes him commit blunders which he might otherwise avoid. During the operation, the instrument is to be held perpendicularly, with the handle nearly at a right angle with the trunk, and inclined slightly towards the right side. The curved portion, securely lodged in the bladder, is hooked up closely against the pubic symphysis. The object of this advice is to prevent the instrument frora pressing upon the rectum, which would thus be in danger of being wounded. By inclining the handle of the staff a little towards the right groin, the curved portion is made to bear against the left side of the perineum, with the effect of rendering it somewhat prominent and thereby facilitating the division of the membranous portion of the urethra. The assistant having charge of the instrument stands on the left side of the patient, in order that he may use his right hand, and also hold the scrotum out of the way. _ The staff which I am in the habit of using is represented in fig. 485. It is shaped like an ordinary silver catheter, and is about ten inches in length, exclusive of the handle, which should be at least two inches long, by two LITHOTOMY—LATERAL OPERATION. 785 lines and a half in thickness, and fifteen lines in width, and perfectly rough on the surface, that it may be the more securely held in the hand. The groove, placed a little towards the left side, and extending Fig. 485. frora near the middle of the instrument, to Fig. 486. within a short distance of its beak, should be perfectly smooth, and as deep and as wide as possible. The instrument, which is warmed and oiled previously to its introduc- tion, should be large enough to distend the urethra to as great a degree as is compati- ble with the patient's comfort. By adopting this advice, it will be comparatively easy to find the staff, and to effect, in a safe and proper manner, the division of the neck of the bladder, and the prostate gland. The surgeon, during the operation, sits upon a low, firm chair, or stool, as he may find it most convenient; or he may place himself, as I usually do, in the half-kneeling posture, rest- ing upon the right knee. I generally prefer this posture, because it affords greater freedom to ray hands and elbows. A piece of old car- pet, or a sheet, is laid upon the floor, under the patient's breech, to receive the fluids. The knife which I have, for many years, been in the habit of using is the one sketched in fig. 486; it is of simple construction, very light and slender, sharp-pointed, and nearly seven inches in length, of which three are oc- cupied by the blade, which hardly exceeds two lines in width. With this instrument, the lateral operation may be safely and expedi- tiously executed in all its stages. For enlarg- ing the opening in the prostate and neck of the bladder, after the withdrawal of the staff, I sometimes use the probe-pointed bistoury, delineated in fig. 487, though the sharp-pointed is quite as safe, provided the extremity be carefully guided along the index-finger as it lies in the bottom of the wound. Grooved staff. Everything being thus prepared—the bowel cleared out, the instruments arranged on the tray, the limbs tied and held out of the way, the staff in the bladder and in the hand of the as- sistant, the breech projecting over the table, and the patient fully under the Fig. 487. Beaked knife. influence of chloroform—the operator is ready to begin. Introducing the index-finger well oiled into the rectum, to induce it to contract, and ascer- tain the position of the staff, and marking with his eye the situation of the tuberosity of the ischium, he stretches the integuments of the perineum with the thumb and finger of the left hand, and commences his incisions. The VOL. n___50 786 DISEASES AND INJURIES OF THE URINARY ORGANS. Lateral operation for stone. knife is entered just by the side of the raphe, on the left half of the perineum ' an inch and a quarter above the margin of the anus, and is carried obliquely downwards and outwards, a Flg- 488, short distance below the tube- rosity of the ischium, and n little nearer to this point than to the anus, as shown in fig. 488. If the part is unusually full, the instrument is plunged in "at the first stroke to the depth of at least one inch; otherwise, it must be used more cautiously. As the knife de- scends, it is gradually with- drawn frora its deep position, so as to give the wound a slop- ing appearance. The length of the incision must be regu- lated by the size of the peri- neum and the age of the pa- tient ; but, in the adult, it should not, in general, be less than three to three inches and a half. In the young subject it must be proportionately smaller. Placing the point of the left index-finger in the upper angle of the wound, the knife is re-entered just by the side of it, and is made to divide, by repeated touches with its edge, the deep cellular substance of the perineum, the trans- verse muscle, and a portion of the Fig. 489. triangular ligament, with a few of the fibres of the elevator muscle. The membranous portion of the urethra being thus exposed, a little in front of the prostate gland, the surgeon feels for the groove of the staff, at the bottom of the wound, and, having found it, he cuts into it through the denuded tube, the finger-nail serving as a guide to the point of the knife, as in fig. 489. The length of the opening in the urethra need not exceed the third of an inch. The knife, inserted into the groove of the staff, through the opening in the urethra, is now carried on into the bladder, dividing, as it passes along, the neck of the organ and the left lobe of the prostate, in a direction obliquely downwards and outwards, which is in that of its long axis. In executing this step of the operation, the rectum is to be held out of the way, by pressing it over towards the right side with the left index-finger, which should be steadily kept in the bottom of the wound, from the moment of the first incision. Great care should also be taken not to prolong the incision in the prostate gland too far back, for fear of penetrating the reflection of the pelvic fascia, and the adjacent venous plexus. As soon as the bladder has been opened, the urine generally escapes in a gush ; the knife is now removed, and the finger, lying in the bottom of the wound, is placed in contact with the staff, which is immediately withdrawn. The urine, as it passes off, frequently forces the calculus down against the artificial opening, so as to afford the surgeon an opportunity of ascertaining its form and bulk. When this does not happen, the finger is carried into the bladder to its full length, and used as a searcher. If the stone is found The finger and knife in the groove of the staff. LITHOTOMY—LATERAL OPERATION. 787 to be disproportionately large, the wound must immediately be dilated, either with the finger or the bistoury, according as the resistance may seem to de- pend upon the prostate or the muscular structures. In elderly subjects, the instrument will generally be necessary, as the gland is not sufficiently lacer- able to yield to pressure. The incisions being completed, the next step of the operation is to extract the calculus. This is to be done with the forceps, fig. 490, which are con- Fig. 490. Lithotomy forceps. veyed into the bladder along the upper surface of the index-finger, lying in the bottom of the wound, in contact with the foreign body. The forceps are introduced with the blades closed, and are used at first as a searcher, as shown in fig. 491. As soon as they are brought in contact with the con- Fig. 491. Mode of introducing the forceps and seizing the stone. cretion, the blades are expanded over it, in the direction of its long axis, and with a firm grasp, to prevent the risk of slipping. Taking care that the instrument does not embrace any of the folds of the mucous membrane, the operator endeavors to extract the foreign substance by gently moving the forceps from side to side, or upwards and downwards, on the same principle as in the delivery of the child's head. The facility with which the stone may he seized depends upon circumstances. In general, it lies in contact with the inner extremity of the wound, and may readily be caught in the embrace pf the blades of the instrument. Sometimes, however, as when it is lodged in the bas-fond of the organ, it refuses to come down, and raay thus embarrass 'he young operator. The difficulty, as will be particularly mentioned here- 788 DISEASES AND INJURIES OF THE URINARY ORGANS. after, is easily remedied by inserting the finger into the rectum, and pushing the concretion forwards against the forceps. When the stone is situated in the superior fundus of the bladder, the forceps must be carried high up, in the direction of the long axis of the pelvis, where they are to be moved about as a searcher. Occasionally it lies behind the pubic symphysis, and cannot be seized until it has been dislodged by pressure upon the inferior part of the hypogastric region, aided by the finger in the bladder. If the calculus is very small, it is sometimes more easily extracted with the scoop, seen in fig.' 492, than with the forceps. The same instrument should Fig. 402. =SKM3fJtL'JL!__________-$& Lithotomy scoop. be used when the concretion has been broken, whether accidentally or de- signedly, into fragments, which must then be removed piecemeal. The scoop is about ten inches in length, and is shaped, as its name indicates, at each extremity, like a spoon, or, instead of this, one end is provided with a suitable handle. An instrument like this may be made very serviceable in extracting an adherent, encysted, or im- pacted concretion. The mode of grasping and holding the stone is exhibited in fig. 493. As soon as the foreign body has been extracted, the bladder is washed out with tepid water, thrown up in a full stream scoop and finger grasping the calculus. from a large syringe. Any pieces or frag- ments that may have escaped the forceps or scoop are thus removed; otherwise, there will almost certainly be a return of the calculous affection, the smallest particle frequently serving as a nucleus for a new concretion. The bladder having been washed out, a female sound is next introduced through the wound into the interior of the viscus, with a view of ascertaining whether any stones or fragments have been left behind. Should this be the case, the forceps, scoop, and syringe are again used till complete clearance is effected. In general, when the stone is rough, it is an evidence that it is solitary ; but to this rule there are occasional exceptions. The operation being finished, the patient is unbound, and conveyed to his bed, a piece of oil-cloth and a folded sheet being placed under his breech, to protect the clothing and absorb the urine. Extent of the Incision of the Prostate.—The wound should in no instance, however bulky the stone may be, extend entirely through the lateral lobe of the prostate, on account of the danger of urinary infiltration. When the concretion is very voluminous, it should either be broken, and extracted piece- meal, or, what is better, the opening should be enlarged by incising the oppo- site half of the gland. If this do not afford sufficient room, the calculus should be crushed. In ordinary cases, I incise the organ only to a very limited extent, and immediately after enlarge the opening with the finger, the pressure of which is generally amply sufficient for the purpose. When it is not, the probe-pointed bistoury is used as a substitute. In old subjects, in whom there is induration with enlargement of the gland, the division is generally obliged to be effected with the instrument. 'The outer wound, on the other hand, should always be ample and dependent. The direction and LITHOTOMY—DIFFICULTIES OF EXTRACTION. 789 extent of the incision in the prostate gland are represented in fig. 494, copied from Scarpa. Fig. 494. Left lobe of the prostate, as it is divided in the lateral operation, a. Marks the incision of the mem- branous portion of the urethra and the side of the gland, b. The left lobe of the prostate. 6*. The right lobe of the organ, c. The bulb of the urethra. Close behind are observed Cowper's glands, d, d. The crura of the penis, e, e. The seminal vesicles. /, /. The deferent ducts, g. The ureter of the left side. Difficulties of Extraction.—Difficulty frequently occurs in the extraction of the stone. This may depend, 1st, upon the stone itself; 2d, upon the blad- der; and 3d, upon the pelvis. 1st. The difficulty may be caused by the lodgment of the stone in the bas- fond of the bladder, which is sometimes converted into a sort of cul-de-sac. The remedy is to raise the stone up, and place it within reach of the instru- ment, by the left index-finger, inserted in the rectum. When the stone is lodged above the pubes, it is to be displaced, while compression is made npon the hypogastrium, with a strong probe, bent into a hook, or it may be drawn down with the index-finger. 2d. The stone may be entangled in the folds of the mucous membrane; or it may be spasmodically grasped by the bladder, which may thus prevent the blades of the forceps from being expanded over it. In the former case the scoop replaces the forceps, or, if this fail, dislodgment may be attempted by throwing cold water into the bladder, in a full stream, from a large syringe. Anaesthetic agents are the most useful in relieving the spasm. 3d. The stone may be encysted. When this is the case, it is advisable to introduce the finger into the bladder and to rupture the cyst with the nail; or, when this is impracticable, to divide it with a probe-pointed bistoury, or ft knife, fashioned like a gum lancet, and furnished with a long handle. Em- barrassment may be occasioned by the presence of a pouch between the bladder and the rectum. 4th. It may be difficult to seize the stone on account of the great depth of the perineum, which is sometimes upwards of three inches. 5th. The stone, under the grasp of the forceps, may break into numerous fragments, be reduced to a soft pulpy mass, or be crushed into small sandy particles. The fragments, according to their size, may be removed with the forceps, scoop, or syringe. oth. Delay and inconvenience may arise from the presence of a considerable number of calculi. 790 DISEASES AND INJURIES OF THE URINARY ORGANS. 7th. Embarrassment may proceed from the manner in which the stone is grasped. When there is reason to believe that it has been seized by its long diameter, the finger should at once be introduced into the wound to ascertain the fact, and to effect the necessary change. Before this can be done, how- ever, the forceps must relax their hold upon the calculus, though there will be no need of withdrawing them. 8th. Embarrassment occasionally results from an inability to find the con- cretion. This may depend upon some of the causes already detailed; or, it may be owing to the expulsion of the stone, especially if it be of small volume, at the moment of completing the section of the bladder and the prostate gland. 9th. But the greatest embarrassment of all that are encountered in the extraction of the stone, arises from its bulk. When the calculus is of unusual magnitude, the extraction is to be accomplished either by simply enlarging the wound, if this has not already been done, to the utmost permissible limits, or by incising the right lobe of the prostate to the same extent as the left; or, finally, by breaking the concretion, and removing it piecemeal. 10th. Dilatation of the wound is effected with the probe-pointed bistoury, carried downwards and outwards in the direction of the original incision, while the stone is held firmly by the forceps. Or, the right lobe of the prostate is divided, if necessary, in the same manner and in the same direction as the left. These two methods may almost always be resorted to with a reasonable prospect of success, when the weight of the stone does not exceed three or four ounces. When the concretion is very bulky, crushing will generally be necessary. The forceps represented in fig. 495 are well calculated for the operation of crushing. They are constructed upon the principles of the ice-masher, and do their work most effectually. 11th. Embarrassment of a very serious, if not an insurmountable character, may arise from unusual narrowness of the pelvis. Fig. 495. Stone-crusher. 12th. The calculus occasionally co-exists with calcareous incrustation of the surface of the bladder. The proper procedure is, first, to extract the calculus in the usual manner, and then to remove the calcareous matter with the forceps, scoop, and finger, aided with the syringe. Lastly, calculi of large size, weighing ten, twelve, and even fifteen ounces, have occasionally been successfully extracted. Most generally, however, the patient dies either frora exhaustion during the operation, or a short time after from the effects of inflammation. Accidents.—The accidents that are liable to occur, during and after the lateral operation, are hemorrhage, prostration, retention of urine, undue in- flammation of the wound, injury of the prostate gland, urinary in61tration, peritonitis, tetanus, wound of the rectum, incontinence of urine, impotence, perineal fistule, orchitis, and explosion of pre-existing disease. LITHOTOMY—HEMORRHAGE. 791 1. Hemorrhage.—The hemorrhage after the perineal section is usually very slight, not exceeding two or three ounces. It may be arterial or venous, primary or secondary. Its principal sources are the artery of the bulb and the superficial artery of the perineum. In old subjects, a copious flow of blood occasionally proceeds from the veins of the neck of the bladder, and of the prostate gland. The pudic artery, in its natural course, can hardly be wounded posteriorly ; anteriorly, however, it is more exposed, and, therefore, in danger of being injured. The accident is most likely to happen when the prostate is divided by the gorget, or the lithotome cache. The artery of the bulb sometimes bleeds profusely ; and, from its deep position, and the readi- ness with which it retracts, is always secured with difficulty. A tremendous gush of blood sometimes proceeds from the transverse peri- neal artery. The bleeding generally follows the first incision, and should immediately be arrested by the liga- Fig. 496. ture. The superficial perineal artery Fig. 497. is seldom cut; when it is, the bleeding ^ is usually insignificant. When the affected vessel is deep- seated, the blood, instead of escaping externally, raay pass into the bladder, where it is either retained, or expelled from time to time in thick clots. The organ, in the latter case, forms a hard, solid tumor, which is more or less ten- der on pressure, and which may mount as high up as the umbilicus. The ex- pulsion of the clots is attended with violent spasm and tenesmus, bearing a close resemblance to labor pains. When the bleeding vessel is acces- sible, the proper means for arresting the hemorrhage is, of course, the liga- ture. When it is very deep-seated, it raay generally be readily seized with Physick's artery forceps, delineated in fig. 496, the edges of the wound being separated with retractors, the fingers, or a pair of lithotomy forceps. When the artery is situated very far back, at the neck of the bladder, or by the side of the prostate gland, it may be ex- tremely difficult, if not impossible, to ligate it. To meet this centingency I devised, some years ago, a pair of for- ceps, which, after having grasped the artery, may be permanently retained, by unscrewing its handle, until all dan- ger from hemorrhage is over. The in- strument is represented in fig. 497. Compression may be resorted to, The author's artery when it is impossible to use the liga- compressor. ture or torsion. A canula, fig. 498, consisting of silver, or gum elastic, three inches and a half long by four lines m diameter, surrounded by charpie, sponge, or cotton, and pierced with two holes at the perineal extremity for securing it, by means of threads, to a T- bandage, is introduced into the bladder, thus serving the twofold purpose of Physick's forceps. 792 DISEASES AND INJURIES OF THE URINARY ORGANS. conducting off the urine, and compressing the bleeding vessel. It should be retained for several days, or until there is reason to believe that all danger of Fig. 498. Canula for plugging the wound in lithotomy. hemorrhage is over. When no canula is at hand, a female catheter, a piece of reed, or the spout of a tin coffee-pot, may be used as a substitute. Plug- ging of the wound is particularly necessary when the hemorrhage proceeds from enlarged and varicose veins at the neck of the bladder and prostate gland, or when the blood oozes from a great many small arteries, too minute to be tied. The operation, of course, always interferes with the union of the wound. Styptics are sometimes useful, especially in deep-seated venous hemorrhage, the best articles for the purpose being alum, acetate of lead, and persulphate of iron. The actual cautery can seldom be required. Occasionally the hemorrhage is promptly arrested by directing a concen- trated stream of cold water from a syringe upon the bleeding spot. Expo- sure of the wound to the cold air, and keeping it free from clots, is also sometimes highly beneficial. Secondary hemorrhage generally takes place as soon as reaction is estab- lished, or the patient has recovered from the shock of the operation. The means already pointed out will usually be sufficient to arrest it. 2. Sinking.—Few patients, at the present day, suffer much from shock in the operation of lithotomy. Should this event arise, recourse must be had to stimulants, care being taken during reaction that over-excitement do not occur. 3. Retention of Urine.—This may be caused by inordinate tumefaction of the wound, and spasm of the urethra; or, as more frequently happens, by closure of the two passages by coagulated blood. In the former case relief is afforded by the catheter; in the latter, by clearing away the blood, and preventing further hemorrhage. 4. Inflammation of the Wound.—Undue inflammation of the wound, if it should take place, usually supervenes within the first forty-eight hours. The action is sometimes erysipelatous, and is then apt to spread. The treatment should be strictly antiphlogistic, combined with gently supporting measures, if there be any tendency to prostration. 5. Phlebitis.—This disease occasionally occurs after this operation. It is most frequently met with in eldetly subjects. The treatment, although anti- phlogistic, is conducted cautiously, and with due regard to the state of the system. When the phlebitis attacks the extremities, the proper local remedies will be leeches, fomentations, iodine, and blisters, followed by free incisions to afford vent to effused and pent-up fluids. The system must be supported by anodynes and stimulants. Yenesection is generally admissible, and the use of mercury, except in so far as it tends to correct the secretions, may com- monly be dispensed with. After the violence of the inflammation has sub- sided, the limb should be bandaged, and, as soon as the patient can move about, change of air should be advised. 6. Lesion of the Prostate Gland.—This gland may be gravely injured in this operation, either by the knife, the finger, the forceps, or the calculus. The most serious mischief is usually inflicted by the forceps. The accident, LITHOTOMY—INCONTINENCE OF URINE. 793 however, is extremely rare, and ought never to happen in the hands of a skil- ful lithotomist. The treatment must be conducted upon general antiphlogistic principles. 1. Urinary Infiltration.—One of the most dangerous effects of lithotomy is an escape of urine into the cellular tissue of the perineum, or of the peri- neum and the parts immediately around the neck of the bladder. Its occur- rence is favored by too free a division of the prostate gland ; by the small size of the wound, or by its being too conical or sloping; by the early and inordi- nate tumefaction of the cut surfaces ; and, above all, by the perforation of the reflected portion of the pelvic fascia. The attack usually comes on within a short time after the operation, and often runs its course with frightful rapidity. Little can be done to arrest the progress of this affection when once estab- lished. Depletion by the lancet, and by purgatives, is wholly inadmissible. The system is to be sustained by such remedies as carbonate of ammonia, quinine, camphor, and capsicum, in combination with the liberal use of brandy and opium. The best topical means are saturnine and opium fomentations, medicated cataplasms, injections of a weak solution of nitric acid or chlori- nated soda, and touching the whole track of the wound as early as possible with nitrate of silver, or the tincture of iodine. When the infiltration is caused by the small size, ill shape, or improper direction of the wound, the defect must be remedied by the knife, to afford a free outlet for the urine. Leeches and hot fomentations may be applied to the hypogastric region. 8. Peritonitis.—Peritonitis seldom follows the lateral operation, but is occasionally observed as a consequence of the high. The treatment must be prompt and vigorous. Blood should be taken by the lancet, or, when that is inadmissible, by leeches to the hypogastrium, succeeded by anodyne fomen- tations. The bowels are thoroughly confined with opium, and the pulse is kept down with aconite and other depressants. 9. Tetanus.—This sometimes occurs, but very rarely; should an attack be threatened, the proper remedies are anodynes and antispasmodics, aided, if the subject be much debilitated, by brandy, wine, or porter. Chloroform is a valuable adjuvant, when there is much suffering, in controlling muscular action. 10. Wound of the Pedum___This accident may happen, but will not be likely to do so if the proper precautions are taken in performing the opera- tion. The opening, which is generally situated immediately in front of the neck of the bladder, soon begins to diminish, and usually closes in a few weeks. The treatment consists in preventing the bowels from acting, except every third or fourth day, by means of anodynes, in washing out the rectum fre- quently with cold water, in permitting none but the most bland and simple food, and in enjoining a strict observance of the recumbent posture. 11. Sloughing of the Pedum.—This is most liable to take place in weakly, dilapidated subjects. The immediate cause of the occurrence is probably slight infiltration of urine, in consequence of the great and unnecessary depth of the wound, or injury done to the recto-vesical septum during the extraction of the calculus. No definite rules can be laid down respecting the treatment, which must evidently be regulated by the circumstances of each individual case. In general, it will be necessary to support the strength by a proper diet, and by tonics, especially quinine, wine, and brandy. 12. Incontinence of Urine.—Incontinence of urine, consequent upon peri- neal lithotomy, is happily infrequent. It is not always easy to determine how this accident is produced. Most commonly, however, it arises, from injury inflicted upon the neck of the bladder during the extraction of a large and very rough calculus, but I have known it to occur when the stone was unusu- ally small. 794 DISEASES AND INJURIES OF THE URINARY ORGANS. When there is a probability that incontinence of urine will take place every effort should be made to prevent it. The patient should be strictly con- fined to his bed, a warm bath should be administered once a day, for twenty- five or thirty minutes at a time, tepid water should frequently be thrown into the rectum, and free use should be made of demulcent drinks. When the affection is fully established, it will be necessary to leech the perineum occasionally, and to apply gentle but steady pressure upon that part with the pad of a T truss. In obstinate cases, cauterization of the neck of the bladder and the commencement of the urethra may be tried. 13. Impotence.—This, like incontinence of urine, is very rare after peri- neal lithotomy. It doubtless depends upon injury inflicted upon the ejacu- latory ducts by the knife, and does not admit of relief. 14. Perineal Fistule.—The wound made in lithotomy generally heals in from three to four weeks; but sometimes it remains open much longer, and occasionally it does not close at all, but degenerates into a fistule, the exist- ence of which is determined by the appearance of the urine at the external opening, and by an examination with a probe. The treatment consists in retaining a silver catheter constantly in the urethra, and in cauterizing, every sixth or eighth day, the neck of the blad- der with nitrate of silver. The patient should be confined to his back, with the nates elevated. When the track is unusually small, and the perineum uncommonly thin, relief may sometimes be afforded by the occasional intro- duction of a heated probe, wire, or knitting needle. In intractable cases, it may be necessary to incise the parts. 15. Orchitis. — Acute swelling of the testicle occasionally follows this operation. I have seen only two cases of it in my own practice; a circum- stance which leads me to suppose that it is infrequent. It seldom comes on before the end of the second or third week, and is no doubt due to injury inflicted upon the ejaculatory ducts in the division of the prostate gland or during the extraction of the calculus. It generally involves one organ only. The treatment is the same as in ordinary orchitis, the disease usually yielding in a few days. 16. Explosion of Pre-existing Disease.—Stone, as is well known, fre- quently co-exists with other diseases, which, whether latent or open, often acquire new intensity on the removal of the vesical irritation. The organs most likely to suffer in this manner are the kidneys, bowels, brain, heart, and lungs. After-treatment.—As soon as the stone has been extracted, the bladder washed out, and the bleeding arrested, the patient is carried to his bed, always properly arranged beforehand. It should be provided with slats, and a cotton, moss, or hair mattress, covered with a sheet, over which is spread a large piece of soft oil-cloth. Another sheet, called the draw-sheet, folded several times, and arranged so as to make the middle of it correspond with the buttocks, is placed upon the top of the oil-cloth, and serves to ward off pressure, as well as to receive the secretions as they flow from the wound. The head and shoulders should be slightly elevated by a pillow. My experience shows that it matters little, if any, what posture the patient assumes after he has been put to bed. I usually, however, request him to lie on his right side for the first five or six hours, to afford the lips of the wound an opportunity of becoming glazed with lymph before he is obliged to urinate. At the end of this period, and, indeed, often much earlier, I permit him to rest upon his back, or upon either side, as may be most agreeable. Young subjects, unless they are incessantly watched, seldom remain in the same posture beyond a few minutes, and I have never seen a case in which any detriment resulted from this source. It is equally unnecessary, in ray judgment, to tie the patient's kuees LITHOTOMY — AFTER-TREATMENT — STATISTICS. 795 together after the operation ; or to introduce a tube into the bladder by the wound, to conduct off the urine, with a view, as is alleged, of preventing infiltration of the surrounding cellular tissue. The expedient can never be required, except in those cases in which the incisions are unusually extensive. The urine sometimes begins to flow by the wound in a few minutes after the operation; but, in general, very little, if any, passes for the first three or four hours. It then usually comes away in a gush, attended with pain and spasm of the neck of the bladder. By the end of the first day, the edges of the wound are generally so much swollen that the urine ceases to issue through the perineum, and takes the course of the urethra. This, however, rarely continues beyond twenty-four or thirty-six hours, when the tumefaction has usually so far subsided as to allow the fluid to resume its original direc- tion. The period at which it begins to pass off permanently by the urethra varies from ten to fourteen days. The change in the direction of the fluid is < generally attended with more or less pain at the neck of the bladder, and a scalding, smarting, or burning sensation in the urethra and head of the penis. The treatment after the operation must be strictly antiphlogistic' The patient is kept quietly in the recumbent position, and all excitement, both bodily and mental, is sedulously guarded against. The pain consequent upon the operation is often extremely severe. It generally makes its appearance as soon as the patient wakes from the effects of the chloroform, and should be promptly met by a full dose of morphia. Demulcent drinks should be used freely throughout the treatment, espe- cially during the first few days. They serve both to allay thirst and to dilute the urine. They may be simple, or combined with nitrate of potassa, bicar- bonate of soda, or dilute nitric acid, according to the particular indications of the case. The diet must be light, unirritant, and of the most simple kind. For the first few days the patient should take little else than panada, gruel, chicken broth, or milk and bread. After that he may use a little rice, toast and tea, a few crackers, or a small quantity of mush and milk. No meat or vegetables should be permitted under five or six days, unless he is decidedly weak. In all cases, it is a rule with me to prevent any action of the bowels for , the first three days, and, in order to accomplish this object, I invariably give a full anodyne immediately after the operation. At the end of this time, a dose of castor oil or Epsom salts is generally ordered, assisted, if necessary, by an enema. Every possible attention should be paid to the cleanliness and comfort of the patient. Excoriation should be prevented; and the scrotum must be kept out of the way of the wound by a suspensory bandage. If the edges of the wound should become covered with the earthy phos- phates, the best remedy is the nitric acid lotion, in the proportion of about four drops to the ounce of water, applied by means of a folded cloth. When the incrustation extends far back, the fluid may be daily injected into the bladder. In raost cases the local application should be aided by the internal exhibition of the remedy. When the wound is tardy in healing, or has con- tracted to a mere orifice, a catheter ought to be permanently retained in the bladder, to conduct off the urine through the natural channel. The wound made in this operation occasionally unites by the first inten- tion; but such an event, desirable as it certainly is, is rarely to be expected under any circumstances. I do not recollect a solitary instance among my own operations, in which the parts were seriously bruised in the extraction of the calculus, or unduly divided in making my deep incisions; and yet I have never had a case of union by the first intention, properly so called. Statistics—Of 895 cases of the lateral operation of lithotomy in the prac- tice, chiefly private, of American surgeons, 851 were cured, aud 44 died, 796 DISEASES AND INJURIES OF THE URINARY ORGANS. making a proportion of 1 death in 20^. In 426 of these the gorget was used, and in 424 the knife, with a mortality for the former of 1 in 23T7ff, and for the latter, of 1 in 19T4T. Of 1,596 cases of the lateral operation in the private and hospital practice of European surgeons, 1,464 were cured, and 132 died, making a proportion of 1 in 12TV Cheselden lost 20 cases out of 213 ; Martineau, 2 out of 84; Kern, 31 out of 334; Liston, 16 out of 115 ; Brett, 7 out of 108; Vericel, 9 out of 109; Chrichton, 14 out of 200 ; Pollak, 7 out of 121; and Dr. Dudley, who has operated exclusively with the gorget, 6 out of 207. I have myself operated with the knife upon 72 cases, with a loss of 4. The circumstances which tend to influence the results of the lateral—as, indeed, of every other operation of lithotomy—are exceedingly numerous and . diversified in their character, and are worthy of profound consideration. The most iraportant of these circumstances are referable, 1st, to the skill of the surgeon; 2dly, the preparation, age, and health of the patient; 3dly, the nature, volume, and situation of the concretion; and, 4thly, the selection of our cases. Relapse.—When it is considered that most vesical concretions have their origin in the kidneys, or, at all events, that these organs are often cotempo- raneously affected, it is not surprising that the disease should occasionally return after operation. What number of cases relapse after being lithoto- mized, is a point for the determination of which we have no positive data. There is no doubt that it is greatly influenced by the nature of the calculous diathesis, and I think it is safe to affirm that persons affected with phosphatic calculi are more prone to suffer a second, and even a third time, than those affected with lithic concretions, or concretions composed of urate of ammonia. Diseases of the urinary organs, or of the digestive apparatus, may be men- tioned as predisposing causes of relapse. Indeed, whatever has a tendency to disorder the general health, will be likely to promote the recurrence of the malady. Injuries of the spine, unless promptly relieved, will almost be sure to be succeeded by relapse. The period at which relapse occurs must, of course, depend upon circum- stances. Occasionally, it is very short; and, on the other hand, a number of months, and even years, may intervene. As a general rule, the phosphatic and amraoniaco-magnesian calculi are more rapidly reproduced than the lithic and oxalic. Varieties in the Lateral Operation.—The operation described in the pre- ceding pages is executed, as has been seen, with the knife, and nothing could possibly be more simple. It is the very perfection of lithotomy. Neverthe- less, there are some surgeons who prefer the use of the gorget, the lithotome cache, or the beaked knife. The operation with the gorget does not differ, in its early stages, from that with the knife. The period for using the instrument is immediately after the incision of the membranous portion of the urethra, The surgeon then ex- changes the scalpel for the gorget, the beak of which is placed in the groove of the staff, guided by the point of the left index-finger. After assuring himself, by drawing the instrument slightly backwards and forwards, that it is in no danger of slipping, he takes hold of the handle of the staff, and, by a simultaneous movement of his hands, he lowers the instrument and the gorget nearly to a level with the abdomen; pushing, at the same time, the latter onward into the bladder. In executing this part of the operation, care should be taken not only that the gorget does not slip out of its place, and thus pass between the rectum and the bladder, but that it is properly lateralized, otherwise there will be great risk of injury to the rectum and the LITHOTOMY—BILATERAL OPERATION. 797 pndic artery. The annexed engraving, fig. 499, represents the gorget as modified and improved by Physick and Gibson. Instead of the gorget, some lithotomists employ a beaked knife, or a probe- pointed bistoury, for dividing the neck of the Fig. 499. bladder and the prostate gland. The instrument FiS- 50°- may be either straight, or somewhat concave on its cutting edge. The one which I generally use, if I use any of the kind at all, is represented at page 785. The single lithotome, invented, I believe, by Frere Come, is seldom employed at the present day. The annexed cut, fig. 500, represents the instrument, as modified and improved by Char- rtere. It will be observed that it has a single blade, moved by a spring, and concealed in a kind of a rod, fixed in a stout handle, and sur- mounted by a beak, to enable it to slide the more easily and securely in the groove of the staff. The extent to which the blade may be opened is regulated by means of a screw attached to the spring. The external incisions having been made in the ordinary manner, and the membranous portion of the urethra being fully exposed, the beak of the lithotome is inserted into the groove of the staff, and passed on into the bladder. The blade is then expanded to the requisite degree, and the division of the deep structures effected in with- drawing the instrument, its edge being directed obliquely downwards and outwards, in the long axis of the prostate gland. Bilateral Operation. — The merit of devising this operation is usually ascribed to Celsus, though it more probably belongs to Le Dran. Its advan- tages have been prominently set forth in modern times by Chaussier, Beclard, and Dupuytren, the latter of whom, having first performed it in 1824, gorget. may be said to have regularized and perfected it. If the bilateral section possesses any advantages over the ordinary method, it must be on the ground of its affording a larger opening for the passage of the foreign body, and that it is attended with less danger to the rectum and the seminal ducts. But even of these the former is, in great degree, counterbalanced by the modern method of dividing the right lobe of the prostate, if the wound in the left be found insufficient for the extraction of Single lithotome. Fig. 501. Double lithotome. the calculus. The operation has sometimes been performed instead of the lateral, on account of difficulty occasioned by malposition of the thigh. It 798 DISEASES AND INJURIES OF THE URINARY ORGANS. requires the same preliminary measures as the other method. The incisions through the perineum, as far as the groove of the staff, are executed with an ordinary scalpel, and the prostate is divided with a double lithotome cache seen in fig. 501, a narrow knife, or a probe-pointed bistoury, according to the fancy of the surgeon. The operation consists in making a semilunar incision across the perineum beginning on the right side, midway between the tuberosity of the ischium and the margin of the anus, but a little nearer the former than the latter, and terminating at the corresponding point of the opposite side, as seen in fig. 502. The concavity of the cut is directed downwards, and its centre, situated Fig. 502. Bilateral operation. at the raphe of the perineum, is about nine lines above the anus. In this direction are successively divided the skin, cellulo-adipose tissue, and super- ficial fascia, together with a few of the anterior fibres of the external sphincter muscle. The end of the left fore-finger is now placed in the bottom of the wound, just as in the ordinary procedure, the staff sought, and the membran- ous portion of the urethra laid open, by an incision not exceeding four lines. The nail of the finger is then applied to the staff, to serve as a guide to the lithotome, the beak of which is next inserted into the groove of the instru- ment, with its concavity upwards. Taking care, by moving the lithotome several times forwards and backwards, that it is securely lodged in the groove, the surgeon seizes the handle of the staff, and depresses it nearly to a level with the abdomen, at the same time that he lowers the lithotome, and pushes it onward into the bladder. As soon as the instrument has reached the vis- cus it is turned round with its concavity towards the rectum, and while it is in this position it is withdrawn, its blades being expanded by pressing their springs. In this manner it cuts its way out, slowly and steadily, dividing in its retrograde course the sides of the prostate, in a direction obliquely down- wards and outwards, as in the ordinary section. The finger now takes the place of the instrument, the situation of the stone is ascertained, the forceps are introduced, and extraction is effected in the usual manner. No statistics have yet been furnished, on an enlarged and reliable scale, of the results of the bilateral operation. In the posthumous work of Dupuytren, who introduced this method into France, and who imparted to it much of its present perfection, is a table comprising 89 cases, of which 19 terminated LITHOTOMY — MEDIO-LATERAL PROCESS. 799 fatally, making an average mortality of 1 in 4}§. It is proper to add that four of these cases occurred in females, who all recovered. Of 118 cases of this operation by American surgeons, as Mussey, Spencer, Eve, Stevens, Willard Parker, and others, 105 recovered, and 13 died, show- ing a mortality in the proportion of 1 to 9TV If, to these cases, we add those of Dupuytren, we shall have an aggregate of 207 cases, with 32 deaths, or a loss of 1 in 6^|. Median Operation.—Attention has recently been directed to this operation bv Professor Rizzoli, of Italy, who, at the date of his publication, had per- formed it eight times, and in every instance successfully. As the name indi- cates, it consists in opening the bladder at the raphe of the perineum, which, as a preliminary step, is rendered as prominent as possible by means of a curved staff. It is not difficult to conceive that this operation might answer admirably in cases of small calculi, while it might be very objectionable in large ones, on account of the inadequacy of the wound made by it. It certainly pos- sesses the advantages of freedom from hemorrhage and from injury to the rectum and seminal vesicles. Medio-Lateral Process.—Professor Buchanan, of Glasgow, proposed, some years ago, to enter the bladder along the median line by means of a rectangular staff, with the groove on the left side, and a straight, narrow knife, with a long edge, shaped at the point like a scalpel, but fitted to stab as well as to cut. The staff being introduced into the bladder, is moved backwards and forwards, over the left index-finger in the rectum, until the prominent angle is distinctly perceived in the perineum, at the anterior verge of the anus, or at that portion of the raphe where the skin and mucous membrane are insen- sibly blended with each other. The instrument is now confided to an assistant, with a request to maintain it firmly in its position, with the handle inclined towards the abdomen. The surgeon, holding the knife horizontally with the edge turned towards the left side, as in fig. 503, penetrates the skin and other tissues of the perineum until the point is partly in the groove of the staff, when he con- ducts it directly onward until it reaches the bladder, a circum- stance which is always indicated by the escape of a few drops of urine. Withdrawing the knife from this position, he now carries it obliquely downwards and out- wards, for three-quarters of an inch, in the direction of the fore- part of the tuberosity of the ischium, and then finishes by Lithotomy with the rectangular staff. cutting, for three-eighths of an inch, almost vertically downwards. If the wound is not sufficiently large to admit of the easy extraction of the calculus, it may afterwards be enlarged to any desired extent. The advantages which Dr. Buchanan claims for this operation are, 1st, that it is more easily and rapidly executed than the ordinary lateral one; 2dly, that it is less severe, because of the less extensive division of the parts; and, 3dly, that it is not attended with so much risk of hemorrhage, of injury to the rec- tum, and of urinary infiltration. It appears from recent statistics that, of 52 operations for stone, performed according to this method, by Dr. Buchanan 800 DISEASES AND INJURIES OF THE URINARY ORGANS. and Dr. Lawrie, in the Glasgow Infirmary, 47 recovered, and 5 died, thus showing a mortality in the proportion of 1 to 10.4. Lithectasy.—Perineal lithotomy is occasionally combined with dilatation a process constituting what may be denominated lithectasy, the object being to make a small opening in the first instance, which may afterwards, if necessary, be increased by pressure. The operation was originally suggested by Man- zoni, of Yerona, early in the present century, and has recently been warmly advocated by Dr. de Borsa, who seems to prefer it to every other expedient, on the ground of its freedom from hemorrhage and urinary infiltration, as well as the rapidity with which it raay be executed, a single minute usually sufficing for its completion. The only instruments required are a staff, a bistoury, and a pair of forceps. Having made an incision through the raphe of the perineum, de Borsa opens the whole of the membranous portion of the urethra, so as to expose the staff to the extent of about ten lines; when, lay- ing aside his knife, he at once passes the left index-finger into the blacdder, along the right side of the instrument, and then, by a semi-rotatory movement of the member, gently and cautiously conducted, he dilates the prostatic por- tion of the tube and the neck of the bladder sufficiently to enable him to introduce the forceps and extract the calculus. The operation is, of course, applicable only to small calculi. A modification of this operation has, within the last few years, been prac- tised by Mr. Allarton, of England. It consists in making an incision, with a long, straight bistoury, directly through the raphe of the perineum, about six lines above the verge of the anus, down upon a curved staff with a central groove, the instrument being previously hooked against the pubic symphysis, and well steadied by the left index-finger in the rectum. The knife, after having reached the staff, is carried a little towards the bladder, but not into it, when it is withdrawn, enlarging, as it retraces its steps, the external open- ing towards the scrotum, so as to make it altogether from an inch to an inch and a half in length. The operator then, inserting into the bladder a probe i surmounted with a bulb, removes the staff, and expands the wound with the i forefinger of the right hand. If the stone be small, it will now probably fall I into the wound, and be forced down by the patient as he strains. Should I this fail, the finger is again used, its size being increased by the addition of F an India-rubber stall, until the dilatation has been carried to the required I extent. If the calculus be rather large, it may be crushed. Redo-Vesical Operation.—The recto-vesical operation, as devised in 1816 i by Sanson, of Paris, is already obsolete. It consists, as the name implies, in cutting into the bladder through the rectum, perineum, and prostate gland. It has been abandoned on account, chiefly, of its liability to be followed by extensive suppuration of the cellular tissue within the pelvis, injury of the i ejaculatory ducts and seminal vesicles, and, lastly, though not least, stercora- ceous fistule, difficult, if not impossible, of cure. A modification of this operation was successfully performed upon a man, aged twenty-six, in 1859, by Dr. Louis Bauer, of Brooklyn, by opening the i rectum just above the prostate, the tube having been previously expanded with a duck-bill speculum. The calculus, weighing an ounce and a half, was i extracted with some difficulty. The wound was accurately closed with five silver sutures, which were removed on the eighth day, the union being per- fect. In a case operated upon, in 1860, by Dr. Noyes, the wound, made through the central portion of the prostate, and enlarged bilaterally, was closed with six metallic sutures, supported by a leaden button. The apparatus was re- moved on the twelfth day, the parts being entirely healed, except at one little i point, which afterwards cicatrized under the application of nitrate of silver. Supra-Pubic Operation.—In the supra-pubic, hypogastric, or high opera- LITHOTOMY — SUPRA-PUBIC OPERATION. 801 tion, the bladder is opened above the pubes, in the direction of the linea alba. Its chief advantages are, that it is free from hemorrhage; that it does not expose the patient to injury of the rectum and the ejaculatory ducts; that there is no risk frora inflammation of the neck of the bladder; that it may be performed where the lateral section is impracticable; and, lastly, that it admits of the more easy reraoval of a large, attached, or encysted calculus. As an offset to these advantages, it is to be remarked that the procedure is liable to be followed by injury of the peritoneum, and by urinary infiltration, not to say anything of the difficulty of executing it when the abdomen is loaded with fat, or the bladder does not ascend any distance above the pubes. The latter of these dangers may, however, in general, be avoided by premising a perineal puncture, to serve as an outlet to the urine, which thus drains off as fast as it reaches the neck of the bladder. The former, too, may usually be guarded against, if the precaution be used, first, to distend the bladder thoroughly before the operation, and, secondly, to push the peritoneum gently before the knife, after cutting through the inferior part of the linea alba. In performing the operation, the patient is placed recumbent upon a nar- row table, with the legs hanging loosely over its lower edge, and the feet rest- ing upon a high chair. The head and shoulders are somewhat elevated, to relax the abdominal muscles. The bladder, if not previously distended by its own contents, is now filled with tepid water until it rises a considerable distance above the pubes. The surgeon, standing on the left side of the patient, makes an incision from three and a half to four inches in length, com- mencing at the pubic symphysis, and extending upwards towards the umbili- cus, in the direction of the linea alba. It should pass through the skin and cellulo-adipose substance, down to the aponeurosis of the abdominal muscles. These structures, being thus exposed, are next cautiously divided to the same extent, any bleeding vessels being at once secured. The bladder will be found at the bottom of the wound, forming a tolerably large, fluctuating tumor, invested merely by a thin layer of cellular tissue. To divide this, a few gentle touches of the knife are sufficient; or, what is better and more safe, the dissection may be effected with the steel end of the handle of the instrument. If the bladder is not sufficiently prominent, it should be rendered so by the introduction of a sound through the urethra, In either case, it is a raatter of paramount importance to secure the organ with a tenaculum before it is incised, in order to prevent it from collapsing, and so sinking down behind the pubic bones ; an occurrence which could not fail greatly to embarrass the subsequent steps of the operation. A puncture is next made into the anterior surface of the viscus, on a level with the pubic symphysis, large enough to admit the index-finger of the left hand, which is at once inserted, and used as a searcher, to ascertain the situation and volume of the stone. The opening is afterwards enlarged, with a probe-pointed bis- toury, to any extent that may be required; the forceps are introduced, and the stone is seized and removed. A short silver tube, carefully rounded at the end, and pierced with numerous apertures at the sides, is now conveyed into the bladder, at the lower part of the wound, and secured by two pieces of tape fastened to a broad roller, the edges of the remainder of the wound being previously approximated by several points of the twisted suture, aided by adhesive strips. Instead of the above procedure, which is often attended with much incon- venience and risk, the best plan is to close the wound in the bladder accu- rately by suture, introduced in such a manner as not to interfere materially with the serous investment of the organ. The operation, which was first performed by Professor Bruns, of Tubingen, ought, in ray judgment, to super- sede the ordinary and more hazardous procedure. The most reliable statistics of the supra-pubic operation are those given VOL. II.—51 802 DISEASES AND INJURIES OF THE URINARY ORGANS. in my Treatise on the Urinary Organs, comprising 180 cases, of which 39 proved fatal, or 1 in 4|. The principal causes of death were peritonitis and urinary infiltration. Frore Come lost 19 cases out of 100, and Souber- bielle 11 out of 39. Mr. Humphry, of England, lately collated the particu- lars of 104 cases of this operation, of which 31 proved fatal, or 1 in 3^. GENERAL RESULTS OF THE DIFFERENT METHODS OF LITHOTOMY. The following table presents the general results of the more important ope- rations described in the preceding pages. Methods. Cases. Cures. Deaths. Proportion of deaths. Lateral operation . Bilateral method • Recto-vesical section Supra-pubic operation . 5418 207 83 180 4829 175 67 141 589 32 16 39 Iin9i 1 in 6J| lia5 ft 1 in 4ft Total . 5888 5212 676 1 in 8} STONE IN THE BLADDER OF THE FEMALE. Women are much less liable to urinary calculi than men. The period of life at which they are most prone to suffer is from the twentieth to the fiftieth year. The symptoms which attend the affection, and the effects occasioned by it, are similar to those which characterize it in the other sex. Stone in the female forms more frequently than in the male upon foreign bodies, either developed there or F1S- 504< introduced frora without. Dr. James Morton, of Scotland, has published the particulars of a case in which he removed, by the la- teral operation, from a woman forty-seven years of age, three calculi and a bone, evidently se- quelae of an extra-uterine con- ception. In sounding, the patient is placed upon her back, on the edge of the bed; and the instrument, a short steel rod, slightly curved at the extremity, is carried about through the interior of the blad- der, so as to explore, if necessary, every recess of this organ. In young children, the finger may, if deemed advisable, be inserted into the rectum; but in grown subjects it is best always to introduce it into the vagina. Quite a number of cases are upon record in which calculi of large size have been expelled spontaneously from the female bladder. The extrusion is sometimes effected suddenly, but, in general, it is accomplished slowly, and with more or less pain and difficulty in voiding the Urethral dilator. STONE IN THE BLADDER OF THE FEMALE. 803 urine. Dr. AV alter F. Atlee, of this city, recently showed me a rough, ovoidal calculus, three-quarters of an inch in its smallest diameter, voided by a woman forty-five years of age, after it had been detained in the urethra for four hours. A little effort with the finger was necessary to complete the extrusion. Slight incontinence of urine followed, but disappeared in a very short time. The common plans of operation, for removal of stone from the female bladder, are dilatation of the urethra, crushing, and incision. The method by dilatation is liable to be followed by incontinence of urine, in consequence of which it has of late years fallen very much into disrepute. It is more particularly adapted to small concretions, unaccompanied by any serious disease of the urethra and the neck of the bladder. The dilatation may be effected slowly or rapidly, by means of instruments especially contrived for the purpose, as the one sketched at fig. 504, or by sponge tents, bougies, or catheters. I commonly use the latter, especially at the beginning, and one of gum is preferable to one of silver. When the stone is small, the necessary dilatation may be effected in a few hours, or, at all events, in a few days. Crushing may be employed when the stone is comparatively soft, and yet so large as to render it impossible to extract it without undue dilatation of the urethra. The object may be effected either with a small pair of lithotomy forceps, rather narrower than common in the blades, or with any of the ordi- nary lithotriptors. The operation of lithotomy is easy of execution, perfectly free from danger of hemorrhage, and not liable to be followed by incontinence of urine. The only instruments which are required for its performance are a straight staff, five inches in length, and a straight probe-pointed bistoury. The staff, fig. 505, being introduced, an incision is made directly upwards towards the Fig. 505. Female staff. pubic symphysis, extending through the urethra and the neck of the bladder, in their entire length. The opening may afterwards, if necessary, be dilated with the finger to almost any extent that may be required for the safe and easy extraction of the calculus. When the concretion, however, is of unusual magnitude, and cannot be thus removed, the incision may be extended down- wards and outwards towards the tuberosity of the ischium. A modification of the above operation, consisting of dilatation and incision, may sometimes be advantageously employed. After dilatation has been practised to a sufficient extent to admit the index-finger, the tube is divided in one half of its length, either anteriorly or posteriorly, according to the judgment of the surgeon. The great object of this procedure is to prevent incontinence of urine. Some surgeons prefer to extract the stone through an incision in the ante- rior wall of the vagina, constituting what is called vaginal lithotomy. The operation is extremely easy of execution, but, inasmuch as it is liable to be followed by fistule, it cannot be too pointedly condemned. Should the neces- sities of the case render such interference indispensable on account of the large 8ize of the calculus, or the presence of disease in the vulva, the edges of the ffound should immediately be approximated by wire sutures. 804 DISEASES AND INJURIES OF THE URINARY ORGANS. FOREIGN BODIES IN THE BLADDER. Fig. 506. Fig. 507. The foreign bodies that may find their way into the bladder are too diversified in their character to admit of any very precise enumeration. The most common, however, as well as the most important, are balls, pins needles, fragments of bone, pieces of straw, or other vegetable substances and bits of catheters and bougies. Such bodies may be introduced into the bladder either accidentally, or, they may be thrust up designedly, but with no intention of leaving them in this unfortunate situation. However this may be, the effects upon the foreign substance and the bladder are gene- rally similar, or, at any rate, if they differ at all, they differ only in a very slight degree. The extraneous body usually becomes in- crusted in a very short time with earthy mat- ter, sometimes attaining a large bulk in a few months. Foreign bodies, introduced into the bladder, occasionally perforate its wall, and, escaping into the peritoneal cavity, excite fatal inflam- mation. The occurrence of such an event will, of course, depend upon the form and consist- ence of the foreign substance. The extraneous body, if small, may be ex- pelled spontaneously; but, generally speaking, it must be extracted by operation. A bullet of ordinary size might be removed simply by dilating the urethra; or, this failing, by Cooper's forceps. When the foreign body refuses to come away of its own accord, or the forceps are unavailing, relief must be attempted by the lateral operation. Many cases are upon record, where bits of gum-elastic catheters and bougies were ex- tracted from the bladder by means of the for- ceps, an excellent pair of which is represented in figs. 506 and 507. When the foreign body is a pin or a needle, it may sometimes be en- trapped by the eye of a catheter, as in the memorable case of La Motte. SECT. II.—DISEASES AND INJURIES OF THE URETHRA. MALFORMATIONS. tract- f • b d- ^e aret^ra ]s naMe to a variety of mal- FCePS 0froemthebLd0err!gn formations, which, though exceedingly rare, ought, nevertheless, to be well understood, on account of their great practical importance, and the sad effects which they exert upon the happiness of the poor sufferer. The most common of these congenital vices are, first, closure or contraction of the meatus; and, secondly, absence, contraction, and change of form of the urethra. The external orifice of the urethra occasionally deviates from its normal MALFORMATIONS OF THE URETHRA. 805 Epispadias. situation, lying much higher up or lower down than usual; and there are cases where it is either extremely small, or altogether occluded, thus inter- fering more or less completely with the passage of the urine. I have seen several instances of double meatus, in neither of which, however, raore than one opened into the urethra, the other ending in a blind pouch. The urethra may be absent, as is exemplified in extrophy of the bladder, in which both the urine and semen are discharged above the pubes. Authors have described what they call a double urethra, but of such a malformation no well authenticated case has ever been re- ported. Sometimes the canal is bifid or cleft, Fig. 508. forming a kind of gutter, running along the dorsal surface of the penis, and constituting what is denominated epispadias, represented in fig. 508. Occasionally, again, it is deficient in front, but well formed behind, terminating, how- ever, always in a narrow orifice, admitting of an imperfect discharge of the urine. It is to this variety of malformation that the term hypospa- dias has been applied. Some of these defects are, of course, irreme- diable ; others, however, admit of relief, though generally not without great difficulty. Occlusion of the external meatus always de- mands prompt interference. When it is caused simply by a duplicature of the lining membrane, forming a sort of hymen, a vertical incision in the direction of the natural outlet is generally all that is required; the edges of the wound being kept asunder by means of a bougie. When the imperforation depends upon the presence of fibrous tissue, and reaches a considerable distance back, the operation will be raore serious, and will require to be performed with a trocar. Hypospadias and epispadias are defects of a serious character, which, be- sides greatly inconveniencing their unhappy subjects, often serve as causes of impotence. Hypospadias presents itself under three varieties of form, of which the most common, as well as the most simple, is the one in which the urethra opens just behind the frenum. In the second, the tube opens at some point intermediate between the first and the scrotum ; and in the third, the urethra terminates at the latter organ, which is cleft at the middle line. In the more simple variety of hypospadias, a cure may be attempted by paring the edges of the fissure and uniting them by means of interrupted sutures over a catheter introduced into the bladder. Any part that may re- main unclosed may be touched with nitrate of silver. The same mode of proceeding is adopted when the fissure exists further back, only that it will be necessary, in addition, to establish an artificial urethra by means of a trocar, pushed in the direction of the natural channel. The canal is kept pervious by a catheter, until it has received a mucous lining, after which the instrument should be worn a few hours every day for a number of months. The treatment for epispadias is conducted upon the same principles as that •or the different varieties of hypospadias just described. In a case treated by Mr. Liston, in which nearly four inches of the urethra were exposed, a complete cure was effected in a few days. The operation consisted in paring the edges of the cleft thoroughly, and putting them together over a catheter, °y means of many points of the twisted suture. Union by the first intention S06 DISEASES AND INJURIES OF THE URINARY ORGANS. took place in the entire track, except near the pubes, where a very minute fistulous opening remained, through which not more than a drop of urine oozed during micturition. This was afterwards closed with a heated needle. The organ was, in all respects, and for all purposes, as perfect as could be desired. LACERATION. The urethra is liable to laceration by causes acting either from without, or from within. Under the first head may be comprised falls, blows, and kicks upon the perineum, or the perineum and penis ; under the second, injury done by the lodgment of a calculus, and the rude, forcible, or injudicious use of catheters, bougies, and sounds. Laceration of this canal occasionally takes place under a violent erection especially if the penis, while in this condition, happens to be struck accident- ally against a hard, resisting body. The accident has also been known to occur during convalescence, after attacks of fever. The rent may be limited to the mucous membrane, or it may involve along with it all the tissues which intervene between the canal and the external surface. The symptoms of this affection are generally sufficiently characteristic. The most prominent are, pain in the affected part, hemorrhage, inability to void the urine, or the discharge of this fluid in a small and imperfect manner, dis- coloration of the perineum, or of the perineum, scrotum, and penis, and great difficulty, if not utter impossibility, of introducing the catheter. The patient is weak and faint, perhaps sick at the stomach, and labors under all the effects of a severe shock. The treatment of this accident raust be prompt and decisive, as there is great danger of infiltration of the cellular tissue of the perineum and scro- tum, from the escape of the urine. If the rent be small, the first thing to be done is to pass a catheter into the bladder, one being selected that is rather over than under the ordinary size. If, on the contrary, the injury is very ex- tensive, or, if some hours have elapsed since its occurrence, and the symp- toms indicate urinary infiltration, no time is to be lost in making numerous and deep incisions into the affected parts. In conjunction with this treat- ment, local bleeding, purgatives, the warm bath, anodynes, fomentations, and poultices may be advantageously employed. HEMORRHAGE. Hemorrhage of the urethra, although uncommon, is always alarming to the patient, and often a source of much embarrassment to the practitioner. It may present itself under two varieties of form, the spontaneous aud trau- matic, of which the latter is the more frequent. Spontaneous hemorrhage is met with chiefly in elderly and middle-aged persons, who have led a life of irregularity and debauch. It occasionally occurs during a violent erection of the penis. Traumatic hemorrhage, on the contrary, usually depends upon direct violence, as, for instance, that caused by the passage of a urinary concretion, the introduction of instruments, or attempts to force a stricture. It is a very common consequence of injury of the perineum. The bleeding, however induced, is seldom copious. Hemorrhage of the urethra rarely requires surgical interference; in most cases it either ceases spontaneously, or it is easily arrested by repose in the horizontal position upon a hair mattress, by iced drinks, and by pressure, for a few minutes, upon the perineum, directly opposite to the part from which the blood proceeds. A cold enema sometimes puts a sudden stop to it. Cold and astringent injections into the urethra, thrown high up, are also FOREIGN BODIES IN THE URETHRA. 807 beneficial. When the case is obstinate, compression may be made by means of a large catheter, introduced into the bladder, and supported with the bandage, the finger, or adhesive strips. The most efficient internal remedies are gallic acid and subacetate of lead, in combination with opium. Alum, given in large doses, is also useful. In very obstinate cases, recourse may be had to spirits of turpentine and the tincture of the chloride of iron, in doses often drops each, repeated every hour. FOREIGN BODIES. Foreign bodies in the urethra may, as to the sources from which they are derived, be arranged under two heads: 1st, foreign bodies which descend from the urinary bladder, or which are developed in the canal itself; and, 2dly, substances forced into the urethra through its natural orifice. I. Foreign Bodies which descend from the Bladder, or are developed in the Urethra.—Most of the foreign bodies which descend into the urethra from the bladder, are simply earthy concretions, which are developed either in the latter organ, in the prostate gland, or in the kidneys. Sometimes, however, they consist of articles which were originally admitted through the urethra, and which have afterwards, in consequence of the force impressed upon them by the bladder in micturition, taken a retrograde course. The concretion may be developed in the urethra itself, but this is rare. The passage of a calculus from the bladder along the urethra is frequently productive of great inconvenience and distress. The intromission is gene- rally suddeu and unexpected, taking place while the patient is engaged in micturition. It is instantly followed by an interruption of the stream of urine, an urgent desire to empty the bladder, severe straining, more or less pain, and a sense of burning or tearing in the urethra. If the substance is small, it may be expelled in a few minutes; if, on the contrary, it is dispro- portionately bulky, it raay be permanently arrested, and give rise to severe suffering, accompanied by retention of urine, painful erections, and probably, also, by slight hemorrhage from laceration of the mucous membrane. The symptoms which attend the passage of a calculus along the urethra may be simulated by those produced by other causes; therefore, to establish the diagnosis it is necessary to institute a careful examination with the finger and the catheter. When the substance is situated far back, as in the mem- branous or prostatic portion of the urethra, the exploration must be conducted with the finger in the rectum. In using the catheter, care should be taken that the substance be not pushed back into the bladder. It is worthy of remark that, when the calculus has escaped from the urethra and lodged in the subjacent structures, the instrument may fail to detect it, even when it is of large size. A calculus, after having remained in the urethra for an indefinite period, sometimes effects its own expulsion by exciting absorption, and, finally, ulcera- tion of the surrounding tissues. When the foreign body is lodged in the posterior portion of the tube, and is obstructing the flow of urine, the safest plan is to push it back into the bladder; whereas, if it is comparatively small, or unusually rough, it should be removed. Before doing this, however, an attempt should be made to favor its expulsion by dilating the urethra. Occasionally extrusion may be effected by injections of sweet oil, or by closing the prepuce, and holding it tightly while the patient is making a powerful effort at micturition, at the same time that pressure is applied along the under surface of the urethra, to urge on the foreign body. When the calculus occupies the spongy portion of the tube, it ought to be extracted, whatever may be its size or form, provided it cannot be extruded 808 DISEASES AND INJURIES OF THE URINARY ORGANS. during micturition. When it is situated near the orifice of the urethra, it may be removed by a pair of narrow-bladed dissecting forceps, but when it is lodged far back in the canal, a wire-loop, as originally suggested by Marini may be used. The only objection to this instrument is the difficulty of pass- ing it behind the concretion, which, when large enough to lodge, usually fills up the entire passage. When these simple means fail, recourse must be had to the urethral forceps, of which there is a great variety. The one to which I give the preference is the articulated scoop, fig. 509, of Bonnet, of Lyons, but it is applicable Fig. 509. ,___„ —flUfl tr\ Bonnet's articulated scoop. only to small substances. It is armed with a stylet, and is furnished with a head for seizing and fixing the foreign body. The instrument, well oiled, is introduced in contact with the concretion, when its blades are expanded over it; the extraction being effected in the raost slow and gentle manner, to pre- vent injury of the mucous membrane. Fig. 510 represents Hunter's forceps, as improved by modern surgeous, for extracting urethral calculi. Fig. 510. Hunter's forceps. Crushing is applicable only when the calculus is soft and friable; but as this can hardly ever be known beforehand, it is rarely available. The opera- tion, moreover, is seldom safe. Excision, which becomes necessary when extraction fails, varies according to the situation of the foreign body. When the concretion is lodged in the prostatic or membranous part of the tube, it is performed very much after the manner of Celsus, in cutting on the gripe, the left index-finger being inserted into the rectum, to protect the tube from harm, and a small incision being made in the direction of the raphe of the perineum. When the calculus is impacted in the navicular fossa, or even farther back, its extraction may generally be easily effected with the forceps represented in fig. 511. Or, this failing, an incision may be raade over it, along the lower part of the urethra, where this tube corresponds with the head of the penis. Fig. 511. Forceps for extracting calculi from the urethra. When the foreign body lies in that portion of the urethra which corresponds with the scrotum, incision should be practised with great caution, from the FOREIGN BODIES — MORBID SENSIBILITY OF URETHRA. 809 fact that it is liable to be followed by infiltration of urine, and all the bad consequences of this accident. In such a case, I would advise immediate cauterization of the wound with nitrate of silver, to favor the deposit of lymph, and an avoidance of micturition until the parts have become fully consolidated. Or, instead of this, an incision might be made through the skin and cellular tissue over the tumor, and the wound stuffed with lint. The requisite amount of inflammation having been excited, the operation is com- pleted by dividing the parietes of the urethra in the usual manner. 2. Foreign Bodies introduced from without.—Of foreign bodies introduced into the urethra from without, the number and variety are quite considerable. The occurrence is sometimes fortuitous, but more frequently it takes place through design. Bits of catheters, bougies, quills, pipe-stems, wood, straw, and other substances, have been accidentally lodged in the urethra, by indi- viduals endeavoring to draw off their urine, relieve a stricture, or provoke onanism. Foreign bodies, introduced into the urethra from without, have a great tendency to pass into the bladder, owing to the suction power of this organ. Very frequently, however, they become impacted in the tube, and they may then, unless they are situated very far back, be usually readily extracted with a pair of delicate forceps, such, for instance, as those represented in fig. 512. MORBID SENSIBILITY. This affection consists mainly, if not exclusively, in an exaltation of the natural sensibility of the mucous membrane of the urethra. It is quite fre- quent in both sexes, but is much more common in men than in women. It is not always easy, or even possible, to ascertain the nature of the exciting causes of this affection, so diversified are they in their character. In the male it is often dependent upon the effects of gonorrhoea and gleet, stric- ture of the urethra, and enlargement of the prostate gland; and, in both sexes, upon disorder of the bladder, the kidneys, ureters, anus, and rectum. Morbid sensibility of the urethra sometimes attends inflammation, ulceration, and other disorders of the uterus, the vagina and vulva. A morbid state of the urine may not only induce it, but maintain it for an indefinite period. Of all the causes, however, onanism and inordinate sexual indulgence are, I have reason to believe, the most common. The symptoms of this disease are subject to great diversity, both as it respects their nature and degree. In the more simple forms, there is merely an exaltation of the normal sensibility of the raucous membrane. When the affection is more fully developed, the local distress is not only more severe but often extends to the surrounding parts, as the perineum, the groin, anus, pubes and genital organs. The bladder also suffers sometimes sympatheti- cally, and at other times from a positive extension of the disease. Occasion- ally the symptoms resemble those of stone in the bladder. When the disease exists in this aggravated form, there is always marked disorder of the general health. When the posterior portion of the tube is involved, seminal emis- sions are apt to take place. The urine is variously altered in its properties; in general, it contains an undue quantity of mucus, and not unfrequently it exhibits, under the microscope, different deposits, especially oxalate of lime and phosphates. The best mode of determining the precise nature of this disorder is the introduction of the catheter. One of medium size is selected, and is passed with the greatest care and gentleness. By this means we are able to ascer- tain the extent and degree of the sensibility, and also whether there be a stricture of the urethra, enlargement of the prostate gland, or disease of the 810 DISEASES AND INJURIES OF THE URINARY ORGANS. bladder. It should be remembered that the healthy urethra is often extremely sensitive on the first introduction of a catheter. The true pathology of this disease is not accurately determined. There is no doubt that it is occasionally caused by inflammation, either subacute or chronic in its character; but very frequently it appears to be owing merely to an exaltation of the normal sensibility of the mucous membrane. In the treatment of this affection, one of the first objects should be to find and remove the exciting cause. In general, marked relief will follow the use of antiphlogistics, assisted by the exhibition of the bicarbonate of soda, either alone or in union with uva ursi and hop-tea, mild laxatives, and anodyne in- jections, with the addition of a small quantity of acetate of lead, Goulard's extract, sulphate of zinc, or nitrate of silver. The general health should be attended to. The introduction of a full-sized catheter, at first once and after- wards twice a day, will sometimes be productive of the best results. In this way, moreover, the affected surface may be directly medicated ; the dilute ointments of nitrate of mercury and belladonna are, especially if used in com- bination, entitled to the first rank in the list of this class of remedies. When there are involuntary seminal emissions, hardly anything short of cauterization of the prostatic and membranous portions of the urethra will be likely to succeed. Whatever mode of treatment be adopted, the patient should refrain from sexual indulgence and exercise on horseback. The best internal remedy, when there is no appreciable local cause for the disease, is, on the whole, the bromide of potassium, given in solution, in doses varying from eight to ten grains three times a day. It seems to act as a sedative, and to make a direct impression upon the affected parts. NEURALGIA. It is not surprising that the excretory canal of the urine should be liable to neuralgia, especially when we consider its structure and functions, and the various sources of irritation to which it is subject. The disease is most common soon after the age of puberty, in persons of a nervous excitable temperament. It is much more frequent in males than in females. Its origin is generally obscure. It raay be caused by external injury, onanism, or frequent sexual intercourse. It is sometimes dependent on a miasmatic impregnation of the system. The pain is of a sharp, pricking character, darting about in different direc- tions with the rapidity of lightning; it often remits or intermits for a few seconds, and then recurs with its former violence; it is generally attended with considerable soreness of the urethra and penis, a frequent desire to mic- turate, and scalding in voiding urine. In some cases the disease is periodical. The treatment of this affection is to be conducted upon the same principles as that of neuralgia in other parts of the body. The cause is, of course, if possible, removed, after which recourse is had to quinine, arsenic, strychnine, and aconite. When the affection is of a purely miasmatic origin, no other treatment is generally required. In the milder forms of the disease, quinine alone will often speedily effect a cure. In obstinate cases, valerianate of iron sometimes succeeds when all other remedies fail. Little is necessary in the way of local treatment. During the paroxysm, the penis may be immersed in warm water, or fomented with hot cloths impregnated with laudanum. The veratria and belladonna ointment is some- times of service. In some cases I have witnessed good effects, especially in cold weather, from making the patient constantly carry his penis in a thick flannel stall to protect it from atmospheric vicissitudes'. It need scarcely be said that all sexual intercourse should be avoided. POLYPOID TUMORS AND STRICTURE OF THE URETHRA. 811 POLYPOID TUMORS. These tumors occur in both sexes, and in different portions of the urethra. In the male, the most common site is the auterior part of the tube, just be- hind the urinary meatus. In women they are also generally situated super- ficially, sometimes projecting beyond the external orifice of the urethra. In the male, these growths are generally small, their volume rarely ex- ceeding that of an apple-seed. They are of a soft, spongy consistence, of a red color, and of a pyri- Fig- 512. forra, conical, or spherical shape, their attachment being usually by a small pedicle. In general, they are solitary, but I recollect one instance in which there were not less than three, situated close together. Their surface is sometimes perfectly smooth, at other times slightly granulated, rough, or studded with villosities. In regard to their structure, they consist of a cellular, or cellulo- vascular substance, invested by a prolongation of the lining membrane of the urethra. A good idea of this variety of morbid growth is afforded by fig. 512, from Mr. Thompson. These polypoid tumors are generally free from pain, in which respect they differ remarkably frora the vascular growths in and around the female urethra. They are usually attended by a thin, gleety discharge, but they seldom materially ob- struct micturition. Their development is tardy and insidious, and they usually manifest no dispo- sition to reappear after extirpation. When deep- Beated, they may exist for years, without the pos- p0iyp of the urethra. sibility of detection. The removal of these excrescences is best effected by excision with the knife or scissors. The surface should always be touched immediately after with nitrate of silver or sulphate of copper. STRICTURE. A stricture is a diminution of the caliber of the urethra, either of a tran- sient or permanent character. The affection, in the former case, commonly depends upon a spasmodic contraction of the tube, and is hence known by the name of spasmodic stricture; it lasts only for a short time, is paroxysmal in its nature, and often disappears as suddenly and unexpectedly as it comes on. In the latter, on the contrary, it is always caused by an effusion of lymph into the lining membrane and the subjacent cellular tissue of the urethra, where a portion of this substance remains, and ultimately becomes organized. To this form of coarctation, to which the succeeding remarks will be limited, the term organic is usually applied, and, as signifying the same thing, the word permanent is occasionally employed. Organic stricture presents itself in various forms. Thus, it may be simple or complicated, common or traumatic, partial or complete, soft or callous, dilatable or undilatable, permeable or impermeable, recent or old; terms which sufficiently explain themselves. Much diversity prevails in relation to the seat, number, form, consistence, and extent of organic strictures. No part of the urethra, except, perhaps, the prostatic, is entirely exempt 812 DISEASES AND INJURIES OF THE URINARY ORGANS. from this disease. The results of my observations lead me to infer that the affection is most common, first, in that portion of the urethra which is com- prised between the scrotum and the head of the penis ; secondly, at the mem- branous part of the tube, or at the junction of this and the bulbous part; and, lastly, at the anterior extremity within a few lines of the meatus. Stricture at the prostatic portion of the canal is altogether an imaginary occurrence. The seat of this disease has recently been very carefully examined by Mr. Henry Thompson, of London. The number of specimens inspected by him was 270, embracing 320 distinct strictures. Of these, 215, or 67 percent. of the entire number, were situated at the junction of the membranous and spongy portions and its vicinity; 51, or 16 per cent, in the centre of the spongy portion ; and 54, or 17 per cent., at the external orifice, and within two inches and a half behind this point. In 226 cases, the stricture was sin- gle, and in 185 of these, it was situated at the posterior part of the mem- branous portion, and in 24, in the anterior. In the majority of cases, there exists but one stricture; frequently, how- ever, I have seen two, and occasionally, though very rarely, three, and even four. Hunter saw an instance of six, Lallemand of seven, Colot of eight. A very common form of stricture is that in which the urethra exhibits the appearance as if a thread or piece of twine had been tied around it. It may embrace the entire circumference of the tube, as exhibited in fig. 513, or only a part of it, and varies in its antero-posterior extent from half a line, or even less, to several inches. I have seen the contraction involve nearly the whole length of the canal. Fig. 513. Fig. 514. Indurated stricture of the urethra. Bridle stricture of the urethra. A very rare form of the disease, called the bridle stricture, fig. 514, is occa- sionally met with. In this variety, the urethra is obstructed by a small, nar- row band stretched across the tube from one side to the other. Sometimes it is arranged so as to divide the passage into two parts. The contracted portion may be soft and elastic, or hard and firm, accord- ing to the duration of the disease, and the degree of transformation of the effused lymph, upon whose presence it essentially depends. Are strictures of the urethra ever impermeable? Much has been said and written upon this subject, especially of late, and it is, therefore, very import- ant that the meaning of the term should be clearly defined, and accurately understood. As long as a stricture admits of the discharge of urine, it cannot, in the true sense of the term, be considered as impermeable, although it maybe im- passable by the bougie, sound, or catheter. A stricture that is impermeable STRICTURE OF THE URETHRA--SYMPTOMS. 813 to urine is very uncommon ; nevertheless, it occasionally occurs, both in the male and female. It has been asserted that there is no stricture that is im- permeable to an instrument of some kind or other; that whenever there is room enough for the passage of urine, there is space enough for the intro- duction of a bougie or probe ; and that, when the surgeon fails to accomplish his object, his want of success is attributable rather to his own awkwardness than to the nature of the obstruction. But the fact that this kind of stricture is ignored by certain pathologists, by no means proves that it does not exist. The urethra, for example, may assume a zigzag direction, or there may be a multiplicity of coarctations, so seriously changing the natural relations of the tube as to offer an insurmount- able obstacle to the passage of the smallest instrument in the hands of the raost adroit and accomplished operator ; but I go farther, and assert, upon the testimony of personal experience, that there is a class of strictures, the result of ordinary causes, which, while they admit of the flow of urine, slowly and imperfectly it may be, do not permit the introduction of any instrument, however small, into the bladder. The symptoms of stricture, considered generally, are a diminution of the stream of urine, which is usually spiral, forked, or dribbling; frequently slow and difficult micturition, often preceded, accompanied, or followed by a sense of scalding; a discharge of thin, gleety matter from the urethra; uneasiness about the loins, perineum, and anus ; pain in coition ; nocturnal emissions ; elongation and thickening of the penis; and hardness at the seat of the ob- struction, detectible by the finger. During the progress of the disease, the patient is liable to be troubled with swelling of the testicle, chordee, hemor- rhoids, hernia, and retention or incontinence of urine. The general health is variously affected, and the slightest exposure, fatigue, intemperance, or irregularity in eating, is apt to be followed by an exacerbation of the local suffering. Although the above symptoms are, in general, sufficiently denotive of the real nature of the disease which produces them, they can, nevertheless, not be regarded as pathognomonic. To establish, in an unequivocal manner, the diagnosis in any given case, it is indispensably necessary to explore the ure- thra with some instrument. The one which I usually select for this purpose is a common silver catheter, of moderate size, and a little conical at the ex- tremity, which is passed down the tube, first to the obstruction, then into it, and lastly, if possible, beyond it. In this manner we may easily obtain an idea of the seat and extent of the stricture, as well as of its consistence. Where greater accuracy is required, I use a wax bougie, which is carried slowly down to the obstruction, upon reaching which the penis is pulled slightly forward, over it, and a mark made upon it with the thumb-nail im- mediately in front of the head of the organ. This will indicate the precise distance of the stricture from the external orifice of the urethra. I never employ the graduated bougie, represented in fig. 515, and so much used by Fig. 515. Ulceration occasionally occurs, followed by a copious dis- charge of bloody, fetid matter. Their 'structure is usually of a soft, fleshy nature, either uniformly, or interspersed with serous cysts, or masses of fibro- cartilage. The only remedy is removal with the knife or ligature. Follicular disease of the vulva. 940 DISEASES OF THE FEMALE GENITAL ORGANS The labia, nymphae, and lower part of the vagina, are sometimes the seat of varicose veins, as seen in fig. 612; the disease is most common in middle-aged Fie. 612. Varicose veins of the vulva. subjects, is usually associated with varicose enlargement of the veins in the inferior extremity, and is subject to great aggravation during pregnancy and delivery. The veins are spread out in an irregularly arborescent manner, and may be many times the natural size. The coats of the vessels may be entirely healthy, but more frequently they are diseased, being attenuated at one point, and thickened at another. In some cases the lining membrane becomes inflamed, causing coagulation of the blood, and the formation of pus. Dur- ing parturition, the enlarged veins may be ruptured by the pressure of the child's head, inducing copious, if not fatal, hemorrhage. No treatment is generally required in this disease, beyond an occasional purgative, recum- bency, and the use of cold water. Should the veins be accidentally ruptured, and the hemorrhage become serious, the bleeding vessels must be sought for, and ligated. Finally, it is not uncommon to meet with occlusion of the vulva, dependent upon adhesion of the labia, or the labia and nymphae. The occurrence is sometimes observed in very young children, indeed sometimes in infants at the breast, and is, of course, always a result of inflammation, not unfrequently caused by want of cleanliness, or the accidents of parturition. When the adhesion is slight, it is easily broken up with the probe or finger; when, how- ever, it is extensive, the knife may be required, used prudently, lest more be divided than is proper. AFFECTIONS OF THE VULVA—NYMPHS — CLITORIS. 941 2. Nymphce.—The nymphae are not often the subjects of disease, inde- pendent of that of the great lips. They are occasionally the seat of hyper- trophy or chronic enlargement, so excessive as to require excision, of encysted tumors, and of encephaloid cancer. Of the latter disease, I met with an extraordinary case, in 1842, in a little girl, five years of age, who died, exhausted, at the end of nine months from the first appear- ance of the tumor. The mor- bid growth, as seen in the annexed sketch, fig. 613, had extensively involved the lym- phatic ganglions of the groin and pelvis. The clitoris was also greatly enlarged. An encysted tumor, filled with serum, sometimes occurs in the nymphae ; generally in married females, from the twenty-fifth to the fortieth year. It is soft, fluctuating, of a rounded or ovoidal form almond to that of an orange Fig. 613. Encephaloid of the nymphae and clitoris. and of variable dimensions, from that of an The diagnosis is easily established by the ex- ploring needle. The most effectual remedy is excision, but a cure may also be effected by the seton and iodine injections. 3. Clitoris.—-The principal affection of the clitoris is hypertrophy, which occasionally amounts to such a degree as to become a source of great incon- Fig. 614. Hypertrophy of the clitoris and nymphae. venience and annoyance. In some countries this organ is naturally much larger than in America and Europe. In Persia, Turkey, and Egypt, hyper- 942 DISEASES OF THE FEMALE GENITAL ORGANS. trophy of the clitoris is often immense, the tumor thus formed perhaps equal- ling the size of an adult's head. The disease is soraetimes congenital; but generally it is caused by protracted irritation. Courtesans were formerly supposed to be particularly prone to attacks of this kind, but the researches of Parent-Duchatelet and others have shown that this is not the fact. When the growth has acquired a large bulk, the only remedy is excision. The operation is usually attended with a good deal of hemorrhage. When the disease is in its infancy, repression may be attempted with cooling and astrin- gent lotions, tincture of iodine, and other sorbefacient means. The annexed cut, fig. 614, affords a good idea of this affection. The case was associated with hypertrophy of the nymphae. 4. Urethra.—The female urethra is rarely diseased. The principal lesions to which it is liable are, stricture, dilatation, and vascular excrescences. a. Stricture is usually situated at the extremity of the tube, and may be so great as to produce much difficulty in making water. In some congenital malformations, the orifice of the urethra opens into the vagina at some dis- tance from the external aperture. Occasionally, as when the mouth of the vagina is closed up by a dense membrane, the urethra is so much dilated as to admit the male organ. These various affections must be met on general principles. b. Vascular excrescences sometimes spring from the female urethra, or are seated around its orifice, as shown in fig. 615. They are of a bright scarlet color, exquisitely sensitive under pres- Fig. 615. Vascular excrescences of the urethra sure, and of a soft, spongy, erectile structure, with a smooth, fissured, or granulated surface. Their shape is generally pear-like, and in size they vary from a small pea to that of a horse-bean. The disease has been observed in young girls under seven- teen, but is most common in adults. Its causes are unknown. The proper remedy is excision, followed by the gentle application of chromic acid. c. Many years ago I assisted my friend, Professor Willard Parker, in removing a polyp from the entrance of the urethra of a young lady of eighteen. It was of a conical shape, nearly an inch and a half in length by three-quarters of an inch in dia- meter, very sensitive, of a bright, florid color, elastic, and compressible. On maceration for a few days, it be- came perfectly white, and seemed to be composed essentially of soft, cel- lulo-fibrous substance, pervaded by Removal of such growths may be effected by liga- numerous bloodvessels ture or excision. d. Inversion and prolapse of the bladder presents itself under two distinct varieties of form, the complete and incomplete; the first consisting in an inversion of all the tunics of the bladder, while, in the second, the inversion is limited exclusively to the mucous membrane. The immediate cause of both varieties is a relaxed and weakened state of the parts, attended with dilatation of the urethra. The exciting cause is violent and frequent strain- AFFECTIONS OF THE VULVA—CATHETERISM IN FEMALE. 943 ings, such as accompany various impediraents to the evacuation of the urine and feces. Severe coughing may be mentioned as a predisponent. In the treatment of the incomplete form of inversion and prolapse, the circumstances mainly to be attended to are, first, to enjoin strict recumbency for a long time ; secondly, to reduce the tumor carefully, and to counteract afterwards any tendency to protrusion by the frequent use of the catheter, and astringent washes and injections; and, thirdly, to correct the general health by chalybeate tonics and other means. The bowels should be main- tained in a soluble condition, and the urine should be voided in the recum- bent posture, the patient lying on her side or back. Excision of the pro- truded part should be studiously avoided, as it might lead to fatal results. Of the complete variety of inversion and prolapse of the bladder, very little is known. The most important signs, in a diagnostic point of view, are, the gradual development of the tumor, its soft and fluctuating feel, and the pecu- liarity of its situation. When we add to these circumstances the fact that there are usually three distinct apertures on the surface of the tumor corre- sponding with those of the urethra and ureters ; that the tumor is easily re- duced by pressure ; that the patient is unable to retain her urine; that the part is not particularly tender, sore, or painful; and that there is not, at least not necessarily, any derangement of the general health, the practitioner can hardly fail to detect the true nature of the malady. In the reduction of the tumor, the patient is placed upon her back, the head and shoulders being elevated, and the thighs, flexed, upon the pelvis, widely separated from each other. The labia are then held apart by an assistant, while the surgeon applies his fingers, previously oiled, to the sur- face of the tumor, aud pushes up that part which came down last, the pressure being maintained steadily, but gently, until the whole of it has slipped up behind the pubic symphysis. When the swelling is bulky, and of long stand- ing, it may be necessary to assist these efforts by means of a catheter, applied to the fundus of the bladder, and carried up in the direction of the urethra. If the tumor has become irreducible, an attempt should be made to dimin- ish its volume and hardness by leeches, fomentations, and other relaxing measures. Chloroform is a valuable adjuvant during replacement. When the parts are restored, the patient should observe the recumbent posture, the urine should be drawn off frequently, and, if the protrusion be considerable, a compress, confined by a T bandage, should be worn upon the mouth of the urethra. When the patient gets up, she should wear an abdo- minal supporter. When the urethra is much dilated, an operation may become necessary. In this case, the inferior portion of the tube may be divested of its mucous membrane, after which the raw surfaces may be approximated by several points of interrupted suture, care being taken to draw off the urine several times a day, until consolidation is perfected. /. Catheterism in the female should always be performed with great deli- cacy under cover of the clothes, while the patient lies upon her Fig. 616. back, near the edge of the bed. ^^^-^. Ocular inspection can be justi- .^^b^^*^^"^^ fe-- liable only when the parts are /^'* x ^*d©~~"^Jlp^ in a state of great disease, or /^^|ti;?:^**^^ '' ^w ^ when the tube has undergone A^^L^'^T^'^^' //fj/' much change in its relative /jJrjPQ^^ 4^0^/'^m1 position. The best mode of »Jr ^J*^ ^mtmiimP1*^^*%w'l proceeding is to apply the ^Hr/ left index-finger to the upper \>' margin of the Orifice Of the jiethod of some surgeons of holding the female catheter. 944 DISEASES OF THE FEMALE GENITAL ORGANS. vagina, which thus serves as a guide to the instrument, which is placed upon its palmar surface, and then moved upwards along the middle line, until its point arrives at the dimple-shaped depression, marking the situation of the orifice of the urethra. The catheter is then passed on, with its concavity upwards, until it reaches the interior of the bladder. Or, the instrument may be held against the under surface of the right index-finger, as in h'g. 616, and pushed on as soon as its tip has discovered the meatus. The female catheter is made of silver, and is not more than five inches in length. Its vesical extremity is soraewhat bent, to adapt it to the shape of the urethra, and is perforated with numerous foramina, iustead of having eye- lets, as that of the male. The other end is provided with two rings, in order to fasten the instrument, when it is necessary to retain it in the bladder, by means of tapes, to a T bandage. It has long been known that the female catheter will occasionally slip into the bladder, being suddenly and unexpectedly drawn from the fingers of the surgeon. It is not very easy to explain the reason of this occurrence. It is, probably, owing to the contractile power of the urethra, aided by capil- lary attraction, and by the suction of the bladder. Although, in general, the female catheter is more easily withdrawn than introduced, yet occasionally the reverse is the case. This occurrence is favored by a relaxed condition of the parts, and appears to be directly de- pendent upon the introduction of a fold of mucous membrane into the eye- lets of the catheter. To avoid this contingency, as awkward as it is painful, the instrument should be provided with numerous small apertures, which will effectually prevent the intrusion of the lining membrane, however flabby. The proper remedy is the retention of the instrument until the accumulating urine forces the impacted folds into their natural situation. All attempts at forcible extraction should be avoided. SECT. V.—GONORRHOEA IN THE FEMALE. Gonorrhoea in women is a very different affection from gonorrhoea in males; in the latter, the disease is generally exclusively confined to the urethra, or it exists simultaneously in this canal and on the head of the penis. In the female, on the contrary, it usually expends its force upon the lining membrane of the vulva, vagina, and uterus, the urethra being seldom implicated to any con- siderable extent. The parts which are generally most violently inflamed are the mucous follicles around the urinary meatus, and the upper portion of the vagina. Occasionally the disease extends into the cavity of the uterus, and thence, there is reason to believe, along the Fallopian tubes and ovaries, the attack thus presenting an analogy with gonorrhoea in the male, eventuating in epididymitis. The interior of the uterus is most liable to become affected in those females in whom that organ has an uncommonly large mouth, thereby allowing the more easy entanglement and retention of the gonorrhceal virus. The occurrence is, however, under any circumstances, unusual. The time which elapses between the contamination and the outburst of the disease is generally somewhat shorter than in men, owing to the fact that the poison is brought in contact with a larger surface. The disease may be simple or com- plicated ; it is more frequently associated with chancre than in the male, and is often followed by excoriations and simple ulcers, especially of the neck of the uterus, and lower extremity of the vagina. The symptoms of the disease are essentially similar to those which charac- terize gonorrhoea in the male. The parts, at first the seat of itching and smarting, soon become hot, swollen, painful, and affected with muco-purulent discharge, often bloody, usually excessively profuse, and, at times, quite fetid GONORRHOEA IN THE FEMALE—DIAGNOSIS — TREATMENT. 945 and even acrid. The scalding in micturition is considerable, though rarely as great as in the male, and the labia, nymphae, vagina, and the neck of the uterus, are frequently covered with aphthae, fissures, and excoriations. In the more severe forms of the disease, there are a sense of weight and fulness in the lower part of the pelvis, and aching pains in the groin, thigh, and perineum. The lining membrane of these parts is of a fiery red color, and covered, here and there, with patches of lymph, of a pale yellowish hue, tough and stringy, and firmly adherent to the surface beneath. During the progress of the attack, the lymphatic ganglions in the groin are apt to suffer, becoming sore, and swollen ; and so much pain and tenderness are often experienced in walking as to compel the woman to keep her bed. Occasionally the inflamed surfaces, instead of being bathed with pus and mucus, are remarkably dry, and the distress is then often proportionately much greater. The diagnosis of gonorrhoea from other affections, especially leucorrhcea, although raost desirable, is frequently very difficult, and sometimes altogether impossible. The distinction is particularly important on account of its medico-legal relations, females laboring under discharge of the genital organs being often suspected of having gonorrhoea, when, in fact, the disease is only of an ordinary nature. In general, the difficulty may be solved by the his- tory of the case, the moral character of the woman, the nature of the dis- charge, and the presence or absence of complications. In leucorrhcea, with which the disease is most liable to be confounded, there is seldom any dis- charge from the urethra, or scalding and smarting in micturition : in gonor- rhoea, on the contrary, these two symptoms usually exist' in a very marked degree. In leucorrhcea, the disease is mostly confined to the vagina and uterus; the discoloration, although considerable, is seldom either great or uniform, and the vulvo-uterine canal is usually free from ulceration. In gonorrhoea, the inflammation always involves the labia and nymphaa; the redness is of a fiery hue, and extensively diffused, the parts having almost an erysipelatous aspect, and marked abrasions, excoriations, or superficial ulcers are nearly constantly found upon the neck of the uterus, as well as upon the vagina. Finally, in leucorrhcea the pain is comparatively slight, and there is no disease of the lymphatic ganglions of the groin, the reverse being the case in gonorrhoea. In attempting to form an accurate diagnosis of these diseases, too much caution cannot be exercised, otherwise there will be great danger of occasion- ally involving the innocent. A thorough examination should always be made with the speculum, not once, but repeatedly, and the moral character of the woman should, in every instance, receive due consideration. If the patient be very young, or of an age when there are usually no sexual propensities, it may be presumed that the discharge is the result purely of simple vaginitis, occasioned by want of cleanliness, the presence of worms in the lower bowel, derangement of the digestive apparatus, or an anemic state of the system. All vaginal discharges are acid, and intermixed with abraded epithelium; but neither the microscope, nor any chemical test at present known, is of any avail in determining whether they are of an ordinary or a contagious character. The treatment of gonorrhoea in the female raust be of a strictly antiphlo- gistic nature, until there is a marked diminution of discharge and local dis- tress, when trial may be made of copaiba, or copaiba and cubebs, though, owing to the fact that the disease is rather a vulvo-vaginitis than a urethritis, these articles geuerally exert very little, if any, influence, in controlling the morbid action. The patient should be confined to her bed, and, if plethoric, be freely bled at the arm, especially if the inflamraation run very high, as denoted by the severity of the pain, and the sense of weight and fulness in the pelvic region, together with the profuseness of the profluvia. The venesec- vol. n.—60 946 DISEASES OF THE FEMALE GENITAL ORGANS. tion should be followed up by a brisk cathartic of the compound calomel pill, or an infusion of senna and sulphate of magnesia; and as soon as the bowels have been thoroughly relieved, recourse should be had to the antimonial and saline mixture, given every three or four hours, according to the exigencies of the case. The diet must be perfectly light and simple, as well as duly restricted in quantity. The local treatment must be in strict consonance with the activity of the morbid action. If this be high, leeches must be applied in considerable num- bers to the groins, vulva, and inside of the thighs; and in all cases the utmost attention must be paid to cleanliness by the frequent use of tepid ablutions and injections of tepid water, containing a little alum, soda, common salt, or acetate of lead. If the discharges be offensive, a small quantity of liquid chlorinated soda may be added to the water. Great care should be taken that the lotions, whatever be their composition, are not too strong, particu- larly at the commencement of the treatment, lest they should tend to increase the morbid action instead of diminishing it. Although stimulating injec- tions are borne much better by the female organs of generation than by those of the male, yet there is no doubt that, unless well tempered, they often do immense mischief. Observation has taught me that it is impossible to pay too much attention to this subject. Another practical precept worthy of notice is that the inflammation will subside much more rapidly, other things being equal, when the affected surfaces are kept well separated, than when they are permitted to be constantly in contact with each other, the warmth and the accumulation of the matter thus occasioned having a tendency to maintain the disease in full vigor. To effect this object, a large tent of patent lint, wet with some gently astringent lotion, as a solution of sulphate of alum, or acetate of lead, should be retained constantly within the vagina, being changed from time to time, as cleanliness and other circumstances may render it necessary. When the inflammation has passed into the subacute or chronic state, the lotion may be dispensed with, and the tent smeared with an oint- ment composed of one part of the ointment of nitrate of mercury to eight parts of simple cerate. Under the influence of this application, when the disease has reached this point, all discharge generally ceases in a few days. When ulcers exist upon the neck of the uterus, or upon the vulvo-vaginal mucous membrane, it may be necessary to touch them gently every third or fourth day with the solid nitrate of silver, or, what is preferable, with the dilute acid nitrate of mercury, the best formula being that of Bennett. The same rule, in regard to the continuance of the treatment, after all discharge has been arrested, should be observed here as in gonorrhoea of the male. The exhibition of copaiba and cubebs is indicated chiefly when the urethra is much implicated; for, as already intimated, the peculiar anti-gonorrhoeal virtues of these articles do not display themselves at all when the disease is confined to the vulva, vagina, and uterus. If buboes arise during the course of the dis- ease, they are to be treated in the usual manner. Abscesses are very apt to form in the labium, in the raore severe forms of gonorrhoea, and should always claim early attention, as they are generally excessively painful, and are liable, when neglected, to occasion serious struc- tural lesion. Their contents are usually excessively fetid, and of a thick, purulent character. SECT. VI.—VESICO-VAGINAL FISTULES. The bladder of the female is liable to various kinds of fistules, deriving their names from the organs with which they communicate, as vesico-vaginal, urethro-vaginal, vesico-uterine, vesico-utero-vaginal, and vesico-rectal. The most common cause of this affection is the accidental laceration of the VESICO-VAGINAL FISTULES — DIAGNOSIS. 947 parts during parturition, in consequence of the pressure of the child's head especially if the accoucheur has neglected to empty the bladder. It is also produced, though, probably, less frequently than is generally imagined by the maladroit useof instruments, inducing either direct rupture, or such an amount of contusion as to eventuate in gangrene and sloughing; by penetrat- ing wounds of the vagina and bladder, and by ulceration, whether occasioned by abscess, simple, syphilitic, or malignant disease, or the pressure of a uri- nary calculus, a pessary, or any other foreign body. The different classes of vesical fistules do not occur with equal frequency Dr. Bozeman, who, as is well known, has paid much attention to the study of the subject, informs me that the examination of a large number of cases justifies him in stating that the vesico-utero-vaginal form of the lesion is de- cidedly the most common; next in point of frequency is the fistule established at the expense of the vesical trigone ; then comes the opening situated at the bas-fond of the bladder; then the urethro-vaginal fistule; and, lastly, the fistule formed by the destruction of a part or the whole of the vesical trigone, and the wall of the urethra, of the trigone and bas-fond, or, finally, of all these parts together. A great deal of diversity obtains in regard to the size, shape, and num- ber of vesical fistules. Thus, the opening may not exceed the diameter of a small shot, or it may be so large as to admit a pullet's egg, or even a small orange. In itsshape it is generally somewhat oval or circular, but occasion- ally it presents itself in the form of a transverse, oblique, or longitudinal rent, slit, or fissure. Its edges are usually well defined, rough, callous, and white' with a slight eversion of the vesical mucous membrane. The induration often extends a considerable distance beyond the fissure, especially when this has been caused by sloughing, and it is, therefore, occasionally very difficult to pare the edges of such an opening. The vagina in the neighborhood of the aperture raay be perfectly sound, or it may be variously altered by disease, according to the nature of the exciting cause of the fistule, the violence of the resulting inflammation, and the acrid character of the discharges. It is not often that there is more than one opening. A singular eversion of the bladder occasionally takes place in vesico- vaginal fistule, the lining membrane passing across the abnormal aperture so as to form a tumor in the vagina. The protrusion, which is seldom consider- able, is generally of so trifling a nature as not to require any special attention. When, however, the artificial opening is unusually large, the whole bladder may project through it, and eventually even protrude at the vulva, as in the remarkable case mentioned in my Treatise on the Urinary Organs. A female affected with vesico-vaginal fistule must necessarily be an object of the deepest commiseration. Incapable of controlling the contents of her bladder, the urine constantly escapes at the vagina, thus soiling her clothes, and giving rise to the most noisome odors, which no amount of cleanliness can entirely prevent. In consequence of this condition, she is rendered unfit , for social enjoyment, and is obliged to spend her life in solitude and retire- ment. But this is not all: the urine, incessantly dribbling away, chafes and frets the parts with which it comes in contact, and thus renders them unfit for the exercise of their appropriate functions. The escape of urine is con- stant when the opening is situated at the bas-fond of the bladder, and is always worse in the erect than in the recumbent posture. The diagnosis of this affection is, in general, sufficiently easy. In most cases, indeed, the escape of the urine by the vagina, instead of through the natural channel, serves at once to point out its true character, whatever may have been the nature of the exciting cause. Its situation, shape, and extent, however, can be determined only by a thorough vaginal examination by weans of the speculum, the woman lying on her back, or, what is better, 948 DISEASES OF THE FEMALE GENITAL ORGANS. resting on her knees aud forearms, with the head as dependent as possible, and the nates considerably elevated. The instrument, well oiled, is then introduced in the usual manner, a catheter being at the same time inserted into the urethra. In this way every portion of the vagina may be most satis- factorily inspected, and any opening, however small, easily detected. In some instances, the speculum is advantageously replaced by the finger, which is carried about iu difl'erent directions, along the anterior wall of the tube, until its extremity comes in contact with the naked end of the catheter. When the aperture is very small, a long, slender probe should be used instead of the latter instrument. The prognosis of vesico-vaginal fistule is, in general, anything but flatter- ing. If a spontaneous cure does occasionally occur, the circumstance is so infrequent that it must always be regarded as an exceptional one. The pro- bability of such an event will be considerably greater, other things being equal, when the accident has been produced by a simple wound than when it has been caused by a severe contusion, followed by a slough, when the open- ing is small than when it is large, and when the lesion is simple than when it is complicated. The presence of malignant disease forbids the hope even of temporary relief by any operation whatever. TREATMENT. The treatment of this affection is palliative and radical; the former con- sisting in the employment of such means as are adapted to promote the patient's temporary comfort, while the latter are designed to effect the per- manent obliteration of the abnormal opening. Frequent ablutions and injec- tions with cold water, either simple or medicated, and the occasional use of chlorinated soda, will prevent excoriations and noisome fetor, and a proper regulation of the diet, with a soluble condition of the bowels, will go far in preserving the general health, which, under opposite circumstances, some- times suffers most severely, the patient becoming nervous, dyspeptic, and hysterical. To guard against the incessant escape of the urine, and enable the poor patient to exercise occasionally in the open air, the vagina should be kept constantly filled with a hollow plug, or caoutchouc bottle, enveloped in oiled silk, and furnished with a tube and stopcock, in order that it may be inflated or emptied at pleasure. Or, instead of this, a reservoir, such as that represented at page 750, may be suspended from the vulva. The radical treatment of vesical fistules has recently been brought to a high degree of perfection, almost exclusively by the labors of two practitioners, Dr. Sims, of New York, and Dr. Bozeman, of Alabama, the former of whom led the way in this laudable enterprise, while the latter has materially assisted in improving it by the invention of a highly ingenious suture. Previously to this, occasional cures of this loathsome affection had been effected by different American surgeons, especially by Dr. Hayward, of Boston, Dr. Alettauer, of Virginia, and my colleague, Professor Pancoast. In the account which I am about to give of this operation, I shall limit Fig. 617. Fig. 618. myself chiefly to Dr. Bozeman's process, both because it is extremely efficacious, and because he has kindly placed at my service a complete set of drawings illustrative of its various stages. The suture of Dr. Bozeman, which has already done such excellent service, is called the button suture, and is composed, first, of a piece of sheet lead, generally of an oval shape, perforated by Bozeman's button. several apertures, about the third of a line in thickness, and variously bent, in order to adapt it to the shape of the parts ; secondly, silver wire, very delicate and flexible, VESICO-VAGINAL FISTULES—POSITION OF THE PATIENT. 949 each thread being eighteen inches in length; and thirdly, leaden crotchets, to retain the apparatus in place. The annexed figs. 617 and 618 afford a good illustration of the more ordinary forms of the button. Before any operation of this kind is undertaken, it is indispensable that the patient should be subjected to a certain amount of preliminary treatment. Without this precaution failure, not success, will be likely to attend our efforts. The treatment need not be protracted, but it should be thorough, both as it respects the parts and the system at large. The most absolute recumbency and cleanliness should be observed; the vagina should be fre- quently syringed with cold water; cold cloths should be kept constantly upon the vulva; the bowels and secretions should be properly regulated ; the diet should be perfectly plain and simple; and large quantities of demulcent drinks should be used to dilute the renal secretion, and deprive it of its acrimony. If the woman be plethoric, blood should be taken from the arm, or from the vulva, perineum, groins, and thighs, by means of leeches. Thus prepared, she will be able to bear the operation with greater impunity, and with a better prospect of a favorable issue. If the parts are much inflamed, they should be touched, every other day, with a solution of nitrate of silver, in the proportion of thirty grains to the ounce of water, until the disease has measurably disappeared. If any con- tractions exist in the vagina, they must be thoroughly divided, care being, of course, taken, while this is being done, not to penetrate the bladder, rec- tum, or pelvic cavity. When the neck of the uterus is imprisoned in the bladder, an effort must be made to reinstate it in its natural position, as well as to relieve it of inflam- mation, before attempting to close the fistule. For this purpose, the cervix, as Dr. Bozeman suggests, is drawn down by means of a blunt hook inserted into its mouth, at the same tirae that the fundus of the organ is dislodged from its position between the vagina and rectum with a sponge mop, the woman, meanwhile, resting upon her knees and arms, so as to bring the parts fully into view. While held in this position, a tent, such as that described in a previous page, is introduced, renewal being afterwards effected once a clay, preceded by injections of cold water, until the uterus is disposed to maintain its place, when the operation is proceeded with. The position of the patient is a matter of paramount importance. When she is obliged to take chloroform, as may be the case when she is very timid, she must lie upon her back, as in the operation of lithotomy; but it will be far better, as it respects a full and ready view of the parts, for her to rest upon her knees and forearms, upon a couch, or a low, narrow table. In this manner, the head and shoulders being depressed, the nates may be elevated to any convenient height, and the light so arranged as to fall directly upon the vesico-vaginal septum in its entire length. The thighs, separated about eight inches from each other, should form a right angle with the table, and the clothing should be so light and loose as to take off all pressure from the abdomen and its contents, which will thus tend to gravitate towards the epi- gastric region. An assistant on each side lays a hand in the fold between the gluteal muscles and the thigh, the ends of the fingers resting upon the great lips. The nates being now simul- taneously pulled upwards and outwards, Fig- 619- the air rushes into the vagina, widely dilating it, and so affording an easy view of the fistule, as well as of the mouth of the uterus. The exhibition will be ren- dered still more perfect if the perineum, the sphincter muscle of the anus, and the recto-vaginal septum, be well raised with Dr. Bozeman's Speculum, fig. 619, Or With Bozeman's speculum. 950 DISEASES OF THE FEMALE GENITAL ORGANS. the duck-bill speculum of Dr. Sims, of which, in the latter case, there should always be at least two sizes. Fig. 620 shows the application of the speculum Fig. 620. Position of the patient in the operation for vesico-vaginal fistule. the position of the thigh and nates, the appearance of the dilated vagina, and the situation of the uterus, the bladder, and vesico-vaginal septum. If the light should be insufficient, a small mirror may be used, the reflection of which will generally render everything perfectly distinct, and enable the operator to proceed without any embarrassment frora this cause. Everything being thus arranged, the surgeon begins to pare the edges of the fistule, a procedure which always requires great care and judgment. As a general rule, the edges should be well bevelled at the expense of the vaginal raucous membrane, as this will afford a more extensive surface for agglutina- tion, and also admit of more firm approximation on the vesical side of the septum. If the opening is circular, unusually large or vertical, the edges should always be sloped in such a manner as to allow them to be brought together transversely, otherwise thorough union will be impossible. The instruments necessary for the easy performance of this part of the operation are a delicate tenaculum, long, slender, toothed forceps, a straight and angu- lar knife, and curved scissors, represented in figs. 621, 622, 623, 624, and 625. The anterior edge of the fistule is pared first, and the best instrument for this is the straight knife, the necessary quantity of substance being taken away in one piece. For refreshing the posterior edge, the curved knife or scissors will be found most convenient. If the opening be very large, this stage of the operation is sometimes interfered with by the protrusion of the vesical mucous membrane, but the obstacle can usually be easily overcome by returning the part, and then filling the bladder temporarily with bits of sponge. The next step of the operation consists in introducing the sutures, the number of which must necessarily vary according to the extent of the fistule. VESICO-VAGINAL FISTULES — OPERATION. 951 The instruments required for this purpose are a stout, straight, spear-pointed needle, a needle-holder, a pair of long, curved forceps, and a small hook. Fig. 621. Fig. 622. Fig. 623. Fig. 624. Fig. 625. Fig. 626. Instruments for vesico-vaginal fistule. The needle-holder, represented in fig. 026, is composed of 111 a clasp with a curved shaft, over which slides a flexible |||j canula. This is set in the socket of a handle, and secured If! J there by a thumb-screw which allows the whole to be sepa- 1; |,|| rated for cleansing after use. During the operation the WM shaft may be bent to any extent that may be desired. The Needie-hoider. instrument is shown with a needle armed with a silk thread, and ready for use. Several needles, ranging frora half an inch to an inch in length, should always be at hand. The distance at which the needle is entered from the anterior edge of the fistule should not be less than a third of an inch, as the object is to take a Fig. 627. Hook for making counter-pressure. very firm hold. The instrument is pushed steadily on, and brought out in the submucous cellular substance of the bladder, counter-pressure being raade 952 DISEASES OF THE FEMALE GENITAL ORGANS. against its advancing point by the little hook represented in fig. 627. The needle is now disengaged from the clasp of the holder by sliding back the canula with the thumb, when its point is seized and drawn out with a pair of curved forceps. Being reinserted in the clasp, it is then carried across the fistule, and entered at the posterior edge, which it traverses in the same manner as the anterior one, being brought out precisely at the same distance, counter-pressure and disengagement of the needle being effected as before. Thus suture after suture is introduced, until the number is completed, the in- terval between each two being about three-sixteenths of an inch. Each thread is now fastened by its proximal extremity to a loop near the end of the silver wire by which it is to be replaced, the knot being pressed Fig. 628. Fork for steadying the posterior edge of the fistule. Fig. 629. down smoothly with a pair of forceps, and well oiled to facilitate its passage across the track made by the needle. The wire is then pulled in its proper place, the posterior edge of the fistule being stead- ied, while this is being done, with the fork, shown in fig. 628. This mode of introducing the sutures is far superior to that of introducing the wire sepa- rately. This part of the operation is exhibited in fig. 629, in a transverse fistule requiring three su- tures. The tying of the sutures, and the arrangement of the buttons, constitute the third stage of the ope- ration. This is easily done with the aid of the suture- adjuster, represented in fig. 630. It consists of a strong rod, curved in the shaft, and set into a han- dle, its distal extremity being perforated and some- what bulbous. The opposite ends of each wire are now passed through the opening in the instrument, and firmly held between the thumb and forefinger of the left hand, when the adjuster is carefully slip- ped down until it comes in close contact with the tissues beneath. Fig. 631 shows the appearance of the parts after all the sutures have been adjusted, and the edges of the fistule approximated. A button, of suitable shape and size, having previously been Fig. 630. Application of the sutures. Suture-adjuster. provided, is now placed upon the wires, as seen in fig. 632 ; its concave sur- face corresponding to the vesico-vaginal septum, with which it is brought in close contact by means of the instrument represented in the annexed cut, fig. 633, the angular and scalloped extremity of which admirably adapts it for VESICO-VAGINAL FISTULES — OPERATION. 953 that object. The crotchet is now slipped down over the approximated ends of each suture, as illustrated in fig. 634, and pressed firmly against the convex Fig. 632. Appearances of the parts after the adjustment of the sutures. Application of the button. Fig. 633. Instrument for securing the button. surface of the button by means of a pair of forceps, to keep the button in place, and the edges of the wound thoroughly united. Finally, the opera- tion is completed by clipping off the wires close to the crotchet, and turning down their short ends, as delineated in fig. 635. Fig. 634. Fig. 635. Slipping down the crotchets. Suture completely adjusted. Fig. 636. Simpson's iron-wire splint, properly adjusted and the ends of the stitches twisted and secured across the lower bar of the splint. Instead of the button of Dr. Bozeman, Dr. Simpson employs a wire splint, alleging that it answers a better purpose for retaining the edges of the wound 954 DISEASES OF THE FEMALE GENITAL ORGANS. and supporting the sutures. It is made by twisting from fifteen to twenty threads of fine blue annealed iron wire into a cord, the ends being firmly plaited together, and the sides provided with a sufficient number of apertures for the passage of the sutures. The splint, the application of which is shown in the annexed cut, fig. 636, is very light, and easily moulded to the part at the time of the operation. Fig. 637. Fig. 638. Druitt's suture needle. For passing the sutures, a great variety of in- struments have been devised. Thus, Mr. Druitt has described one with a fish-hook curve, deline- ated in fig. 637, and which may, doubtless, be occasionally employed with advantage, though its application must, from its peculiar shape, be very limited. Dr. Simpson prefers a tubular needle, invented by Startin, and seen in fig. 638. The instrument is represented of full size, with the wire projecting at the end, which is a little thicker and larger than it ought to be. A part only of the handle is exhibited. The instrument which I myself employ for introducing the nee- dle is a pair of slender forceps, straight, and rather long in the blade, with a serrated surface. Nothing could possibly answer the purpose bet- ter, or be more simple. For securing the sutures, the ends of the wire may simply be twisted with a pair of forceps; or the object may be effected with an instrument specially devised for the purpose, as that, for example, of Dr. Coghill, exhibited in fig. 639, reduced to one-half the proper size. Its extre- Startin's suture needle. VESICO-VAGINAL FISTULES — MODIFICATIONS. 955 Extremity of wire twister. mity, as will be seen by a reference to fig. 640, is furnished with two short lateral tubes, for the passage of the wire. For my own part, I have always operated with the shot, as originally suggested by Fig. 639. Dr. Sims, having found it both easy of application, Fig. 640. » and eminently effective. Certain modifications of this operation are fre- quently necessary, growing out of the situation of the fistule, or the condition of the parts. Thus, as Dr. Bozeman has so well pointed out, in the urethro-vaginal lesion, the button must be rather long in the antero-posterior direction, very con- cave, and extended well forward in front of the urinary meatus, so as to support the catheter, its extremity being soraewhat notched. The edges of the opening are brought together transversely ; and the catheter, a gum-elastic one, is introduced before the sutures are adjusted, and is retained, if possible, until the cure is completed. In fistules involving the vesical trigone and the root of the urethra, or of the trigone and bas-fond, or of all these parts together, in which the anterior border of the opening is immovably fixed to the pubic arch, with the concavity presenting backwards, the button requires to be bent upon its convexity. Considerable modification is required when the fistule extends into the neck of the uterus. The paring of the edges being effected in the usual manner, the button is carefully adapted to the shape of the parts, its posterior border being generally notched to ac- commodate the anterior lip of the cervix. A semicircular but- ton is required when there has been so much loss of substance of the vesico-vaginal septum as to render it impossible to draw the anterior border of the fistule up to the posterior. The line of coghiii's perforations corresponds with the former border, while the notch wire twister, in the button projects over the anterior lip of the neck of the uterus. Fig. 641. When the neck of the womb is lacerated, and buried in the bladder, the first object is to restore the organ to its natural position in the vagina, in order that, after the cure is completed, the menstrual fluid may resume its natural outlet. To do this, it is necessary to enlarge the fistule in the vesico-vaginal septum on each side, transversely, thus disengaging the organ somewhat, and affording more space for paring the anterior lip of the cervix. In inserting the sutures in the posterior border, the vesical mu- cous membrane is pierced by the needle, which, being carried into the bladder through the fistule, is entered far in on the vesi- cal side of the cervix, and brought out from behind forwards, the object of the procedure being to obtain such a hold upon the womb as to enable the operator to pull its neck downwards and backwards during the adjustment of the sutures, restoration of the displaced organ being impracticable in any other way. The button for this variety of fistule requires to be bent upon its con- vexity, and to be notched above for the support of the anterior border of the neck of the uterus. During these various procedures, which must necessarily be more or less tedious and fatiguing, both to the patient and the operator, great advantage will be derived from the use of several Sims's catheter 956 DISEASES OF THE FEMALE GENITAL ORGANS. sponge mops, of various shapes and sizes, for wiping away the blood and the secretions. The bleeding is usually insignificant, and readily stops of its own accord. The operation being over, a Sims's catheter, fig. 641, is in- serted into the bladder, a gum-elastic tube, about fifteen inches in length, having been previously secured to its outer extremity, in order to conduct the urine into a large bottle lying iu a hollow between the patient's thighs. After-treatment and Effects.—Much of the success of this operation, and indeed, of every other of a similar kind, will depend upon the after-treatment. As soon as the patient is put to bed, she should take a large anodyne, for the twofold purpose of allaying pain and inducing quiescence of the bowels, which, in no case, should be disturbed under ten, twelve, or fifteen days. The diet should consist exclusively of tea and crackers, custard, rice, and jelly, with water as the common drink. Opium is given twice a day in as large doses as can be borne, and the patient is never permitted, even for a moment, or for any purpose whatever, to assume the erect posture, though she may, if she prefer it, lie on either side. The catheter is to be removed as often as may be necessary to keep it clear of blood, mucus, and calculous matter; once a day, once every other day, or once every third day, according to the circumstances of each individual case. The vulva and orifice of the vagina should be syringed at least twice in the twenty-four hours with cold water, a large bed-pan being placed under the nates during the operation to receive the fluid as it runs off. Should undue inflammation arise, leeches and even the lancet should be called into requisition, and that with the least pos- sible delay; purging is still carefully avoided, especially if there be no marked derangement of the digestive organs, and the utmost attention is paid to cleanliness. Both the part and system are occasionally endangered by erysipelas. In a patient under my charge several years ago, although raore than usual care had been bestowed upon the preliminary treatment, a most violent attack of this disease took place within a few days after the operation, commencing on the right buttock, and gradually spreading over the upper part of the thigh, perineum, and vulva, from which it speedily extended into the vagina, causing large deposits of lymph, with a strong disposition to cohesive action. The constitution suffered very much, and at one time I was not without serious apprehension in regard to the ultimate issue of the case. Notwithstanding all this, however, the woman made a good recovery, though several months elapsed before she fully regained her strength. Peritonitis has occasionally occurred after this operation, and it is well enough always to have an eye to the possibility of such an event; so that, should it show itself, it may be promptly combated. It will rarely appear before the third day, or after the sixth or eighth. The sutures should not be removed, on an average, before the tenth day; if taken out sooner, the adhesions will be apt to give way, and thus necessi- tate a repetition of the operation. The patient being placed in the same position as in the first instance, the ends of each suture are clipped with a pair of curved scissors, when the button is lifted off, and the wire gently drawn away by taking hold of its proximal extremity, previously well sepa- rated from the other. The patient, instead of sitting up or walking about, observes the recumbent posture for several days longer, and the use of the catheter is continued until there is reason to believe that the new cicatrice has acquired sufficient strength to resist the pressure of the distended bladder and the traction of the surrounding parts. With regard to the results of this operation, we have unfortunately no statistics on an enlarged scale. In a communication, kindly addressed to me in 1859, Dr. Bozeman informed me that he had operated altogether upon 33 patients, of whom 29 had been completely cured, 2 were still under VESICO-RECTAL FISTULES. 957 treatment, 1 was incurable, and 1 had died. The whole number of fistules was 44, of which 40 had been completely closed, 3 had reopened after having been closed, and 1 refused to unite. Although I believe that the process above described is by far the best that has yet been devised for the relief of this affection, it cannot be denied that excellent cures are occasionally effected without it, simply by the ordinary thread or wire suture. If I am not misinformed, Dr. Sims now operates alto- gether with the latter, without the aid of clamps, the use of which was once so much insisted upon by him ; and Dr. Agnew, of this city, has recently succeeded in several cases by a similar procedure. SECT. VII.—VESICO-RECTAL FISTULES. A vesico-redalfistule occasionally occurs as a result of wounds, ulceration, abscess, or malignant disease. The characteristic sign of the lesion is an interchange of the contents of the two contiguous reservoirs, the urine pass- ing into the bowel, and the feces into the bladder. In consequence of this occurrence, the parts are apt to become sore and irritable from the contact of substances which are entirely foreign, and, therefore, injurious to them. Moreover, the constant introduction of fecal and other matter into the blad- der is liable to give rise to calculous concretions, and to retention of urine. The more simple forms of this affection will often disappear of their own accord. In all cases, the bowels should be maintained, for days together, in a perfectly quiescent state by morphia, opium, or laudanum, and the rectum should be washed out several times in the twenty-four hours with cold water, or, if the discharges be fetid, with a very weak solution of chlorinated soda. The recumbent posture should be carefully observed; the diet should be of the most, bland and simple character; and drinks of every description should be used as sparingly as possible. As the case progresses, the closure of the fistule may often be greatly promoted by the constant retention of the catheter, which thus conducts off the urine as fast as it reaches the bladder, and, of course, prevents it from passing into the bowel. If nature fails to accomplish her purpose, a cure may not unfrequently be effected by the use of nitrate of silver, acid nitrate of mercury, or the actual cautery, applied through the intervention of an anal speculum. In very ob- stinate cases, especially when the abnormal opening is situated very low down, the edges raay be pared, and united by suture, as in vesico-vaginal fistule; the parts being previously dilated by the bougie, and widely opened at the time of the operation by means of blunt hooks. When this proceeding does not afford the requisite room, it would be perfectly proper to divide, as a pre- liminary step, the sphincter muscle. Some years ago, I met with a case of vesico-vagino-redal fistule, the patient being a woman, aged twenty-seven. The accident occurred during a pro- tracted labor. For the first twelve months, the urine dribbled X)ff constantly by the anus ; but, after that period, she was able to retain it for half an hour, or even an hour, at a time, especially when in the erect posture. The rec- tum, which thus served the purpose of a sort of accessory reservoir for the uriue, was unusually tender and irritable, while the anus constantly exhibited an inflamed and excoriated appearance. After the re-establishment of men- struation, that function was always performed with great regularity, though rather sparingly, at every lunar month, generally lasting about three days. The catamenial fluid, which was of the natural color, was discharged by the anus. The urethra presented nothing peculiar at its orifice, but all attempts to pass an instrument, even the smallest pocket-probe, proved abortive. Finding it impossible to restore the vagina, I introduced a large curved 958 DISEASES OF THE FEMALE GENITAL ORGANS. trocar into the urethra, for the purpose of re-establishing the natural channel for the urine. The operation was performed without difficulty, the woman being under the influence of chloroform, and a self-retaining catheter was immediately inserted into the bladder. By wearing this, off and on, for seve- ral weeks, the passage was completely restored to its former size, the urine being discharged in as full a stream as ever, and that not oftener than five or six times in the twenty-four hours. The fact is, she had the most thorough control over the bladder, the general health was excellent, and not a drop of urine wras voided by the anus. The menstrual fluid passed off by the bladder. SECT. VIII.—LACERATION OF THE PERINEUM. Fig. 642. Laceration of the perineum, usually a casualty of parturition, in conse- quence of the large size and rapid descent of the child's head, or the mala- droit use of instruments, occurs in various degrees, from the slightest division of the skin and raucous tissues, to the union of the vagina and rectum into one cavity. In the latter case, there is} of course, more or less involvement of the recto-vaginal septum, the rent, perhaps, reaching up from six to eighteen lines. Owing to the laceration of the sphincter muscles of the anus, an accident which always necessarily attends the worst forms of the lesion, the woman has seldom any control over her bowels. The treatment of this affection varies according to its extent and character. The more simple forms will gene- rally promptly get well of their own accord, especially if proper care be bestowed upon them soon after their occur- rence, in the way of rest, thorough approximation of the limbs, and cleanliness, assisted by light diet and constipa- tion of the bowels. When the rent is extensive, recourse must be had to the quilled suture, the stitches being in- troduced very deep, and retained until there is a certainty of complete adhesion of the opposed surfaces. A similar plan of treatment is employed when the case has been neglected, but, in addition to this, it will be necessary, before arranging the ligatures, to see that the edges of the fissure are properly refreshed. This is usually easily done with the bistoury and forceps, aided with the scissors. The raw surfaces should not, on an average, be less than two inches in length by from nine to twelve lines in width. The borders of the recto-vaginal septum are also well pared, and carefully united, as a preliminary step, two stitches always sufficing for the purpose. In sewing up the perineal portion of the fissure, at least three ligatures will be necessary, the first being inserted at the verge of the anus, and the last at the base of the labia, through their substance. The hold should be very firm, otherwise there will be danger of premature separation. In performing this operation, the patient, brought fully under the influence of chloroform, is placed upon her back, in the same position as in the operation of litho- tomy, the bowels having been thoroughly cleared out the night before. For sewing up the recto-vaginal septum the best instrument that I know of is the one represented Needle for sewing up at PaSe 565> in the section on staphylorraphy. The lijra- the perineum. tures for the perineal fissure are readily introduced witu LACERATION OF THE PERINEUM. 959 the aid of the instrument depicted in fig. 642. The eyelet should be large, so that the thread may be easily reinserted above, after transfixion has been effected on the opposite side. The ends of the ligatures are then sepa- rated, and secured over two pieces of bougie, as seen in the adjoining sketch, fig. 643, from Mr. Brown. Should there be much tension, the operator may Fig. 643. Laceration of the perineum. now divide the sphincter muscle of the anus, frora an inch to an inch and a half exterior to this opening, the incision beginning about three lines in front of the coccyx, and extending some distance outwards and backwards, the gap being left to fill up by granulation. Such an expedient, however, will sel- dom be required ; at all events, I have not myself been obliged to resort to it in any of my cases. The operation being over, the patient is placed in bed, her knees lying upon a pillow, and being tied together, to prevent any strain upon the perineum. A grain of morphia is at once given, in order to relieve pain and lockup the bowels, which should not be moved, if possible, for at least ten or twelve days. The diet should be as concentrated as possible, and, if there be any evidence of debility, a due allowance of brandy should be afforded. For the first three or four days, the cold water-dressing is used, and a syringeful of cold water is occasionally thrown into the vagina. The sutures should not, on an average, be disturbed under a fortnight, or until there is reason to believe that the union is perfect. Strict recumbency should be maintained for at least a week longer. 960 DISEASES OF THE FEMALE GENITAL ORGANS. PERINEAL BANDAGE. Finally, it is necessary to add a few words respecting the perineal bandage, for retaining dressings upon the vulva, perineum, and anus, as well as for affording support in prolapse of the uterus and rectum. It consists, as the adjoining cut, fig. 644, sufficiently indicates, of two distinct pieces, a circular and a per- pendicular, the former passing round the hips, and the latter over the perineum and vulva, where it is provided with a pad, covered with oiled silk. It is then split in two, each strip being brought up in front, and attached to the circular girth. SECT. IX.—AFFECTIONS OF THE MAMMARY GLAND. The mamma is liable to inflammation, abscess, hypertrophy, neuralgia, and various kinds of tumors, both innocent and malignant. The latter, in fact, appear to have a sort of pre-emption right to this organ. MAMMITIS. Inflammation of the breast, technically termed mammitis, is chiefly observed during lactation, in consequence of suppression of the cutaneous perspiration, or retention of the milk, causing over-distension of the lactiferous ducts. It may also arise from too free living, neglect of the bowels and secretions, and from the effects of external violence. It generally comes on within the first fortnight after parturition, beginning in the form of one or raore ovoidal lobules, hard and tender to the touch, somewhat deep-seated, and not exceed- ing the volume of an almond. As the inflammation progresses, other lumps appear, and, gradually coalescing, at length involve the whole breast, glandu- lar structure and connective tissue as well. The organ is now exceedingly large, hard, and heavy, exquisitely painful, and intolerant both of manipula- tion and pressure. The skin is hot, discolored, tense, and glossy, pitting, perhaps, here and there slightly under the finger. The secretion of milk is either arrested, or, at all events, much diminished, and great difficulty is experienced in emptying the organ, the choked-up ducts being seemingly indisposed to part with their contents. Well-marked constitutional symptoms are always present at this stage of the disease. The patient is hot and fever- ish, or alternately hot and chilly, the tongue is dry and coated, the pulse is full and frequent, the bowels are constipated, and the urine is scanty, high- colored, and loaded with urates. If permitted to go on, the inflammation soon passes into suppuration, the event being announced by the ordinary local and constitutional phenomena, especially throbbing, an erysipelatous blush of the skin, and rigors alternating with flushes of heat. The treatment of acute mammitis must be conducted upon strictly anti- phlogistic principles, early and vigorously enforced. If the patient is very plethoric, blood is taken from the arra, or by leeches from the seat of the disease, the bowels are moved by active purgatives, vascular action is con- trolled by the antimonial and saline mixture in combination with aconite or veratrum, and the lightest possible diet is enjoined, with an avoidance of fluids of every description, thirst being allayed by the use of ice. The breast Fig. 644. Perineal bandage. ABSCESS OF THE BREAST—TREATMENT. 961 must be well supported with an appropriate bandage, and the surface must be kept constantly wet with warm water-dressing, medicated with acetate of lead and laudanum. If suppuration be threatened, an emollient poultice, if not too heavy, will generally be found to be very grateful. Pain is allayed by anodynes, conjoined with diaphoretics, especially if there be dryness of the skin. The breast should be relieved at least twice a day of milk, either by suction with the mouth or a suitable pump, the child receiving its nourish- ment from the sound organ. A speedy check may often be put to an incipient mammitis by rubbing the affected organ thoroughly several times a day with warm oil and laudanum, or mild ammoniated liniment, the friction being made in the direction of the lactiferous ducts, that is, from above downwards towards the nipple, by the nurse, as she stands behind the patient, and supports the posterior surface of the breast with one of her hands. This mode of treatment, which is particu- larly insisted upon by Dr. S. C. Foster, of New York, generally exerts a powerful effect upon the indurated gland, softening it in a short time, reduc- ing the swelling, and promoting the flow of milk. When the disease has.lost its acute character, sorbefacient liniments and unguents may advantageously be employed; or, what is often much better, strapping of the breast with adhesive plaster, on the same principle as in chronic inflammation of the testicle. Each strip should be three-fourths of an inch in width, and long enough to extend once and about a third around the organ, the application being commenced at the base, and continued by circular and vertical turns, until the whole is completely enveloped, a suitable opening being of course left for the nipple. The dressing will require renewal about every forty-eight hours. The local treatment in these chronic cases will generally be immensely promoted by a properly regulated diet, and by an occasional cathartic of blue mass and colocynth, or black draught. ABSCESS. When mammitis passes into suppuration, the raatter always collects in the form of an abscess, which may be situated either in the interlobular substance of the gland, in the cellulo-adipose tissue beneath the skin, or in the con- nective substance behind the organ, the frequency of the occurrence being in the order here stated. The symptoms denotive of the event are, an increase of the pain, which is throbbing, deep-seated, and continued, a dusky or pur- plish appearance of the skin, a sense of fluctuation, especially if the matter has already accumulated in considerable quantity, aud rigors or chilly feel- ings, alternating with flushes of heat, and followed by copious sweats. When the pus is situated at an unusual depth, its presence is often indicated by an (edematous state of the subcutaneous cellular tissue. The matter which is formed in this disease is generally of a thick, cream- like consistence, and of a whitish or pale yellowish color. When the inflam- mation has been very high, it is apt to contain flakes of lymph and pure blood, the latter being usually in a state of coagulation. Milk is almost always a- prominent ingredient. Even when it exists in so small a quantity as to be undiscoverable by the naked eye, its presence may, in general, be readily de- tected by the aid of the microscope. The quantity of pus varies from a few ounces to upwards of a quart, the average being from four to eight ounces. From a week to a fortnight is the time required by the abscess to work its way to the surface. The treatment of mammary abscess consists in an early and free incision, for the twofold purpose of relieving pain and saving structure. The edges of the wound are prevented from closing by the use of the tent. The most vol. n.—61 962 DISEASES OF THE FEMALE GENITAL ORGANS. suitable application for the first few days will be an emollient poultice, or the warm water-dressing. All rude squeezing, with a view of promoting the eva- cuation of the pus, must be avoided, as it is calculated not only to produce pain, but also to aggravate inflammation. When the treatment of mammary abscess has been neglected, or misman- aged, the matter is extremely apt to burrow, dissecting the lobules of the glands from each other, and also, in many cases, from the surrounding parts, thus causing extensive havoc, and the formation of numerous sinuses; some- times as many, perhaps, as half a dozen. Such cases are always attended with great suffering, both local and constitutional. Until lately, the treat- ment used to be as cruel as it was generally tedious and unsatisfactory, the object being to trace out the passages with the director and knife, with a view, as was alleged, of healing them from the bottom, a tent being maintained in them for the purpose. Within the last few years, a more scientific mode of management has been extensively pursued in this country, in consequence of the recommendation of Dr. Foster. It consists simply in the application of compressed sponge, confined by means of an appropriate bandage, aided by a suitable diet, and attention to the bowels. The sponge, freed of dirt, per- fectly soft, elastic, and large enough to cover the entire breast, is thoroughly dried, and then effectually compressed by keeping it for twenty-four hours under a heavy weight, as, for example, a common letter copying-press. Thus prepared, it is bound upon the affected organ over a piece of patent lint, to prevent irritation of the skin, by means of a roller passed several times around the chest, above and below the sound breast. It is then saturated with tepid water, which has the effect of expanding it towards the diseased structures, pressing the walls of the sinuses together, and at the same time forcing out their contents and absorbing them. The sponge is changed once in the twenty-four hours. A little pain generally attends the first application, but this usually disappears in fifteen or twenty minutes, and does not recur after- wards. The improvement under this treatment is most rapid, the worst cases generally recovering in a few weeks. If the general health is much impaired, it should be conjoined with the use of tonics, a nourishing diet, and exercise in the open air. The organ, after recovery, may be allowed to remain inac- tive, or suckling may be resumed, if it should be deemed necessary. In my own practice, I have usually succeeded, without difficulty, in reliev- ing such cases by systematic compression with adhesive strips, or, what is better, with strips of gum ammoniac and mercurial plaster, applied quite firmly, and in such a manner as not to interfere with the discharges. I have often effected excellent cures, under such circumstances, simply by wrapping up the breast in the ammoniac and mercurial plaster, without cutting it into strips. The chronic abscess of the breast is often a very troublesome and annoying affection, the raore so because of the difficulty occasionally experienced in the diagnosis. I have repeatedly had patients sent to me from a great distance under the supposition that they were laboring under malignant disease of the mamma, when their only ailment was a chronic abscess. What is still worse is that the organ has occasionally been extirpated in such cases, as I have myself known it to be in two instances. Such stupidity cannot be too severely reprehended, especially as there is not the slightest excuse for it, the use of the exploring needle always promptly revealing the true nature of the disease. It is probable that the chronic mammary abscess is occasionally of a stru- mous nature, especially when it attacks, as I have known it to do in several instances, young, unmarried females; but, in general, it will be found to he the result of ordinary inflammation, occurring during suckling, and proceed- ing in a very slow and stealthy manner, in consequence of some defect in the constitution, or of some obstruction in the lactiferous ducts. In most cases, GANGRENE—SORE NIPPLES. 963 the disease takes place in the breast which the child has been unable to use on account of a sore or retracted nipple. Sometimes the excitino- cause is a blow or contusion, perhaps so trivial as not to attract any attention at the moment. The disease usually begins in the forra of several hard lumps, which, gra- dually coalescing, at length unite into one solid mass, of irregular shape, and of firm consistence; sometimes involving only a portion of the breast, and at other times the entire organ. Occasionally the glandular structure escapes completely, the morbid action being confined exclusively to the cellular tissue around, behind, or in front of the breast. By and by, a process of softening begins, and steadily progressing, a large accumulation of pus occurs, pressing upon the parts in every direction, and fluctuating distinctly under the finder. Marked enlargement of the subcutaneous veins usually attends, especially when the disease is of long standing, but there is no discoloration of the skin, and seldom any severe pain; merely, perhaps, a sense of weight and of uneasiness. The general health is not materially affected, and there is no involvement of the surrounding lymphatic ganglions. The disease may last for months. The treatment of chronic mammary abscess is by evacuation, and support of the breast by the gum ammoniac and mercurial plaster, aided by the band- age. Recovery will be promoted by attention to the diet and bowels, and by the use of tonics and alterants. The cure is generally perfect. GANGRENE. The mammary gland is astonishingly exempt from gangrene. Such an occurrence, indeed, is possible only in very unhealthy females, or in women who, in addition to scrofulous or syphilitic disease, have been suffering, at the time of the inflammatory seizure, under an impoverished state of the blood. A few cases are upon record where gangrene of this gland was occasioned, in middle-aged females, by the protracted use of ergot. In erysi- pelas and carbuncle the cellular tissue around the gland sometimes mortifies, the mamma itself generally escaping. The treatment of this affection, how- ever induced, is to be conducted in the same manner as in gangrene in other parts of the body, and, therefore, does not require any special notice. SORE NIPPLES. Women, during their confinement, particularly if it be a first one, are extremely liable to suffer from inflammation of the nipple, speedily terminat- ing in ulceration. The sores have generally the appearance of superficial fissures, cracks or abrasions, attended with a thin, serous, or sero-sanguino- lent discharge, and excessive pain, usually of an itching, smarting character, i Occasionally the ulceration extends to a great depth, partially separating the nipple from the breast, and thus greatly augmenting the suffering. The affected parts are red and inflamed, the breast feels tender and hard from the accumulation of milk, and the sebaceous follicles around the nipple are irri- tated and sensibly enlarged. The disease usually appears within the first few days after delivery, in consequence of the application of the child's mouth, which never fails to aggravate it. The treatment consists in the application of collodion, in thoroughly empty- ing the breast at least three times a day with the pump, and in the use of an active purgative, along with a light, dry diet, the object being a partial suppression of the milk. If both nipples are affected, the child should be compelled to suck through the mediura of a heifer's teat, until the parts are 964 DISEASES OF THE FEMALE GENITAL ORGANS. cicatrized. Meanwhile, as well as afterwards, they should be carefully pro- tected from the pressure of the clothes, by means of an appropriate glass. When collodion fails to afford relief, various astringent remedies may be employed, as weak solutions of alum, zinc, or copper, in union with tannin. Nitrate of silver, in the proportion of two grains to the ounce of water, some- times answers a good purpose. Yellow wash, prepared with one-fourth of a grain of the salt to the ounce of water, makes an excellent application for superficial chaps of the nipple, but caution must be observed in its use. Oc- casionally nothing affords such prompt relief as the ointment of the nitrate of mercury, diluted with six or eight times its weight of lard. A strong solution of borax, thickened with brown sugar, and rendered stimulating with brandy, is a favorite domestic remedy, from which I have frequently derived great benefit. In most cases, the foundation of this disease is laid during pregnancy, from a want of proper attention to the parts. In general, all difficulty may be successfully prevented by the avoidance of pressure, and the use of some astringent wash, as alum and tannin, for the purpose of hardening the nipples. The nipple is often very short, imperfectly developed, or flat and retracted, much to the annoyance both of the mother and child. Numerous plans have been suggested for raising it when thus affected, but there is, perhaps, none so good as the application of a large bottle with a long neck, in which the air has been rarefied with hot water. The water having been poured out, and the mouth of the bottle placed over the nipple, a vacuum is formed as the bottle cools, which thus establishes a powerful and equable suction, thereby effectually elongating the parts without any serious inconvenience to the mother. Most of the suction tubes and pumps, properly so called, do more harm than good in these states of the nipple. NEURALGIA. Neuralgia of the breast may occur at any period after puberty, but is most common in young females from the age of fifteen to thirty. It is character- ized by exquisite pain, darting through the part like electricity, and extending generally to the corresponding shoulder and axilla, and sometimes down the elbow to the fingers. The suffering, which resembles that of tic douloureux, and which often observes a regular periodicity, is very much increased prior to menstruation, and is sometimes so severe that the patient is unable to lie upon the affected side, or bear the weight of the bedclothes. The disease may last for years, and is met with mostly in persons of a nervous, irritable temperament, with deficient menstrual secretion. The morbid action is commonly confined to several of the mammary lobules, which either retain their natural bulk and appearance, or, what is more com- mon, they are converted into small, solid tumors, distinctly circumscribed, movable, and highly sensitive to the touch. Occasionally these swellings seem to be seated in the connecting cellular tissue rather than in the glandu- lar structure; they seldom exceed the size of a marble, an almond, or a wal- nut ; they never suppurate, and they sometimes disappear spontaneously. More or less disorder of the general health usually attends this affection; the patient looks pale and thin, is remarkably susceptible to atmospheric impressions, and nearly always suffers under marked derangement of the menstrual function, the discharge being unusually scanty, and attended with a great deal of pain. In most of the cases that have fallen under my obser- vation, the disease was associated with neuralgia in other parts of the body. The treatment is to be conducted upon ordinary anti-neuralgic principles. The general health having been amended by a proper regulation of the diet and HYPERTROPHY OF THE MAMMARY GLAND. 965 the use of purgatives, the patient is placed under the influence of quinine, or, if there be evidence of anemia, quinine and iron, in union with arsenic, strych- nia, and aconite, cannabis Indica, or stramonium, steadily and persistently continued, with an occasional intermission, until a decided impression has been made upon the complaint. Sometimes the exhibition of colchicum and morphia proves highly beneficial; and I have seen cases in which nothing appeared to answer so well as the antimonial and saline mixture, with aconite. The most suitable local remedies are anodyne liniments and plasters, preceded, if there be considerable tenderness and swelling, by leeching. The breast must be well supported and protected from pressure. The menstrual func- tion must receive due attention. HYPERTROPHY. Hypertrophy of the mamma, fig. 645, is not uncommon, nor is it, as might be supposed, confined entirely to the female sex. I have repeatedly seen both breasts of the male enlarged many times beyond their normal bulk, and not Fig. 645. a few cases are recorded where they have freely, and, for a long time, secreted milk. In women, the swelling is com- monly associated with amenorrhoea; but it sometimes occurs during pregnancy, and disappears soon after delivery. Oc- casionally the affection begins at an early period of life, and goes on progressively increasing until the breast acquires an enormous bulk. Of this, an interesting case came under my observation in 1857, in a colored girl, nearly seventeen years of age, a patient of Dr. Hanly, of this city. The hypertrophy involved both organs, but not in an equal degree, the right being more than twice the volume of the left, and weighing, by estimate, upwards of fifteen pounds, its length ex- ceeding fifteen inches. They were of a very firm consistence, considerably nodu- lated, and quite tender on manipulation. The subcutaneous veins were enormously enlarged. The hypertrophy had com- menced without any assignable cause, when the girl was twelve years of age. When I first saw her, she had been con- fined a fortnight, and I was informed that her breasts had much increased in size both during and since her pregnancy. Her general health had become much impaired, and she was excessively emaciated. Dorsten gives a case of this kind, in which the left breast weighed sixty-four pounds. The true nature of this disease is not determined. In some cases the affected organ retains its normal structure, at least apparently so; whereas in others it is materially altered, being preternaturally dense and firm, and deprived of its glandular character. The interlobular cellular tissue is much augmented in quantity, and similar changes are generally witnessed in the cellulo-fatty substance surrounding the organ. Occasionally the enlargement is associated with retention of the milk. Hypertrophy of the mammary gland. 966 DISEASES OF THE FEMALE GENITAL ORGANS The treatment of mammary hypertrophy is generally conducted upon em- pirical principles. The use of sorbefacients would necessarily suggest itself in such a disease, but it does not appear that it has hitherto been of any marked benefit. The most suitable article would be iodine, administered internally, and applied to the affected organ, either in the forra of tincture or of ointment. Gentle and protracted ptyalism might be serviceable. Occa- sionally benefit has accrued from the steady and persistent exhibition of the hydrochlorate of ammonia, in doses of frora ten to twenty grains, thrice a day. Whatever remedies be employed, special attention should be paid to the improvement of the general health, which is often much impaired. The breast should be well supported, to take off weight.and tension. Strapping the organ carefully with ammoniac and mercurial plaster would probably exert a more powerful sorbefacient influence than any other local means, though I am not aware that it has ever been fairly tested. Extirpation should be resorted to when the tumor, refusing to yield to treatment, is so large as to cause severe suffering and inconvenience, gradually, but effectually, undermining the general health. ATROPHY. Atrophy of the mamma is a natural effect of old age. When the men- strual function ceases, the gland begins to diminish in volume, and the wast- ing gradually progresses, until, at length, the whole organ is reduced to a soft, flabby mass, of a dirty, grayish tint, in which it is often difficult to detect any of the natural structure, except the lactiferous ducts, which are seldom completely effaced. Sometimes the gland shrinks early in life, particularly in married females who do not nurse their offspring. Atrophy of this viscus occasionally results from the effects of neuralgia, and the use of certain medi- cines, as iodine and hemlock. This lesion presents little of surgical interest. When it occurs in young females, as a consequence of the use of medicines, neuralgia, or habitual pres- sure, immediate measures should be adopted for its arrest, otherwise the organ may be irretrievably lost. FISTULE. During lactation, a galactophorous duct is soraetimes included in a wound of the breast, and, unless the edges of the integuments be very closely approxi- mated, a lacteal fistule may remain. The same consequences may be pro- duced by a rupture of the canal from the inordinate accumulation of milk. A more common occurrence is the formation of accidental outlets, from the irritation of multilocular abscesses. These passages are often of considerable depth, tortuous, numerous, lined by an adventitious membrane, and attended with a great deal of induration of the surrounding parts. The disease will usually disappear of its own accord, as soon as lactation is over, and frequently even long before that event. If the case be trouble- some, a cure should be attempted by the application of compressed sponge, aided, if necessary, by stimulating injections. CALCAREOUS CONCRETIONS. Calcareous concretions are met with in the breast, either in its substance or in the lactiferous ducts; they are commonly small, not exceeding an ordi- nary pea, and are observed chiefly in connection with fibrous and other tumors. I have seen these bodies only in two instances, in females far advanced in life. They were of a whitish color, irregularly spherical in shape, and of a hard, MAMMARY GLAND — APOPLEXY — BENIGN TUMORS. 967 solid consistence, like dry mortar. A case has been described by Berard, in which the outer portion of the mamma was converted into a complete osseous shell. Unless these concretions prove a source of inconvenience or annoyance, they should be let alone, especially if the patient has not passed the child- bearing period, as an operation might be attended with serious injury to the lactiferous tubes. APOPLEXY. The breast is liable to apoplexy, consisting in an effusion of blood into the connecting cellular tissue, resembling an ecchymosis produced by a blow or leech-bite. Generally there is only one such spot, but there raay be several, coming on a few days before the menstrual period, and disappearing within the first week or two after; though sometimes they continue for more than a month. The disease seems to depend upon some sympathetic action be- tween the uterus and the breast, causing a great determination of blood to the latter, eventuating in the rupture of some of its smaller vessels. The affected parts are always of a dark, livid hue, and are exquisitely tender on pressure, the pain sometimes shooting down to the ends of the fingers. The treatment of this affection consists in sorbefacient applications, espe- cially if some time has elapsed since its occurrence. When the effusion is recent, it will generally promptly disappear under cold saturnine and opiate lotions. BENIGN TUMORS. Under this head may be included various kinds of growths of a benign or non-malignant character, as the sero-cystic, hydatic, lacteal, and adenoid. 1. SERO-CYSTIC TUMORS. Tumors of the breast, containing serous cysts, are sometimes met with ; chiefly in married females between the twentieth and fortieth years. The dis- ease, constituting what was formerly called cystic sarcoma, is strictly of a benign character, and is never reproduced after removal. Its progress is always very tardy, and is seldom attended with any decided disorder of the general health, the chief inconvenience caused by the morbid growth arising from its weight and bulk, which are sometimes enormous. How the affection originates is unknown. It usually begins in the interlobular cellular tissue of the gland, which, as the disease advances, is completely annihilated. Two distinct forms of cystic disease of the breast are met with, the unilo- cular and the multilocular. In the former, the cyst, as the name implies, is single, and composed of a membrane which bears a very close resemblance to the peritoneum, its inner surface being perfectly smooth and glossy, while the outer is intimately connected to the surrounding parts by short, cellulo- fibrous tissue. Occasionally the cyst is intersected by membranous bands, sepa- rating it into a number of distinct compartments, of varying size and shape. When this is the case, the cyst is said to be multilocular. Various fluids are found in these sacs. Generally they are of a serous nature, more or less viscid, coagulable, of a saline taste, and of a limpid, or pale yellowish ap- pearance ; but cases occur in which they are of a reddish, olive, brownish, claret, or blackish hue. Not long ago, I saw an instance in which the fluid was of the color of the tincture of iodine. Sometimes, again, it is of a lac- tescent nature, whey-like, or rauco-albuminous. Finally, there are cases, although they are rare, in which the fluid contains cholesterine, flakes of lymph, and other substances. 968 DISEASES OF THE FEMALE GENITAL ORGANS. Cysts of the character now described often attain a large bulk, being capa- ble of holding from twenty to sixty ounces of fluid. Yery frequently, again, the cysts are multiple, their number, perhaps, rang- ing from a few dozens to many hundred. When this is the case, they are generally very small, their volume varying from that of a hemp-seed to that of a pigeon's egg. Their shape is usually spherical, ovoidal, or conical. When young, they are smooth, trans- Fig. 646. parent, elastic, vascular, closely ad- herent, and filled with a clear, wa- tery fluid, slightly saline in its taste, and scarcely coagulable by heat, alcohol, or acid. Their parietes, however, are liable to become opaque and thickened, from the ef- fects of inflammation, and the same cause generally induces remarkable changes in the contained fluid, which may be lactescent, bloody, oleagi- nous, glairy, or gelatinous. Difl'er- ent cells of the same tumor often have dissimilar contents. The mor- bid mass is sometimes entirely com- posed of cysts; at other times a con- siderable proportion of solid matter is interposed between them, commonly of a tough, cellulo-fibrous nature. The characters of the multiple form of this disease are well seen in fig. 646, from a preparation in my cabinet. The diagnosis of this malady is often obscure, especially in its earlier stages. The chief signs of distinction are, the gradual and steady growth of the tumor, the absence of pain and of lymphatic involvement, a sense of fluctuation, more distinct at some points than at others, the natural appearance of the integuments, and the retention of the general health. When any doubt exists, it will usually be promptly dispelled by a resort to the exploring needle. When the tumor is large and of long standing, it sometimes manifests a disposition to ulcerate, but, in general, as it goes on increasing, the skin gradually accommodates itself to its size. The only reliable remedy for this disease is free excision, including, if the tumor is unusually bulky, an elliptical portion of integument. If the cyst is unilocular, and not very large, a cure may generally be effected with the seton, or the injection of iodine. Or, instead of these, the sac may be laid open, and irritated with a tent. When the cyst is very capacious, nothing short of excision will answer, and there is the raore reason for its performance when there is a probability that the tumor has completely annihilated the glandular structure of the organ. Cystic disease of the breast. 2. HYDATIC TUMORS. Hydatids seldom infest this gland, at least in the females of this country. In the examination of a great number of breasts, I have not met with more than two cases. They always belong to the class of echinococci, and are most common between the ages of twenty-five and fifty. Varying in volume between a currant and an orange, they may occur in any portion of the organ, the proper substance of which they generally completely destroy. They are of globular figure, and present themselves either in clusters, or as bodies perfectly distinct from each other. When of considerable size, it is not uncommon to find within the old hydatids young ones, hanging by narrow footstalks, and LACTEAL TUMORS. 969 having precisely a similar configuration and structure. The contained fluid is generally thin and limpid, but it may be thick and glairy, like the white of egg. In the older hydatids, especially such as are partially dead, there is sometimes an admixture of blood, pus, albumen, or curdy raatter. These bodies may exist either alone, or in connection with other morbid products ; and, when large and numerous, are productive of extraordinary enlargement of the breast, cases now and then occurring where the organ weighs from eight to ten pounds. As in the cystic tumor, so in this, the diagnosis is often very difficult, if not impossible. In its earlier stages, the disease is liable to be confounded with scirrhus; afterwards, when it has attained a large bulk, with encephaloid. The most important signs are, the tardy progress of the case, the unimpaired state of the general health, the absence of lymphatic involvement, the natural appearance of the skin, and the globular or ovoidal shape of the tumor, together with its large size and want of adhesion to the surrounding struc- tures. The pain is usually much greater than in mere cystic disease, although there is soraetimes none at all, and there is but little fluctuation, except when the tumor has acquired a large bulk, when it is always well marked. There is nothing, however, of a truly diagnostic character in any case, except the escape of some of the contents of the tumor. The only remedy for the hydatic tumor is thorough excision, performed as soon as possible after the establishment of the diagnosis. The operation is never followed by relapse. 3. LACTEAL TUMORS. The breast, in consequence of the occlusion of some of its lactiferous ducts, is liable to an inordinate accumulation of milk, forming a distinct swelling, known as the milk tumor. It is generally of a globular or ovoidal shape, and is capable of acquiring a large bulk, as is evident from some of the reported cases. Thus, in one related by Professor Willard Parker, in a woman, aged thirty-five, three quarts of fluid were evacuated at the first ope- ration, and half that quantity in a week afterwards. In an instance recorded by Scarpa, the breast measured thirty-four inches in circumference, and gave vent, on being punctured, to upwards of a gallon of pure milk. It has been supposed that the sac in which the fluid is contained, is formed by the dila tation of the lactiferous tubes ; but, considering the rapid development of the tumor, and the enormous volume which it occasionally attains, the more plausible conjecture is that the milk is poured out into the connecting cellu- lar tissue of the gland, which is thus gradually condensed into a sort of cyst. The swelling usually begins within the first month after delivery, and often attains a large bulk in a few weeks. It is attended with a peculiar sense of distension, without any decided pain, and distinctly fluctuates under the finger. On cutting into it, the contents are found to be of a whitish color, and of the consistence of milk, cream, or whey. The general health is unimpaired. When the tumor is unusually voluminous, there is always marked enlargement of the subcutaneous veins. There is a form of milk tumor of the breast, in which the contents are of a solid character, bearing a close resemblance to butter, and hence called the butyroid tumor. It consists of a cyst, inclosing a yellowish, concrete sub- stance, of the appearance of butter, cheese, or casein. Microscopical and chemical examinations render it highly probable that this formation takes its rise in a deposition of milk, consequent upon the rupture of a lactiferous duct, the more fluid portions being absorbed, while the solid are retained, and thus gradually assume the properties here assigned to them. The disease is very uncommon, and the diagnosis must necessarily be very obscure. 970 DISEASES OF THE FEMALE GENITAL ORGANS. The treatment of the milk tumor should be conducted upon the same prin- ciple as that of any other encysted formation ; that is, either by the injection of some stimulating fluid, as the dilute tincture of iodine, the seton, or the tent, care being taken that the resulting inflamraation does not run too high. When the tumor is solid, the proper operation, of course, is excision. 4. ADENOID TUMORS. The breast is liable to a species of fibrous transformation, not unlike that which we occasionally see in the testicle. It is principally observed in young females, either single, or married and without offspring. The tumor, which is slow in its formation, is free from malignancy, and is seldom attended with any marked disorder of the general health. The breast feels hard, usually somewhat unequally so, and often acquires a considerable bulk, producing perhaps, ultimately, considerable inconvenience by its weight. The subcu- taneous veins become gradually enlarged, but there is hardly any pain, and no involvement of the neighboring lymphatic ganglions. The nipple is generally natural. The disease usually arises without any assignable cause. The intimate structure of this tumor consists of a pale grayish, pink, or bluish substance, nearly homogeneous, friable, easily crushed, and very simi- lar to that of a hypertrophied lymphatic ganglion. Hence, the term adenoid, now generally applied to this form of mammary tumor. Some parts of it may be so hard as to creak under the knife, and specimens occur which pos- sess all the properties of old fibrinous concretions. Minute cells, variable in size and number, are occasionally scattered through it. Generally the tumor is inclosed by a distinct capsule of condensed cellular tissue. The probability is that the transformation commences in the interlobular sub- stance of the organ, and that new fibrous tissue is superadded, which, by its pressure, causes at first atrophy, and finally total destruction of the primitive glandular texture. The adenoid mamma is occasionally filled with small nodules, of a rounded form, from the size of a filbert to that of a common hickory-nut, hard, almost inelastic, movable, inclosed in cysts, and perfectly distinct from each other, the intervals between them being occupied by fibrous substance. In a speci- men in my cabinet, removed from a married, but sterile, female, aged thirty- three, each breast coutains at least a dozen of such masses. The disease had been in progress for upwards of three years, and was attended with considerable enlargement of each gland, but there was an entire freedom from pain, lymphatic involvement, and disorder of the general health. The organs were perfectly mov- able, and numerous nodules could be felt in their substance in every direction. The nipples were badly developed, but not more retracted than we often see them in women who have never borne children. Upon making a careful examination of the little bodies above described, I found that they all consisted of a kind of cyst, inclosing a mass bearing a striking re- semblance to a cauliflower, being com- posed of a fibrous membrane, of a white, glistening appearance, thin, and semi- Adenoid tumor of the mamma, exhibiting f ° , Lc, ,, j ... ,, m ~f .1 ;. ... . .. , . , transparent, folded like the ruffle of a its cystiform arrangement and internal struc- « ,,,,., ture. shirt, and studded with an immense num- MALIGNANT TUMORS OF THE BREAST — SCIRRHUS 971 her of small, delicate excrescences, looking very much like the warts which are so often met with upon the penis. They all adhered by a broad base or stem, and were made up each of a number of minute granules, resembling the eggs of certain insects. Under the microscope, Dr. Da Costa and myself found the stems to consist of fibrous tissue, while the granules were composed, for the most part, of rounded bodies, presenting a delicate, fibrillated stroma, inclosing small, ovoidal, and spindle-shaped cells in varying proportion. The hard part of the mamma, that in which the nodules were developed, consisted of bundles of very dense fibrous tissue, wavy, and extremely distinct. Fat-cells were here and there embraced in its meshes. The adjoining cut, fig. 647, represents, though very imperfectly, the internal structure of these nodules. The only remedy for this tumor is excision, but such a measure will only be required in the event of the morbid growth being very large, painful, or inconvenient by its weight. Sorbefacient applications, and the exhibition of iodine, are usually of no benefit. Com- pression might be tried in the early stages of the disease. The microscopic features of the ordinary fibrous tumor of the mammary gland are well exhibited in fig. 648, from a drawing by Dr. Packard, from one of my clinical cases, a wo- man, aged forty-three. A sec- tion of the growth, treated with acetic acid, revealed 1st, por- tions of lactiferous tubes, some lined with epithelium, and others showing merely a base- ment-membrane ; 2d, fibrous tissue; and, 3d, fibro-plastic cells in small numbers. The tumor, about the volume of a large fist, had commenced seven years previously, and had laterally been the seat of sharp, shooting pains. There was no retraction of the nipple, lymphatic involvement, enlargement of the subcutaneous veins, or serious disorder of the general health. MALIGNANT TUMORS. The most common malignant diseases of the mamma are scirrhus and en- cephaloid. Melanosis and colloid are extremely infrequent. 1. SCIRRHUS. Scirrhus of the breast is most common soon after the decline of the menses, in married females, the greatest number of cases occurring between the ages of forty-five and fifty-five. It is extremely rare to meet with an instance before the fortieth year. Old maids occasionally suffer from it, but much less frequently, relatively speaking, than women who have borne children. Its origin is generally spontaneous, although it is often referred by the patient to the effects of a blow or some other external violence. It has been known to happen in four or five members of the same family, and occasion- Fig. 648. Fibrous mammary tumor, a. Gland tube, containing nucleated cells, b. Fibrous tissue, c. Fibro-plastic cells. d. Free nuclei. 472 diameters. 972 DISEASES OF THE FEMALE GENITAL ORGANS. ally it co-exists with scirrhus in other parts of the body. An instance now and then occurs in the male. It usually begins insidiously as a small cir- cumscribed lump, hard and irregular to the touch, and somewhat tender on pressure. As the disease progresses, the whole gland becomes involved, assuming a firm and knobby character, movable, and the seat of occasional pain, of a sharp, lancinating, darting nature Advancing still farther, the tumor gradually contracts adhesions to the surrounding parts, especially to the pectoral muscle, so that eventually it can no longer be lifted up, or pushed about. In the meantime the nipple is retracted ; the skin is puck- ered and discolored ; the superficial veins enlarge, and assume a deep bluish tinge; and presently ulceration sets in, leaving one or more circular sores, with hard, depressed, angry-looking edges, and a foul, sloughy base. The discharge is thin, ichorous, offensive, and often so acrid as to corrode the healthy skin. Gradually the irritation extends to the neighboring lymphatic ganglions, which either become white, firm, and tumid, or they are rendered preternaturally soft and vascular, having often a bloodshot appearance. The retracted appearance of the nipple is well shown in fig. 649, from a patient at the Jefferson College clinic. It often begins early in the disease, Fig. 649. Fis. 650. Scirrhus of the mamma, showing the characteristic retraction of Scirrhous tumor of the breast, the nipplo. exhibiting a section of the re- tracted nipple. and is produced by the manner in which the lactiferous tubes are compressed by the scirrhous matter. This effect is admirably exhibited in fig. 650. Although scirrhus generally commences in the glandular structure of the mamma, yet occasionally its primitive seat is in the common integuments and in the surrounding cellulo-adipose tissue. In the former case it usually pre- sents itself in the form of a small, rounded tubercle, scarcely larger than a shot, of a bluish color, firm, superficial, movable, and free from pain. This, gradually increasing, finally involves the glandular structure, the skin, mean- time, becoming hard, discolored, and intimately adherent to the subjacent parts. In the other variety of the disease, a firm, oblong, or spherical lump, of considerable volume, is from the first felt deeply imbedded in the adipose tissue around the organ, with which it has apparently as yet no connection. SCIRRHUS OF THE BREAST — SYMPTOMS. 973 crisp, a dry, 651. Scirrhous mamma laid open to show its lobulated structure. It may readily be lifted away with the thumb and finger, but it soon contracts adhesions, gradually contaminates the adjacent structures, slowly approaches the surface, and at last breaks out into a foul, irritable, fungous ulcer. On dissection, the mamma is found to be inelastic, firm, dense, and like cartilage, which it also resembles in color; sometimes it is of fibrous texture, like the interior of an un- ripe pear, and of a light grayish tint, inter- spersed with yellowish lines, probably the remains of lactiferous ducts; more rarely the organ is soft and succulent, presenting a considerable number of small vessels, and yielding, upon pressure, a thin, opaque, serous fluid, occasionally blended with milk. These appearances frequently occur to- gether, forming so many zones, gradually and insensibly running into each other. In some instances, again, the tumor contains one or more cavities, filled with purulent raatter, or with a viscid, ropy fluid, not un- like the synovia of the joints. The malady, as already stated, usually commences in a few lobules ; but as it pro- gresses, the whole organ becomes converted into a firm, solid mass, with a rough, tu- berculated surface. In the annexed sketch, fig. 651, taken from a specimen in my cabi- net, a large number of nodules are seen, the largest of which, hard and crisp, like car- tilage, and of an oblong, spherical* shape, scarcely equal the size of a pullet's egg. Fig. 652 exhibits a section of one of these bodies. Scirrhus of the breast sometimes remains stationary for a considerable length of time, when, taking a fresh start, it rapidly as- sumes the characters above assigned to it. certain eventually to return, either at the cicatrice, or in the contiguous lym- phatic ganglions. The tumor is sometimes invaded by gangrene, even before ulceration has commenced. In a case of this kind, which came under my observation a few years ago, and which is described in the chapter on scir- rhus, the morbid growth was lifted completely out of its bed, the cavity being afterwards filled up with healthy granulations, though the disease re- turned subsequently in the neighborhood of the original affection. The symptoms of scirrhus of the breast are usually characteristic. Its lump-like origin in the body of the organ, the slow but steady progress, the great hardness and comparatively small volume of the tumor, the sharp, lan- cinating pain, the retraction of the nipple, the gradual adhesion of the gland to the surrounding structures, and the ultimate involvement of the neighbor- ing lymphatic ganglions, as those of the axilla and subclavicular region, are phenomena which it is impossible to misinterpret. The nature of the scir- rhous ulcer is also peculiar. It has an excavated appearance, as if a portion of the tumor had been punched out, with a foul bottom, and steep, everted edges. The discharge is thin, sanious, fetid, irritating, and more or less abundant. Hemorrhage sometimes occurs, but seldom to any extent. Re- traction of the nipple generally exists in a marked degree, and often begins at an early period of the complaint. Enlargement of the lymphatic ganglions, which seldom shows itself before the end of the ninth or tenth month, is gene- Section of a scirrhous nodule. When removed, it is almost 974 DISEASES OF THE FEMALE GENITAL ORGANS. Ulceration of a scirrhous breast. rally very conspicuous after ulceration, especially in the axilla. In the more severe forms of the disease, it generally affects those also of the subclavicular region and even those of the neck. Swelling, pain, and numbness of the corresponding extremity always attend the malady in its latter stages, and greatly augment the suffering, the limb becoming per- fectly stiff and useless, and feel- ing like a mass of lead. The annexed drawing, fig. 653, taken from a clinical case, exhibits the condition of the scirrhous breast in the advanced stage of the disease, after the occurrence of ulceration. The tumor was of unusual volume. The general health is variously affected. In most cases it re- mains comparatively good until ulceration begins, when it usu- ally rapidly declines, the body becoming emaciated, and the countenance exhibiting that pe- culiar sallow, cadaverous appear- ance, so denotive of the cancer- ous cachexia. The pain, in the latter stages of the disease, is generally atrocious, depriving the patient both of appetite and sleep. The duration of the disease is far from being uniform. Left to itself, it generally terminates fatally at a period varying from eighteen months to two years and a half. Occasionally death happens much sooner; and, on the other hand, instances occur in which it does not destroy life under ten, fifteen, or even twenty years, although such an event is extremely uncommon. When ulceration has once fairly begun, the health is rapidly undermined, and death usually follows in a few months. During the progress of this disease, secondary scirrhous growths sometimes appear; generally in the skin and cellular tissue of the breast, or in the parts immediately around, in the form of tubercles varying from the volume of a small shot to that of a pea, exceed- ingly firm and solid, slightly movable, very tender on pressure, and the seat of sharp, pungent pain. They often exist in large numbers, as in fig. 654. Thus, in one case I counted upwards of thirty. Occasionally they occur both over the mammary gland and at some distance from it. In an instance recently under my care, in a female upwards of fifty, whose breast had been the seat of an enormous scir- rhous tumor, of nearly two years' standing, tubercles of this kind ap- peared a few weeks before death upon the corresponding side of the trunk near the spine, shoulder, neck, and head, and also upon the upper part of the opposite arm. As these secondary growths increase in size, they project beyond the skin, and exhibit a red, vascular, angry appearance. ^? Secondary scirrhous nodules ENCEPHALOID OF THE BREAST. 975 2. ENCEPHALOID. In comparison with scirrhus, encephaloid of the mamma is an extremely rare disease. No reliable statistics have been published respecting the favorite period of its attack, but, judging from ray own observations, I ara inclined to believe that it is most common in elderly subjects. I have met with it, however, repeatedly before the age of thirty-five, and in one instance in a girl of fifteen. Of its relative frequency to encephaloid in other organs, it may be stated that of one hundred cases of the disease analyzed for me by Dr. Cassot, only six occurred in the breast, the eye being affected in ten, and the scrotum and testicle in fourteen. Encephaloid of the mamma usually begins, without any assignable cause, as a small tumor in the substance of the gland, which generally increases with frightful rapidity, often acquiring the bulk of a large fist or even of a foetal head in the course of a few months. Like scirrhus, it is at first mova- ble, but eventually it is firmly united to the surrounding structures, which it is sure, in time, to involve and contaminate. The pectoral muscle, in parti- cular, is liable to suffer in this manner. The lymphatic ganglions, however, generally escape longer, comparatively speaking, than in hard cancer, and I have seen several cases in which, although there was extensive ulceration, they were entirely free from disease. Moreover, the subclavicular and cervical ganglions are less liable to suffer than in scirrhus. The tumor is usually knobby or tuberculated, and of varying degrees of consistence, being firm and incompressible at one point, soft at another, and perhaps fluctuating at a third. There is seldom any marked retraction of the nipple, even in the advanced stages of the malady. The subcutaneous veins are always greatly- enlarged; the pain is comparatively slight; and the parts are generally sin- gularly tolerant of manipulation. Ulceration sets in at variable periods; Fig. 655. Fungus heroatodes of the mamma, in its open bleeding state. rarely before the ninth month or later than the twelfth. The resulting sore is peculiar. Its character is essentially that of a fungus, projecting beyond 976 DISEASES OF THE FEMALE GENITAL ORGANS. the surrounding level, soft, red, and the seat of more or less bleeding, and of a constant sanious, or thin, fetid, and sanguinolent discharge. The edges of the ulcer are sharp and undermined, and often drawn tightly over . the protruding mass. Like the scirrhous ulcer, the encephaloid is intracta- ble; its tendency is to spread, not to heal, neither having the power of form- ing healthy granulations. The external characters of the fungating and bleeding stage of the disease are well shown in fig. 655. The general health in encephaloid usually suffers at an early period ; the patient loses flesh and strength, and the countenance exhibits a sallow, withered appearance, denotive of the profound impression which the disease is making upon the system. The pulse is small, frequent, and irritable, the appetite fails, sleep is interrupted by the pain and the discharges, night- sweats set in, and thus the case steadily progresses, from bad to worse, until life is worn out by exhaustion. Sometimes the immediate cause of death is hemorrhage. The period at which this occurs varies, on an average, from about six to twelve months. The characters of encephaloid are, in general, too well marked to admit of mistake, especially if the disease has taken a fair start. The great size, rapid growth, and comparative softness of the tumor, the healthy condition of the nipple, the enormous enlargement of the subcutaneous veins, the absence for a long time of severe pain, and the early constitutional involvement, will always serve to distinguish it from every other disease of the mammary gland. When, however, any doubt exists as to the diagnosis, as there may when the tumor has been developed with extraordinary rapidity, or when it presents well-marked evidence of fluctuation, the exploring needle raay be used ; of course, with great caution. After ulceration has begun, error is impossible. The anatomical characters of encephaloid of the breast do not differ from those of soft cancer in other organs of the body. The structure of the tumor is seldom uniform, either as it respects its consistence, color, or composition. Thus, on making a section of it, one portion may perhaps be of a fibro- cartilaginous character, another pulpy and brain-like, and a third probably hematoid, or cystiform. Cavities or Fig. 656. cells, containing different kinds of fluids, are often interspersed through it. Large clots of blood, sometimes of a black, brownish, or yellowish- buff color, and of varying degrees of consistence, are also sometimes met with. The tumor has no capsule, except what is derived from the sur- rounding cellular tissue, which is occasionally considerably condensed; its surface is rough and lobulated, and its substance is usually pervaded by numerous vessels, many of them of large size. Hence the rapidity of its growth, its large bulk, and the fre- quent and exhausting hemorrhages after ulceration has commenced. It soraetimes co-exists with encephaloid or scirrhus in other organs. Fig. 656 affords a good idea of the hematoid form of encephaloid of the mamma. The tumor from which the drawing was taken was removed from a negress, thirty years old, and was of very large size. Encephaloid of the mammary gland, of the hematoid variety. COLLOID AND MELANOSIS OF THE BREAST — TREATMENT. 977 3. COLLOID AND MELANOSIS. Colloid, alveolar, or gelatiniform cancer rarely attacks the breast. The tumor advances slowly, and seldom exceeds the volume of the fist or of a foetal head. Externally, it is of a light grayish color, dense, firm, glistening, and irregularly lobulated; internally, it is comparatively soft and succulent, yielding some moisture on pressure, and tearing into hard, jelly-like strings. The cellular arrangement, so well marked in alveolar cancer of the stomach, is seldom very distinct in that of the breast. Melanosis of the breast occurs either as an infiltration amongst the granules of the gland, or, as is most frequently the case, in the form of small, spherical nodules, of a black, sooty color. Of this disease, I saw an interesting speci- men, some years ago, in an old female who died of pulmonary phthisis, accom- panied with scirrhus of the left mamma. The little tumors, five in number, were distinctly encysted, and contained a thin, ropy fluid, of the color and consistence of China ink. TREATMENT. The treatment of malignant diseases, in general, has been so fully dis- cussed in the first volume, as to render it altogether superfluous to say anything of a formal character respecting that of the malignant diseases of the breast. The great aim, in every case, whatever may be the nature of the malady, should be to maintain the health as nearly as possible at the normal standard, by a proper regulation of the diet, bowels, and secretions, with a careful suspension of the affected organ, and an avoidance of pressure by the dress. Pain and tenderness should be relieved in the usual manner. All ideas of specifics must be discarded. The case must be managed upon general principles, precisely as the most common disease. Leeches often prove useful when there is inordinate vascular turgescence ; and under such circumstances, also, much benefit often results from astringent lotions. Ano- dyne plasters are frequently extremely soothing. Systematic compression, formerly so much vaunted, has been proved to be utterly useless. When ulcer- ation takes place, the leading indications are, to moderate discharge, mitigate pain, promote cleanliness, and sustain the strength. In regard to interference with the knife, nothing could be more unpromis- ing. Although I have removed the breast in numerous cases, I have never, in a solitary one, succeeded in effecting a permanent cure ; and such is pre- cisely the result of the experience of the profession generally. If, as is alleged, a radical cure occasionally follows the use of the knife, the circum- stance is to be ascribed either to good luck, or, what is more probable, to the fact that the disease for which the operation is performed was not of a malignant, but simply of an ordinary character. It has been asserted that, although malignant affections of the breast cannot be cured by ablation of the affected organ, yet that it has the effect of prolonging life, on an average, from six to eighteen months. This may be possible, but, if it be, the fact remains to be established by reliable statistics, founded upon well-observed cases after excision. In many cases, as every one knows, the patient is lost sight of as soon as the parts have recovered from the immediate effects of the operation, and iu many more the history is obtained only very imperfectly. I have not known more than three or four instances where the woman lived longer than six or eight months without relapse, or an outbreak of the dis- ease somewhere. Others may have been more fortunate, but this is strictly what I have myself seen, in cases unequivocally cancerous. When the tumor vol. n.—62 978 DISEASES OF THE FEMALE GENITAL ORGANS. occurs late in life, and is of tardy development, the chances are that the patient will get on better after excision than under opposite circumstances. I am sure that the use of the knife has occasionally hastened the fatal event. My practice, for many years, has been not to interfere, if the disease is, on the one hand, in great degree dormant, or, on the other, uncommonly rapid in its progress. Xo conscientious surgeon will, of course, ever operate when there is extensive ulceration of the tumor, great involvement of the lymphatic ganglions, well-marked evidence of the cancerous cachexia, or co-existent malignant disease in other parts of the body. Occasionally, I have been induced to remove a carcinomatous breast merely with a view of making the poor patient more comfortable, by relieving her temporarily of pain, profuse discharge, and excessive fetor; but, in general, such a course is not advisable. It need hardly be added that encephaloid disease «f the mamma always proves fatal more rapidly than scirrhus, whether it be let alone, or whether it be subjected to operation. EXCISION OF THE BREAST. Extirpation of this gland is generally a very easy and simple affair. It is only when the organ is much enlarged by disease, or when it is very vascular, that the operation is likely to prove annoying and embarrassing, especially if there be not a sufficiency of assistants. During its execution, the patient may either sit up or lie down ; the latter posture I always prefer, as it gives us better control over the parts, at the same time that chloroform may be administered with greater safety. In most cases, it will be necessary to remove a portion of integument, par- ticularly if the breast be at all large, or if there be any cutaneous involvement, either actual or impending. Hence the incisions should usually be elliptical, as shown in fig. 657 ; and it will always be well, if possible, to Fig. 657. make them in the direction of the fibres of the great pectoral i muscle, as this will tend to facilitate both the liberation of the A organ and drainage after the operation. The surgeon, however, is / \ not always able to control this matter, owing to the peculiar condi- I tion of the parts, and he will, therefore, occasionally be obliged to y / make his incisions very oblique, or, indeed, almost perpendicular. Y In all cases an attempt should be made to save enough integument for the easy reunion of the edges of the wound; for I deem it a matter of great moment that as much of the wound as possible should be healed by the first intention, believing that such a result will be much less likely to be followed by speedy relapse than when the wound is permitted to gap. The integuments being properly stretched, and the arm held off nearly at a right angle from the body, the knife is thrust through the skin and cellulo- adipose tissue, and carried round the diseased mass in such a manner as to include every particle of it, the lower incision being always made first. The dissection is then performed in the direction of the fibres of the pectoral muscle, which should be thoroughly exposed by the removal of its fibrous envelop. If any arteries of considerable size spring, they should immediately be compressed by the finger of an assistant, and carefully tied as soon as the operation is over, together with any of the smaller branches that might after- wards become a source of hemorrhage. When the tumor is inordinately vascular, it may be prudent to ligate each vessel as soon as it is divided, but this is generally an awkward and unnecessary procedure. Before the parts are approximated, the wounded structures are examined with the greatest care, in order that not the slightest particle of the morbid substance may be left. In fact, the very atmosphere of the disease should be removed. BANDAGES FOR THE BREAST. 979 The adjoining sketch, fig. 658, affords a correct illustration of the position of the patient in this operation, and of the lines of the incisions. Fig. 658. Excision of the breast. If any of the lymphatic ganglions in the axilla are involved, they should be dealt with in the same manner as the breast itself, either by an extension of the outer angle of the incision, or by an incision immediately over the affected structure, which is then generally readily enucleated with the finger or the handle of the scalpel. I make it an invariable rule, in excision of the mammary gland, not to approximate the parts until four or five hours after the operation, lest second- ary hemorrhage should arise, and thus necessitate the removal of the dressings. The wound should be covered, in the interval, with a light, soft cloth, fre- quently wet with cold water. Care should be taken to use only a few stitches, and to press the flaps well down with long adhesive strips, aided by a com- press and a bandage, carried around the upper part of the chest. The arm should be supported in a sling, the treatment should be strictly antiphlogistic, and the dressings should not, as a general rule, be disturbed until the fourth day. When there is a want of integument, or injurious tension, it will be well, in the former case, to borrow a sufficiency from the neighboring parts, and, in the latter, to ease the flaps by suitable incisions, practised a short distance from the edge of the wound. BANDAGES FOR THE BREAST. The breast, like other organs, demands, when diseased, proper rest and support. The duty of the surgeon is very imperfectly discharged if he does not attend to these important points. For ordinary purposes the organ raay be easily sustained with a light silk handkerchief, thrown around the opposite shoulder, and so arranged as to make equable pressure. _ When greater nicety is required, a special apparatus may be used, consisting of a silk or gum-elastic web, adapted to the shape and size of the gland, and secured to the body by shoulder-straps and a body-piece, the mode of construction and application being similar to those of the suspensory bandage for the scrotum. A beautiful contrivance of this kind is made in this city at the Nurses' Home. Sometimes the object may be advantageously attained by means of two 980 DISEASES OF THE FEMALE GENITAL ORGANS. broad adhesive strips, carried loosely across the breast, as in fig. 659; or by splitting a piece of old linen into two tails, one of which is fastened rouud Mode of supporting the breast by strapping. the body, while the other is passed over the shoulder, thus supporting the organ in the form of a sling, as exhibited in fig. 660. Fig. 660. Sling for the breast. DISEASES OF THE BREAST IN THE MALE. The mammary gland of the male, although existing only in a rudimentary state, is liable to the same diseases, benign and malignant, as that of the DISEASES OF THE BREAST IN THE INFANT. 981 female, but only, as experience has shown, in very rare instances. The most frequent affections here, according to ray observation, are hypertrophy, indu- ration, and neuralgia, which, indeed, are generally associated, and are suffi- ciently common to render them objects of great practical interest. In 1859, not less than three cases of these diseases were at the same time under my care at the Jefferson Medical College Clinic, all the patients being young men other- wise in gcod health. In each the organ was very hard, decidedly enlarged, remarkably tender on pressure, and the seat of sharp, darting pains, liable to frequent exacerbations. Occasionally both glands are involved, but, in gene- ral, the affection is limited to one. The treatment of these several affections must be conducted upon the same principles as in cases of mammary neuralgia, or irritable breast in the female. In general, however, the result is anything but satisfactory; for, although temporary amelioration may soon follow, it is only after a long time, and frequent relapses, that permanent relief is obtained. The most reliable reme- dies are quinine, arsenic, and strychnia, with a minute quantity of bichloride of mercury, aided by occasional leeching, and the use of sorbefacient and anodyne plasters. Abscesses sometimes form in the mammary region of the male, either in the substance of the gland immediately below the integuments, between the gland and the pectoral muscle, or beneath the latter, especially when the sup- puration has been provoked by external violence, as a fall or blow. The diagnosis is generally easy, and the treatment sufficiently obvious. The breast of the male has been found to be enormously hypertrophied, forming a large, heavy mass, at the front and side of the chest. It is also occasionally the sesft of adenoid, fibro-plastic, and encysted tumors. The adenoid and fibro-plastic growths sometimes ulcerate, throwing out fungous, cauliflower-like excrescences, which, independently of their alarming appear- ance, are more or less painful, and the seat of a fetid discharge. The proper remedy is extirpation. Of the malignant diseases of the male breast the most common is scirrhus; encephaloid is very infrequent, and it is questionable whether it has ever been the seat of melanosis and colloid. Hard and soft cancers pursue the same course here as in the other sex ; they are most common in elderly subjects, and are generally easily distinguished by their external characters. Extir- pation is always followed by a recurrence of the disease, though usually not so soon as when it affects the female breast. DISEASES OF THE BREAST IN THE INFANT. Xew-born infants are subject to a peculiar intumescence of the breast, consisting in inflammation of the glandular structure of the organ and of the surrounding cellulo-adipose tissue, the nipple, which is usually a good deal enlarged, forming the centre of the swelling. The part feels excessively hard, and is exquisitely tender on pressure. Under an erroneous supposition that the disease is caused by an accumulation of milk, the breast is often rudely squeezed; a circumstance which never fails to aggravate the morbid action. If improperly managed, suppuration may occur, as I have witnessed in quite a number of cases. Both breasts are sometimes involved. The disease gene- rally appears within the first fortnight; sometimes, indeed, within the first few clays, or at so early a period as to induce the belief that it is congenital. As it advances, the part becomes excessively painful, and the child is feverish and restless. The disease, in its incipient stages, generally readily yields under the use of sweet oil and laudanum with a little ammonia, applied quite warra, and rubbed in well frequently with the bare finger. In the intervals the surface 982 DISEASES OF THE FEMxVLE GENITAL ORGANS. should be constantly covered with a thick layer of flannel saturated with n solution of hydrochlorate of ammonia, in the proportion of one drachm to eight ounces of water and two of vinegar. When the disease is obstinate, or already far advanced, a leech may be applied, followed by a teaspoonful of castor oil. In the event of suppuration, an early puncture is made. AFFECTIONS OF THE MAMMARY REGION. The mammary region is subject to encysted tumors, either congenital or acquired, single or multiple, simple or compound. Their contents are varia- ble, but, in general, they are strictly serous, and of a pale straw or amber color. Their volume ranges from that of a pea to that of an adult head; they fluctuate distinctly under pressure, are free from pain, and often grow with great rapidity. The most remarkable instance of congenital cyst of this region that I have ever witnessed was under my charge in 1847, in a male infant, aged three weeks. The tumor was of a globular shape, and measured thirteen inches in circumference at its base; it was somewhat lobulated, soft, elastic, fluctuating, and translucent, like a hydrocele, the skin being perfectly sound, but traversed by several large veins. It was occupied by nearly a pint of yellowish, serous fluid, saline in taste, and readily coagulable by heat and acids. A cure was readily effected by the use of a seton, consisting of a few silk threads, retained for forty-eight hours. The inflammation consequent upon the operation soon yielded to the use of saturnine lotions and a dose of castor oil, and the little patient made an excellent recovery. Such a tumor might be laid freely open, and mopped with tincture of iodine. • Scirrhus sometimes affects the mammary region instead of the mammary gland, its most common site, in this event, being the space between the outer and lower border of the breast and the axilla. I have seen several instances of this kind, in which the organ in question remained completely intact, from the commencement of the disease to its termination in death. The malady begins apparently in a lymphatic ganglion in this situation, from which it gradually extends in different directions until, at length, an immense tumor is developed, possessing all the characteristics of scirrhus. In a case recently under my observation, in an Irish female of seventy, both sides were impli- cated, though not in an equal degree. The disease was first noticed, in the form of a small lump, two years previously, while on her voyage from Europe to this country. She suffered excruciating pain of a sharp, lancinating nature, and her general health was rapidly declining, with a tendency, on the part of one of the tumors, to ulceration. In none of the cases of this disease that have come under my observation was there any involvement of the axillary lymphatic ganglions, though it is easy to suppose that such a complication might arise during the progress of the affection. Other morbid formations, as encephaloid, keloid, epithelioma, and chronic abscesses, are liable to occur on various parts of the chest, but, as they pre- sent nothing peculiar, they require no special notice here. GUNSHOT WOUNDS OF THE EXTREMITIES. 983 CHAPTER XX. DISEASES AND INJURIES OF THE EXTREMITIES. GUNSHOT WOUNDS. Gunshot wounds of the extremities are of frequent occurrence in time of war, and commonly require much judgment for their successful management, as they involve every possible grade of injury from the most insignificant scratch to the most appalling mutilation. The collapse is often so great as to cause death either immediately, or within a very short period after their receipt, the system, perhaps, never making the slightest effort at reaction. In the inferior extremity the shock and danger to life are always proportionately greater than in the superior, gunshot wounds and fractures sharing, in this respect, the same fate as common wounds and fractures. These effects increase in a marked degree as the injury approaches the trunk, precisely as in amputa- tions, those of the foot and leg being attended with much less risk than those of the thigh and hip. During the war in the Crimea, the ratio of mortality after amputations for gunshot lesions was, in round terms, 14 per cent, for the foot, 22 for the ankle-joint, 30 for the leg, 50 for the lower third of the thigh, 55 for the middle third of the thigh, and 86 for the upper third of the thigh, all amputations of the hip-joint having proved fatal. Gunshot injuries of the extremities may, very properly, be arranged under the following heads, according to the nature of the parts involved : 1st. Wounds simply or mainly of the muscles; 2dly, wounds of the vessels; 3dly, wounds of the nerves ; 4thly, wounds of the joints ; and, 5thly, wounds of the bones. 1. Wounds of the Muscles.—Gunshot wounds of the muscles, or simple flesh wounds, are not, in general, of themselves dangerous, even when of large extent, but they may readily become so when they occur in a person of intemperate habits or impaired constitution, or even when the health was excellent at the time of the injury, from exposure, fatigue, or improper man- agement. Erysipelas will then be very liable to arise, followed by high ex- citement, and by the formation of large abscesses, the pus often burrowing extensively among the surrounding structures ; ordinarily, however, such in- juries will, for the most part, do well, the patient making a rapid recovery with a good use of the limb. Of upwards of three hundred cases of flesh wounds of the upper and lower extremities which I saw after the battle of Bull Run, very few died. Indeed, most' of the men were able in a short time to return to duty. Shell wounds of the muscles are usually more dangerous than wounds made with rifle balls. In the hospital at Georgetown,! saw a man, aged thirty-eight, who died at the end of seven days from a frightful wound of the outside of the thigh, at least ten inches in length by four in width, caused by the bursting of his musket. As an offset against this case, I may mention one which occurred during the Mexican war, in a young pri- vate of the 2d Kentucky Regiment, who made an excellent recovery, although it would be difficult to conceive of a more terrible flesh wound. Here the muscles of the ri«-ht hip and of the outer and back part of the thigh, as low down as the popliteal space, were alraost entirely torn away by a shell, which at the same time denuded the head of the femur and the femoral artery, the 984 DISEASES AND INJURIES OF THE EXTREMITIES. pulsations of which were distinctly perceptible at the inner side of the limb. Notwithstanding this horrible mutilation, rapid recovery took place, and when I saw the man, three months after the accident, the parts were nearly cicatrized, without much impairment of function. Flesh wounds of the shoulder and back, inflicted by gunshot, are not, in general, dangerous. Of twenty-six men belonging to one of the Kentucky regiments, who were injured in this situation at the battle of Buena Vista, in 1847, not one died. The ball in nearly all had penetrated the deltoid mus- cle, and, passing upwards over the shoulder, lodged in the neck and back, from which it was afterwards extracted. The treatment of such injuries resolves itself into the removal of foreign matter, and the use of water-dressing, with rest and elevation of the limb, and attention to the diet, bowels, and secretions. The eschars, if there be any, will usually separate in five or six days, followed by healthy granulations, and there will seldom be any necessity for dilating the parts, unless there should be excessive tension, as when they are invaded by erysipelas, or wheu matter forms and threatens to burrow among the neighboring structures. 2. Wounds of the Bloodvessels.—The large vessels suffer much less fre- quently in gunshot wounds than might at first sight be supposed, their great resiliency enabling them to glide out of the way of the flying missile. An instance has been recorded by Mr. Guthrie in which a ball passed between the femoral artery and vein without dividing either. The fact is, this class of injuries is comparatively exempt from copious hemorrhage. It is only when a large artery or vein is perforated that the patient, unless promptly succored, will be likely to bleed to death. Sometimes a vessel, instead of being opened, is merely contused and slightly lacerated, the ball grazing its coats, which, inflaming, raay ultimately give way, and thus lead to trouble- some, if not destructive, hemorrhage. Such an event, which it is not always in our power to foresee, but which may reasonably be anticipated when the missile has passed in the direction of a large artery without having occa- sioned any serious bleeding, is most liable to occur from the sixth to the eighth day, and is always greatly to be deplored, inasmuch as, arising at a period when it is not expected, it may prove fatal before the necessary assist- ance can be rendered. It is, therefore, highly proper, in all such cases, to keep the limb for several days constantly encircled with a tourniquet, the use of which should be fully explained to the patient and his attendants, so that there may be no serious loss of blood in the absence of the surgeon. A vessel, grazed by a ball, does not always, unless devitalized, give way under the effects of its injuries ; on the contrary, the wounded part is often successfully repaired, or the canal at the site of the mischief is permanently obliterated by the formation of a clot. The causes of secondary hemorrhage in gunshot wounds of the extremities are, 1st, injury inflicted upon the vessels by the missile, or by a sharp spicu- lum of bone; 2dly, the premature detachment of the clot, in consequence of sudden and violent bodily exertion, attended with great increase in the force and rapidity of the heart's action ; and, 3dly, a want of plastic power in the blood, dependent upon the hemorrhagic diathesis, or the effects of an inade- quate supply of vegetable food. The period at which the bleeding thus oc- casioned sets in varies, on an average, from five to twenty days. The treatment of a wounded artery consists in exposing it at the seat of the injury, and applying two ligatures, one above and the other below the opening. This should be done as speedily as possible after the accident, before there is any considerable inflammation or swelling. Tying the vessel at its cardiac side alone will not suffice ; unless it be secured also at its dis- tal extremity, hemorrhage from the recurrent circulation will be inevitable. The operation should be performed even when all bleeding has ceased; espe- cially if the patient is obliged to be transported to any distance. Venous GUNSHOT WOUNDS OF THE NERVES AND JOINTS. 985 hemorrhage may generally be effectually arrested by compression ; the liga- ture should be employed only in the event of its failure. When the wound involves the principal artery and vein of a limb, ampu- tation will generally be required, in anticipation of the mortification which is so liable to occur in such an event from the interruption of the circulation. The operation, in fact, is sometimes demanded even when only one of these vessels is severely injured. 3. Wounds of the Nerves.—Unless the nerve is very large, a gunshot wound of it will not be likely to eventuate in any trouble, beyond a slight temporary paralysis or loss of sensation. Under opposite circumstances, however, the mischief may be very great; for then there may be, in addition to these effects, danger of mortification from the interruption of the nervous fluid, just as a limb may perish from the want of blood when its main artery has been divided. The mortification, in such a case, may be direct—that is, it may be caused by the mere suspension of the nervous power of the parts—or indirect, through the medium of inflammation ; the latter being the more common. Occasion- ally a gunshot wound of the nerves is followed by severe neuralgia, lasting, perhaps, for years, if not during the remainder of life. In the English army in the Crimea, only 23 cases of gunshot wounds of the brachial plexus and larger nerves, as the median, ulnar, and sciatic, are re- ported to have occurred; of which 9 proved fatal, being 41 per cent, of the whole. The cause of death in 5 of the cases was tetanus. Partial division of the nerves was sometimes followed, especially in the upper extremity, by total loss of sensation and power, which, though occasionally recovered from, often ended in atrophy, or atrophy and contraction of the muscles, with permanent disability of the limb. It is not always easy to decide upon the proper course of treatment in gun- shot wounds of the nerves. In the milder cases, the same plan should be adopted as in common flesh wounds. If the nerve is completely, but irregu- larly, divided, or much contused and lacerated, the safest procedure will be to cut off its ends smoothly, and to tack them nicely together with silver- wire sutures, hoping for ultimate reunion through the agency of plastic mat- ter; but, if the intervening space be considerable, such treatment would, of course, be improper. If the main nerve of a limb has been completely severed, amputation may be required, especially if the injury be complicated with lesion of an important vessel; but, even then, the surgeon should greatly hesitate before he undertakes so terrible an operation. 4. Wounds of the Joints.—The gravity of gunshot wounds of the joints has been recognized by all practitioners, military and civil, since the invention of firearms. The principal circumstances influencing the prognosis are the size and complexity of the articulation, the extent of the injury, and the state of the system and previous health of the patient. A gunshot wound of a gingly- moid joint is, in general, more dangerous than one of a ball-and-socket joint, and a gunshot wound of the hip, knee, and ankle, than one of the shoulder, elbow, or wrist. The structures around the articulation often suffer severely, thus adding greatly to the risk of limb and life. Of 65 cases of gunshot wounds of different joints, related by Alcock, 33 recovered, but of these 21 lost each a limb. Of the 32 that died, no operation was performed upon 18. Gunshot wounds of the smaller joints often do well, although they always require long and careful treatment. Lesions of this kind involving the shoul- der are frequently amenable to ordinary means. If the ball lodge in the head of the humerus, it should be extracted without delay, its retention being sure to excite violent inflammation in the soft parts, and caries or necrosis in the bone, ultimately necessitating amputation, if not causing death. If the bone is at all shattered, the proper operation will be resection. Gunshot injuries of the elbow generally do well under resection ; it is only when there is extensive lesion of the soft parts, along with great comminution 986 DISEASES AND INJURIES OF THE EXTREMITIES. of the bones, that amputation will be likely to be required. Similar remarks are applicable to gunshot injuries of the wrist and carpal joints. Gunshot wounds of the hip, knee, and ankle joints are always to be con- sidered as serious accidents, very liable to be followed by loss of limb and life. The danger is a hundred-fold increased when there is severe involve- ment of the articular extremities of the bones. Gunshot wounds of the knee are the most dangerous of all. Of upwards of forty cases of this kind in the French hospitals in the Crimea, in which an attempt was raade to save the limb, all, except one, proved fatal. Of nine cases which occurred in India, not one was saved. Guthrie never saw a gunshot wound of the knee-joint, attended with severe injury of the bones, recover without removal of the limb; the experience of Larrey was of the same nature; and Esmarch declares, as the result of his observation in the Schleswig-Holstein campaigns, that all lesions of this description demand immediate amputation of the thigh. Dreadful injury is sometimes inflicted upon a joint indirectly, as when a ball, passing through the extremity of a long bone, causes a fissure, which extends through the synovial membrane. Occasionally the missile traverses a joint, channelling a groove into the articular cartilage, but not inflicting any serious lesion upon the integuments. Such accidents, although, perhaps, apparently insignificant, are often followed by the raost violent inflammation, imperilling both limb and life. Patients soraetimes perish from secondary involvement of a joint, its structures taking on fatal action in consequence of a severe wound in its immediate vicinity. Lastly, an articulation may suffer terribly from gunshot injury without any external wound, as when it is struck by a partially spent ball or shell. When, in the raore violent forms of these articular injuries, an attempt is made to save the limb, the patient often perishes within the first three or four days, from the conjoined effects of shock, hemorrhage, and traumatic fever. If he survives for any length of time, large abscesses are liable to form in and around the joint, the matter burrowing extensively among the muscles, and causing detachment of the periosteum, with caries and necrosis of the bones. From all, then, that precedes it raay be assumed, as a general proposition, that, in the milder cases of these injuries, especially as they occur in the more insignificant joints, the ordinary precepts of conservative surgery should be enforced ; whereas, under opposite circumstances, it will generally be neces- sary either to resect the articular extremities of the bones, or to remove the limb at a suitable distance above the seat of the injury. Excision is adapted chiefly to gunshot wounds of the joints of the superior extremity, while am- putation is more frequently required in those of the inferior extremity. All large wounds of the knee-joint, or even comparatively small ones, if they involve the epiphysis of the femur or tibia, imperatively demand the latter operation ; and few cases of gunshot injuries of the ankle will be likely to arise on the field of battle in which such a procedure would not be preferable to excision. 5. Wounds of the Bones.—The effects of balls upon the osseous tissues are subject to great diversity. In the first place, the injury raay be very super- ficial, involving merely the periosteum or this membrane and a little of the compact substance of the bone; or, secondly, the missile may simply strike the bone, causing more or less severe concussion of its substance, without penetration, but yet inflicting a sufficient amount of mischief to induce violent inflammation, terminating in abscess, caries, or even necrosis; or, thirdly, the ball, as it courses along, may plough a groove into its surface, also liable to be followed by bad effects; or, fourthly, the vulnerating body may enter the bone, breaking and comminuting it, each fragment, as it is driven about among the soft parts, becoming thus an additional source of injury. The old round ball often glanced when it came in contact with a bone, but the Minie ball almost invariably perforates it, grinding it at a fearful rate, and so producing the very worst form of compound fracture. GUNSHOT WOUNDS OF THE BONES. 987 The number of fragments is extremely variable; thus, there may, on the one hand, be only two, three, or four, or, on the other, as many as a dozen, twenty, or even thirty. Their size, too, is very indefinite. Some of the fragments may be entirely detached, while others may retain their connec- tion with the main body of the bone, either by osseous tissue or through the periosteum. A long bone, instead of being broken, may be simply perforated. Hennen relates two cases in which the shaft of the femur was thus pierced, and three cases are referred to by Esmarch, in which a similar accident befell the upper third of the tibia. The lesion has also been observed in the humerus, radius, and ulna. A bone is sometimes terribly shattered by a large stone, struck and set in motion by a round shot, or a fragment of shell. Occasionally, again, a severe fracture is produced by a ball in ricochet without any apparent injury what- ever of the integuments, as in a case which I saw at Washington City, in a sergeant of Rickett's Battery, who was struck in this way on the arm by a twelve pound shot, which broke the humerus at three different points, but did not even bruise the skin. The treatment of this class of injuries, in its milder forms, must be con- ducted according to the ordinary rules of practice; by rest, elevation, and medicated water-dressing, aided, if necessary, by leeches and scarification, especially if erysipelas should arise. If the bone be severely broken and comminuted, resection or amputation will probably be required, and should be performed at once, as soon as reaction is sufficiently established. Gun- shot fractures of the femur are particularly dangerous, especially when inflicted with the Minie ball, and nearly always demand amputation, in consequence of the frightful shattering of the bone, causing not only great shock, but, if the patient survive, rapid and extensive swelling of the soft parts, followed by copious infiltration of pus. In the Crimea, a bad compound fracture of the thigh was considered as synonymous with death ; and the surgeons of the Black Sea Fleet never attempted to save a limb after such an injury, except at the risk of the patient's life. Stromeyer, in commenting upon the subject, declares that gunshot injuries!of the shaft of the femur are among the most dangerous lesions of the bones, and he adds that they are particularly apt to end unfavorably when they are produced tty a piece of exploded bomb or a grazing cannon ball, without division of the soft parts. A remarkable instance of recovery, nevertheless, occasionally occurs in gunshot fracture of the femur. Of this description is the case of Lieut. Adams, detailed in the chapter on gunshot wounds in the first volume of this work. The injury could hardly have been more frightful, and yet he got well with a very useful limb. An example like this should certainly serve to admonish the military surgeon not to sacrifice indiscriminately every limb, even when the injury is apparently of the most desperate nature; unfor- tunately, however, he cannot always, on the field of battle, carry out the dictates of his judgment; everything around him is unpropitious, and he is, therefore, often compelled to use the knife in cases which, under more aus- picious circumstances, as it respects locality, air, nursing, aud after-treatment, he might possiblv have saved. Gunshot fractures of the patella, unless attended with great comminution of this bone, and penetration of the knee-joint, do not necessarily require amputation. The cases observed by Hennen, Stromeyer, Tripler, and other military surgeons show that such accidents are often followed by excellent recoveries. Extensive laceration, on the contrary, of the ligament of the patella, with wound of the synovial membrane, will usually result badly if an attempt be made to save the limb. _ Gunshot fractures of both bones of the leg are also, generally speaking, bad accidents; great swelling, followed by diffuse abscess, usually rapidly 988 DISEASES AND INJURIES OF THE EXTREMITIES. sets in, and, unless the patient is peculiarly fortunate, he will be very apt to sink under the effects of erysipelas, pyemia, osteomyelitis, or hectic irritation, not to say anything of the danger of mortification, which is often very great, especially when the bones are comminuted, at the same time that severe injury has been sustained by the soft parts. Gunshot fracture of the fibula alone is usually much less serious than similar injury of the tibia. Gunshot fractures of the tarsal bones are generally grave accidents, liable, if an attempt be made to save the limb, to lead to very serious consequences, especially when the injury has been inflicted by a Minie ball or a piece of shell. I have seen several instances of the kind caused by the common round ball, which were promptly followed by tetanus and death, and such occur- rences are by no means infrequent in military practice. Gunshot fractures of the arm, forearm, and hand are, compared with similar lesions of the inferior extremity, in general, of a much less grave character, requiring, on the one hand, much less frequently amputation, and admitting, on the other, much oftener of resection. A great deal, of course, will depend, in every case, upon the extent of the comminution, and the amount of injury sustained by the more important soft structures. A very terrible form of contusion is sometimes inflicted upon the upper extremity of artillerymen by the premature explosion of the gun in the act of loading ; causing excessive commotion of the entire limb, horrible lacera- tion of the soft parts, and raost extensive infiltration of blood, accompanied, in many cases, by comminuted fracture, and penetration of the wrist and elbow joints. The constitutional shock is usually great. If an attempt be made to save the parts, diffuse suppuration, and more or less gangrene, will be sure to follow, bringing life into imminent jeopardy. The proper remedy is amputation, performed promptly at a considerable distance above the apparent seat of the injury, otherwise mortification will be apt to seize upon the stump. Gunshot fractures of the extremities are often attended with frightful hemorrhage, in consequence of the injury sustained by the soft parts from the loose splinters which are often driven about in every direction. The blood raay proceed altogether from the smaller vessel!, and the amount effused may be such as to cause the most extensive infiltration of the areolar tissue, both beneath the skin and among the muscles ; or a large artery or vein raay be opened, producing great distension of nearly the entire limb, especially if there be accidental closure of the wound. However this may be, the parts will be found, immediately after the occurrence, to be cold and numb, and of a remarkably pale appearance, soon succeeded by a mottled, purplish hue, and this, in turn, if the patient survive, by a greenish or brownish color. When an attempt is made to preserve the limb, the first duty of the sur- geon is to extract all the loose pieces of bone, and the second to place the ends of the fragments in accurate apposition, retention being afterwards effected in the usual manner. Special attention must be paid to drainage and cleanliness. Splinters, unless very small and sharp, that still retain a decided connection with the parts, whether by osseous matter or periosteum, should not be molested, as they will in all probability soon reunite, and thus afford important aid in the process of repair. If they are thrown off during the suppurating stage, it will be sufficiently easy to extract them through the sinuses in the soft structures. At all events, it will be well, in every case, not to be over officious; for by too much cutting and pulling an enormous amount of harm may be done, not only by causing improper waste of blood, but by interrupting nutrition, and permitting too free access of air. When, in addition to serious injury of the bones, there is extensive infil- tration of blood, the case may generally be regarded as a bad one, likely, if an attempt be made to save the limb, to eventuate in mortification. In the ONYXITIS. 989 slighter forms of the accident, the blood will usually rapidly disappear under the use of the roller and of spirituous lotions. In the treatment of gunshot wounds of the carpus and metacarpus, the greatest care should be taken to pick away every particle of loose bone, and to place such pieces as are retained in the most suitable position for accurate and speedy reunion. Unless this be done, the hand will become enormously swollen, numerous abscesses will form, and the soft parts will be so com- pletely matted together by lymph and new osseous matter as to render them permanently stiff and useless. Similar measures should be adopted in the treatment of gunshot injuries of the tarsus and metatarsus. If amputation be advisable, it must not be performed too near the seat of the injury, as the effects of the mischief often extend much farther than the eye can discern, especially when it has been inflicted by a shell or heavy ball. The proper time for performing the operation is the moment sufficient reac- tion has taken place. ONYXITIS. Onyxitis usually begins in a small circumscribed swelling of the ungueal matrix, attended with more or less pain and discoloration of the skin. A narrow ulcer or cleft soon appears at the root of the nail, and gives vent to a thin, ichorous fluid. The sore gradually extends, until it finally involves the whole of the ungueal matrix, or even the entire nail. The surface has a foul, dirty aspect; the margin is thin and sharp; the discharge irritating and offensive. The skin around the ulcer is indurated, tender, and livid; the nail is. yellowish, brownish, or black, dry, and disfigured; and the affected member, often twice or thrice the normal size, has a peculiar bulbous ap- pearance. In some instances the nail becomes loose, and ultimately drops off. The pain is generally slight, but occasionally it is so excessive as to deprive the patient of appetite and sleep for days and nights together. The disease is slow in its progress, and raay continue for many months before it is arrested. Although not strictly of a malignant nature, its tendency is to destroy the affected nail, and to produce serious changes in the surrounding structures. Onyxitis is most frequently met with in the great toe, thumb, and index finger. It occurs chiefly in scrofulous, ill-fed subjects, before the age of twelve or fifteen. External injury, as a bruise Fig. 661. or puncture, may produce the disease, but in most instances it arises without any known cause. The general health often suffers in this complaint, and the secretions are alraost always considerably disordered. The annexed drawing, fig. 661, frora a clinical case, con- veys an excellent idea of this affection as it Fig. 662. Malignant onyxitis of the index finger. Malignant onyxitis of the big toe. occurs in the great toe, and fig. 662, frora Druitt, as it shows itself in the finger. 990 DISEASES AND INJURIES OF THE EXTREMITIES. The treatment of onyxitis is sufficiently simple. After the bowels have been cleared out, and the secretions re-established, the system should he brought under the influence of mercury, carried to the extent of slight ptyalism. The best preparations are calomel and blue pill, the latter of which is usually preferable, because it is more mild and gradual in its opera- tion. It may be administered two or three times a day, in the proportion of from three to five grains at a dose, with a small quantity of opium to pre- vent griping and purging. As soon as the gums become tender, the medi- cine raust either be entirely withheld, or used at longer intervals, and in smaller quantity. The effects of the mercury, however, should be steadily maintained for several successive weeks, otherwise the disease will be sure to reappear, or to resume its original character. The local treatment should be of the mildest description. The sore should be washed several times a day with tepid water and soap, and its surface kept constantly covered with scraped lint, wet with a weak solution of chlorinated soda, creasote, nitric acid, or the compound tincture of myrrh and aloes. In several instances I have derived great advantage from the use of lime water, containing two grains of bichloride of mercury and the same quantity of opium to the ounce. When there is much inflamraation in the parts around the sore, the warm water-dressing, or an emollient poultice, will afford great relief. An oint- ment composed of two grains of arsenious acid and an ounce of spermaceti ointment occasionally acts almost as a specific. As soon as the ulcer assumes a healthy aspect, the best application is the opium cerate. Evulsion of the nail can answer no useful purpose, nor is it proper to amputate the affected part, unless, after the cure is effected, it is found, by its bulk or unseemliness, to interfere with the convenience and comfort of the patient. SECT. I.—SUPERIOR EXTREMITY. 1. AFFECTIONS OF THE HAND AND FINGERS. The hand and fingers afford frequent opportunities for surgical interference, on account of deformities which not only greatly mar their beauty and sym- metry, but seriously impede the exercise of their functions. These defects may be either congenital or acquired, being the result of various kinds of diseases and accidents, particularly paralysis and burns. The principal mal- formations met with here are, a deficiency or redundancy of parts, a webbed condition of the fingers, and organic contraction of the muscles and palmar aponeurosis, constituting a species of distortion analogous to club-foot. CONGENITAL IRREGULARITIES OF THE FINGERS. A deficiency in the number and size of the fingers is occasionally observed, one or two being sometimes entirely wanting, or they are so stunted as to give the hand a very singular, unseemly appearance. In a case recently at my clinic, the fingers were all very short and stumpy, each being deficient in a phalanx. They were connected together by thick webs, smooth on the palmar surface, but rough and grooved on the dorsal, and were provided each with an excellent, well-shaped nail. The thumb was small, but natural, and had no membranous attachment to the index finger. The person, who was a member of the profession, enjoyed a very good use of the limb. In some cases, there are only two fingers with jthe thumb; and not long ago I saw an instance where there was but one. The members, under such circumstances, may be of the natural shape and size, or they may be variously changed in their appearance, being generally thick and clumsy, or more or less contracted and stumpy. Occasionally they have a bulbous, knotty look, HYPERTROPHY OF THE FINGERS. 991 Supernumerary thumb. as if the umbilical cord had been twisted around them, and thus interrupted their natural growth. The thumb, I believe, is rarely affected in these mis- haps to the fingers. A supernumerary finger is uncommon, while it is by no means rare to see an additional thumb, as in fig. 663. Such a freak is occasion- Fig. 663. ally met with on both sides, and there are some curious cases on record where each hand had a supernumerary thumb, and each foot a supernumerary toe, the individuals being, in other respects, perfectly well formed. Some of these cases have been hereditary. When an additional finger exists, it usually occurs in connection with the little finger. The supernumerary member is generally a good deal smaller than the nor- mal one, but well-shaped, and furnished with an excellent nail. Occasionally it is bulbous, knobby, curved, and quite unseemly. Its attachment may be purely cutaneous, but in most cases it will be found to be through the me- dium of a separate joint, having a distinct synovial membrane. A deficiency of fingers is, of course, an irremediable affection. If the per- son belongs to the higher ranks of society, something may be done to supply it by the adaptation of artificial fingers, secured to a glove, which, when worn, as it readily may be in company, shall hide the defect. Any supernumerary piece that may exist is readily taken away by a very simple operation, care being taken to leave a sufficiency of integument to cover the wound, and to remove the part close to its attachment. I have seen two cases where, a portion of the proximal phalanx being left, an un- seemly projection remain- ed, not at all creditable to FiS- 664- the skill of the surgeon. The operation may be done in a few weeks after birth ; if neglected until the per- son attains the age of man- hood, he will be very apt to grow indifferent about it. A webbed condition of the fingers, fig. 664, is easily remedied by passing a bistoury vertically from ^51 WJ/III/// below upwards, through the redundant fold, and, after having removed what webbed fingers. is superfluous, tacking the edges of the wound together by several points of the interrupted suture, or allowing it to heal by the granulating process. The fingers are afterwards supported upon a carved splint, lint, spread with simple cerate, being inter- posed between them, to prevent readhesiou. HYPERTROPHY OF THE FINGERS. Hypertrophy of the fingers, although uncommon, is now and then observed; generally as a congenital vice, but soraetimes as an acquired one. It usually 992 DISEASES AND INJURIES OF THE EXTREMITIES. affects several fingers, either simultaneously or successively, the others remain- ing sound. All the component structures, hard as well as soft, are equally involved, and the result is that there is often great and inconvenient defor- mity, the parts being heavy, cumbersorae, and perhaps nearly twice as thick and long as in the natural state. The affection, of the true nature of which we are ignorant, is occasionally hereditary, and it has also been observed in several members of the same family. The treatment consists of systematic compression and sorbefacient applications, as the tincture of iodine, and the ointment of iodide of lead. If these means fail, as they generally will, and the enlarged member is not only useless, but unseemly and inconvenient, the only resource is amputation. CONTRACTION OF THE HAND AND FINGERS. Permanent contraction of the thumb and fingers from rheumatism, burns, paralysis, and other causes, is not uncommon, and is liable to be attended with the most distressing deformity and inconve- Fig. 665. nience. Such a condition is sometimes the result of a congenital vice, as in fig. 665, frora one of my clinical cases. The distortion may exist in various degrees, and may be occasioned simply by a contraction of the tendons, of the palmar apo- neurosis, or of a diseased cicatrice, or all these structures may be involved simultaneously, as is, perhaps, in fact, most generally the case. The in- odular tissue left by burns and scalds has an aston- ishing contractile tendency, which often resists the most ingenious efforts of the surgeon to overcome it, and which, in time, is capable of producing the most horrible deformity, the fingers being bent like claws, deeply imbedded in the substance of the hand, or firmly united to one another. In paralysis, the fingers are frequently permanently Contraction of the thumb. flexed, in consequence of the shortened condition of the tendons of the flexor muscles, while the ex- tensors are elongated, and completely deprived of their functions. The immediate cause of these contractions, or the nature of the structures on which they directly depend, can be determined only by a careful examina- tion, and the result must, of course, govern the treatment. The shortening occasioned by rheumatism, if existing in a high degree, will hardly be amen- able to any remediable measures, however judiciously employed; it is only in the milder and more recent cases that much benefit need be looked for. The use of colchicum, assisted by calomel aud opium, and the application of iodine and anodyne liniments, are the means chiefly to be relied upon. When the disease has been deprived of its acuity, an attempt may be made to break up the adhesions within the joints, and to restore the contracted muscles to their proper length, by gentle flexion and extension, or passive motion, the cold douche, and sorbefacient lotions, together with the splint and bandage, to maintain the hand constantly in a straight position. When the deformity is occasioned by permanent shortening of the muscles, or tendons, as in fig. 666, however induced, tenotomy is of questionable pro- priety, experience showing that, although the operation may relieve the dis- tortion, the patient never regains any material use of the affected part; on the contrary, indeed, he is generally made worse by it. Hence the judicious surgeon should long hesitate before he undertakes a procedure likely to be followed by such a result. In particular should this be the case when all, MALFORMATIONS AND DEFORMITIES OF THE HAND. 993 Fig. 666. or nearly all, the fingers are involved; for it has happened under such cir- cumstances that what little use of the hand the poor patient still possessed was entirely destroyed by the division of the tendons, their ends refusing to unite. When one finger only is concerned, and the object is to relieve an ugly and incon- venient deformity, no objection whatever can be urged against the operation. It will thus be seen that there is a remark- able difference between tenotomy of the hand and fingers and tenotomy of the feet. In the latter, the ends of the divided tendons always unite with great promptness, so that the patient, if the case be well managed, is sure, in time, to acquire a good use of his extremity; in the hand, fingers, and forearm, on the con- trary, there is rarely, if ever, any perfect re- union, and the consequence is that the opera- tion, so far as the functions of the limb are concerned, is a complete failure. The cause of this difference seems to be the existence of a larger amount of syn o vial fluid in the sheaths of the tendons of the superior extremity than in those of the inferior, and the greater amount of space which inter- venes between these structures, when divided, in the former than in the latter of these situations. When the deformity is dependent upon the contraction of the palmar aponeurosis, as in fig. 667, it may, in general, be readily rectified by the free division of the resisting parts by a subcutaneous operation with a delicate, -pointed tenotome. These parts are well displayed in fig. 668. The Contraction of the ring finger. Fig. 667. Fig. 668. Contraction of the fingers. Contraction of the palmar aponeurosis. aponeurosis may, if necessary, be cut completely across where it covers in the palm, and any of its digital slips that may seem to be at fault may then be successively traced out and severed. The after-treatment demands great attention. The hand and fingers must be enveloped in a bandage, and then carefully bound upon a well padded carved splint, frequent washing, friction, and passive motion not being neglected. Deformity of the hand and fingers arising from the vicious cicatrices of burns and scalds, as in fig. 669, seldom admits of satisfactory relief. When the inodular tissue presents itself in the form of narrow bridles, it may be completely exsected, and the wound approximated by suture ; or the bands may be cut across at different points, and the gaps healed by granulation, the limb being maintained in the extended posture during the cicatrizing process, VOL. n.—63 994 DISEASES AND INJURIES OF THE EXTREMITIES. Fig. 669. Vicious cicatrices of the fingers. as well as for some time after, in order to prevent a recurrence of the con- traction. When the cicatrice involves a large surface, nothing short of its entire removal, and the transplanta- tion of a flap of healthy integument, will be likely to answer any useful purpose. The graft might be bor- rowed from the other arm, or from the chest, as might seem most feasible. Fig. 670. CLUB-HAND. The hand is sometimes distorted in such a manner as to present an appear- ance analogous to club-foot, especially the variety called varus. Hence it is generally termed club-hand, an appearance well seen in fig. 670. The affection is occasionally con- genital, but in the great majority of cases it supervenes in consequence of paralysis, or a loss of antagonism in the two classes of muscles. The alterations are characteristic. The hand is inverted, the internal margin inclining strongly upwards, the fingers are more or less flexed, and the carpus seems to be par- tially dislocated from the radius and ulna, forming a marked projection at the inner border of the limb. Sometimes the hand is turned in the opposite direction, in imitation, as it were, of valgus, or the everted variety of club-foot. However this may be, the affection is not unfrequently associated with distortion of other parts of the body, and usually occurs in persons of a debili- tated frame, or in such as are particularly prone to suffer from nervous diseases. Very recently, I saw a case in which both hands and both feet were clubbed, the patient being a child three months old. The treatment consists in attention to the removal of the exciting cause, and the improvement of the general health. To accomplish the latter, a course of chalybeate tonics, exercise in the open air, and the daily use of the cold shower-bath, will be the best means. Electric currents may occasionally be passed through the affected limb, and the surface may be frequently rubbed with some stimu- lating lotion. If the case be recent, and the deformity comparatively slight, forced extension, repeated several times a day, and long-continued, will sometimes effect a cure. When this fails, an attempt may be made at rec- tification by the employment of appropriate apparatus, similar to what is used in the milder forms of club-foot; but, under opposite circumstances, division of the affected tendons alone will enable us to relieve the distortion, although a long time will elapse before there will be much improvement of the functions of the parts. The muscles whose section will generally be necessary are the long palmar, the flexors of the radius and ulna, and the superficial flexor of the fingers, the knife being introduced with the greatest caution, lest injury be inflicted upon the arteries and nerves of the forearm. Club-hand. REMOVAL OF RINGS FROM THE FINGERS —WHITLOW. 995 REMOVAL OF RINGS FROM THE FINGERS. Serious difficulty is sometimes encouutered in removing rings from the fingers, either in consequence of tumefaction caused by their pressure, or of the iucreased size of the member, as when the ring, put on early in life, has not been taken off for a long time. Most generally, however, it arises from a small ring being forced upon a disproportionately large finger. If relief be not promptly afforded, severe inflamraation will ensue, terminating in ulcera- tion and perhaps in gangrene. Several methods may be adopted for effecting this object. In the first place, the hand may be immersed in ice-water to cause contraction of the finger; or the finger may be tightly bandaged, and then held in ice-water. If these expedients fail, a piece of pack thread, or saddler's silk, well waxed, should be closely and firmly wrapt round the finger, beginning at the distal extremity, and extending as high up as the ring.' The thread is then passed by means of a small blunt bodkin under the ring when, drawing it very tightly, the ring is gradually forced down as the ligature is untwisted. Should this plan also prove fruitless, the only other resource is to cut the ring in two with a file, or a delicate pair of bone- nippers. WHITLOW. This disease, technically called paronychia, and vulgarly felon, is an affec- tion of the thumb or finger, commencing in inflammation, which soon termi- nates in suppuration, and sometimes even in gangrene. It is distinguished by the great severity of its pain, and exhibits itself under two varieties of form, the superficial and the deep, the former being limited to the skin and cellular substance, whereas the latter involves not only these structures, but also the tendon, periosteum, and bone. Whitlow is very rare in children, and I do not remember ever to have met with it in infants. It is most common between the ages of twenty and thirty- five, but is also sufficiently frequent in elderly persons, cases occasionally occurring after the eightieth year. Females are more subject to it than men, and the probability is that certain occupations predispose to its development. Thus, washerwomen, and other persons who have their hands habitually immersed in water, are particularly obnoxious to it. At times, the disease is epidemic, as happened a few years ago in various sections of the Union, and when an unusual number of cases, in both sexes, and of different ages, fell under my observation and treatment. An affection similar to whitlow is occasionally met with in the toes. In the superficial forms of whitlow, the inflamraation is generally seated immediately around and beneath the nail, commencing either at the side of the finger, upon its dorsal surface, or at its extremity. Without much, if any swelling, the part is of a dusky reddish aspect, tender on pressure, and exqui- sitely painful, throbbing violently and incessantly, and causing more or less constitutional disorder. In from two to three days after these phenomena present themselves, matter is observed in the finger, lying just beneath the epidermis, which is elevated into yellowish vesicles around the side and back of the nail; in many cases, pus is also situated below the nail, especially at its posterior extremity; and sometimes, again, it is found chiefly, if not exclusively, in the cellular substance immediately beneath the true skin. The inflammation generally extends some distance up the finger, and occasionally even over a considerable portion of the hand, which may be a good deal swollen, stiff, and painful. Not unfrequently, a reddish line, indicating the course of an absorbent vessel, is seen running along the limb, as high up, perhaps, as the axilla. 996 DISEASES AND INJURIES OF THE EXTREMITIES. In the deep-seated variety of whitlow, the inflamraation involves all, or nearly all, the structures of the finger, and is frequently followed by the destruction of one or raore of the phalanges. The pain is of extraordinarv severity, depriving the patient of sleep for days and nights together; throb- bing, tensive, and diffused, often ex- Fig. 671. tending as high up as the elbow and even to the shoulder; steady and persistent, but greatly aggravated by depending position, and only subsiding with evacuation of the inflammatory deposits, or the death of the part. The swelling also is great, sometimes enormous, involv- ing both finger, hand, and wrist; the skin is red and cedematous, hav- ing a puffy, erysipelatous aspect; Paronychia of the thumb. and the whole limb is often stiff and useless. If the morbid action be Fig. 672. not speedily checked, matter will form deep among the tissues, in the pSSf^ll^r^ connecting cellular substance, within •iri*pKj!*~^ the sheaths of the tendons, and be- Necrosis of the bones in whitlow. neath the periosteum, and, spreading in different directions, will cause extensive havoc, burrowing along the finger and hand as far up, perhaps, as the wrist and forearm. In neglected cases, gangrene occurs, followed by sloughing of the tendons, and exfoliation of the phalanges. The external characters of whitlow are well illustrated in fig. 671, while the effects which the disease often exerts upon the bones are displayed in fig. 672. Whitlow, in its more severe forms, is always attended with well-marked constitutional disturbance. The patient, tortured with pain, is feverish, and unable to sleep; his appetite is gone; his head, back, and limbs ache; the face is flushed, and the pulse is strong, hard, and frequent. In some cases delirium is present. How this disease is produced, or what its real character is, is still a mooted question. The most plausible conjecture is that it is a bad form of inflam- mation, not unlike carbuncle, occurring in a constitution more or less de- praved, in consequence of a disordered state of some of the secretions, particularly those of the digestive apparatus. In the female, it is occasion- ally associated with irregularity of the menses, but whether as an effect or coincidence, we are unable to determine. My belief is that it is quite impos- sible for whitlow to occur in a constitution that is entirely sound. I should, therefore, infer that it is a peculiar form of inflammation, self-limited in re- spect to its tendency to terminate in suppuration. There is no disease with which paronychia is likely to be confounded. Its peculiar situation, the severity of the pain, the dusky appearance of the skin, and the speedy occurrence of suppuration, will always enable the practitioner to distinguish it readily from other affections. Boils and carbuncles never occur upon the extremity of the fingers. In the treatment of this affection very little is to be expected from the employment of abortive measures, since, as has already been stated, its tend- ency is always to pass into suppuration. In its milder forms, and earlier stages, the morbid action may be limited occasionally by a brisk cathartic, and the application of the undiluted tincture of iodine, raade two or three times in the twenty-four hours, with an emollient poultice, wet with laudanum, in the intervals; but, in general, the disease will go on, in spite of all that we can VARICOSE ANEURISM OF THE FINGERS. 997 do, to the formation of matter. When the swelling is very considerable, leeches may soraetimes be used advantageously in the vicinity of the focus of" the inflammation, and in such instances I have also occasionally experienced great benefit from the application of a pretty large blister. To relieve the excessive pain, opiates must be given in full doses, and it will be well, also, for the patient to take, every three or four hours, a dose of the antimonial and saline mixture. It need hardly be added that the hand should be kept perfectly quiet, in an elevated position. The above means are, however, at most, only palliative, relieving pain, and, perhaps, limiting morbid action, but not eradicating it; "scotching but not killing the disease." The great and indispensable remedy, after all, is the knife, employed early and boldly, not expectantly and timidly ; the inci- sion being long and deep, the edge of the instrument grating upon the bone. Suppuration is, if possible, anticipated, and structure thus saved. When the matter has been permitted to burrow, numerous openings may be necessary, and extensive mischief may take place, before we may be able to reach the point of repair, the fingers, hand, and wrist long remaining stiff, painful, and unserviceable. Dead bone is removed as soon as it is easily separable, the periosteum being as little interfered with as possible, and amputation always avoided, experience having shown that a new phalanx is sometimes formed, and that, even when this does not happen, the boneless finger will be both useful and sufficiently seemly. When the violence of the inflammation has subsided, the parts should be kept constantly wet with some anodyne and astringent lotion, alcohol and laudanum, or a solution of opium and hydro- chlorate of ammonia. At a still later period, they should be well douched, first with warm, and then with cold water, dried, and rubbed with soap lini- ment, or camphorated mercurial ointment, and supported with a bandage, each finger being enveloped separately. These directions may seem trivial, but those who have ever had whitlow in their own persons, or who have seen much of the disease in others, will not fail to appreciate their value. VARICOSE ANEURISM OF THE FINGERS. The fingers are liable to varicose aneurism, consisting, as the term implies, in an enlargement of the arteries and veins, superficial as well as deep ; usually commencing before birth, and progressively augmenting un- Fig. 673. til, as seen in fig. 673, it occa- sions great deformity and in- convenience. In some instances, the disease extends over the hand, the forearm, and even the arm, as high up as the axilla. The fingers are of a purple co- lor, of a soft, spongy consist- ence, nodulated, and several times the natural bulk. They pulsate synchronously with the heart, and are readily dimin- ished by pressure, but immedi- ately regain their former size When the pressure is disCOn- Varicose aneurism of the fingers. tinued. Dissection shows the . vessels to be not only enlarged, but also tortuous, thickened, and indurated, with a predominance, at one time, of the arterial, and, at another, of the venous element. The disease is rarely attended with pain. 998 DISEASES AND INJURIES OF THE EXTREMITIES. The treatment of this affection is unsatisfactory, as it has hitherto proved re- fractory under every variety of local measures. So long, therefore, as it causes no serious inconvenience, or evinces no disposition to increase, no attempt should be made to molest it. A spontaneous cure is, of course, never looked for. When the enlargement is limited to several arterial trunks, ligation may be employed, the varicose veins being afterwards treated by injections with the persulphate of iron. If the deformity is very great, nothing short of amputation will suffice. PHLEGMONOUS INFLAMMATION AND ABSCESS OF THE HAND. A very distressing forra of inflamraation, closely resembling whitlow, occa- sionally occurs in the hand, generally in the palm, in consequence of external violence, as a puncture or contusion. It is deep-seated, commencing either in the palmar aponeurosis, in the sub-aponeurotic areolar tissue, or in the sheaths of the muscles. However this may be, all these, as well as the other structures, both hard and soft, rapidly become involved in the morbid action, which often spreads over a large extent of surface. The symptoms are those of violent inflammation ; the parts are excessively swollen, of a dark red or livid color, and the seat of exquisite pain, of a throbbing, pulsatile character. The fingers and wrist are stiff and tumid, and there is always high constitu- tional excitement, not unfrequently attended with intense headache and even delirium, especially when matter is about to form. The treatment of this disease must be prompt and energetic. Blood must be taken freely frora the part by leeches, or even from the arm, if the patient is at all plethoric; the bowels must be thoroughly evacuated, apd vascular excitement must be subdued with depressants. The hand, elevated and kept at rest, is surrounded with cloths wet with a strong solution of acetate of lead and laudanum, and no time is lost in letting out pus. If this be neg- lected, the worst consequences are to be apprehended, as necrosis of the bones, anchylosis of the joints of the fingers, and permanent contraction of the tendons. Occasionally mortification occurs. TUMORS OF THE HAND AND FINGERS. The thumb and fingers are occasionally the seat of various kinds of tumors, benign and malignant, interfering with their comfort and usefulness, and re- quiring removal. Both classes of affections are, however, very uncommon as primary developments. I was obliged, not long ago, to amputate the thumb of an elderly lady for a melanotic disease of twelve years' standing, and I have removed several fingers on ac- Fig. 674. count of epithelioma; but, of genuine primary scirrhus and en- cephaloid of the thumb and fin- gers, no example has ever fallen under my notice. Among the benign tumors of the thumb and fingers, the most common is the enchondromatous, fig. 674, beginning early in life, in children of a stunted, rickety formation, and soon attaining so great a bulk as to interfere mate- rially with the usefulness of the part. The growth, which is hard, Enchondroma of the index finger. tense, and incompressible, and TUMORS OF THE HAND AND FINGERS. 999 which takes its rise in the osseous tissues, is often multiple, several masses affecting the same finger, or even the same bone. Now and then, nearly every finger suffers. Its volume varies from that of a pea to that of an orange. The formation is generally unattended with pain, the only inconvenience which it occasions being caused by its weight and size. If permitted to go on unre- strained, or if imperfectly removed, it may assume malignancy, but such an event is uncommon. The diagnosis of the enchondromatous tumor is very easy, the history of the case, the absence of pain, and the peculiar form, density, and situation of the tumor, always sufficiently declaring its character. The only remedy is ablation, not of the tumor, but of the finger upon which it is situated. If the mass be merely excised, speedy recurrence will be in- evitable, with a tendency, in all likelihood, to malignancy in consequence of rapid cell formation, the part being softer than originally, and growing with unusual vigor. When the tumor involves the hand, a portion of it also must be sacrificed. Terrible suffering and deformity of the thumb and fingers, with great im- pairment, if not total loss, of function, occasionally arise from gouty deposits in the phalangeal joints. The affection, of which the annexed sketch, fig. 675, from Garrod, affords a good illustration, usually coincides with similar Fig. 675. Gouty deposits in the joints of the fingers and burse of the elbow. formations in other parts of the body, especially the elbow, knees, toes, and heel, and is evidently dependent upon the retention of the lithate of soda, the morbific material of gout, the kidneys being unable to eliminate it with suffi- cient rapidity. The fingers, at first merely stiff and painful, present a tube- roid appearance, looking, as Sydenham expresses it, like a bunch of parsnips, and becoming ultimately completely immovable and useless. The substance upon which the deformity depends is originally of a soft, creamy consistence, and of a whitish,'grayish, or dark color; but, by degrees, it assumes the solidity of chalk or mortar, so that, if several pieces coexist, the diseased joints sometimes rattle like bags of marble. As the swelling augments, the concretions approach the surface, causing attenuation, and finally ulceration, of the skin with a partial discharge of the characteristic material. The treatment consists in rectifying, by appropriate diet, purgatives, col- chicum and alkalies, the peculiar state of the system upon which the forma- tion of the lithic acid depends, and in removing, if necessary, by puncture and pressure the inspissated matter from the affected joints. Amputation 1000 DISEASES AND INJURIES OF THE EXTREMITIES. must not be thought of, unless the pain and deformity are excessive, and can- not be relieved in any other way. 2. AFFECTIONS OF THE ELBOW. The large synovial burse which is interposed between the tendon of the triceps muscle and the top of the olecranon, and which in some instances is multilocular, is liable to inflammation and great distension from the accumu- lation of its natural secretion, forming thus a swelling, occasionally of extra- ordinary size, at the posterior and lateral aspect of the elbow. The parts are tender on pressure, and impart a peculiar crepitating, fluctuating sensation, which readily distinguishes it from other affections in this situa- tion. The usual cause of the disease is external violence, though it some- times arises spontaneously. The morbid action may become chronic, or even pass into suppuration ; and in cases of long standing the coats of the syno- vial bag are occasionally very much thickened and indurated. Now and then such a tumor contains loose fibroid bodies, resembling small melon seeds in appearance. The treatment consists in the application of leeches, blisters, and sorbe- facient lotions, with rest of the parts, and an occasional purgative. If the accumulation of fluid is unusually great, an incision may be made, and the surface of the pouch mopped with dilute tincture of iodine. Matter should always be promptly evacuated. Anchylosis of the elbow is a frequent consequence of caries, dislocations and fractures, and may present itself in various degrees, from the slightest stiffness to complete osseous immobility. The forearm is generally bent nearly at a right angle, but occasionally it is in the straight position, thus rendering it, in great measure, if not completely, useless for the ordinary purposes of life. The treatment must depend upon the nature of the adhesions, whether they are fibrous or osseous. In the milder cases, the proper remedy is the lacera- tion of the morbid connections by forcible flexion and extension with the aid of chloroform, regular passive motion being afterwards maintained to prevent relapse. Osseous union, if not too strong, may be broken up with the per- forator, introduced subcutaneously; or, if the operation fail, or is contra- indicated, resection may be employed, a V-shaped portion of bone being cut out from the back part of the elbow, with the view of establishing a false joint. Sometimes the anchylosis depends mainly upon osseous adhesions of the olecranon, the rest of the articulation partially retaining its integrity. In two cases of this kind I have succeeded in effecting excellent cures by forcibly breaking this process; an operation which is usually not difficult in recent cases, as the osseous tissues are then always more or less softened. The elbow-joint is sometimes rendered useless by the contraction of the brachial aponeurosis and the tendon of the two-headed flexor, in consequence of paralysis, rheumatism, or burns. The proper remedy consists in the divi- sion of the affected parts, the operation being performed in such a manner as not to interfere with the brachial artery, and extension being afterwards made with an angular splint, united by hinges, and worked by a screw. In this manner, the limb may often be restored to usefulness iu a very short time, especially when there is no serious disease of the joint. 3. AFFECTIONS OF THE SHOULDER. Paralysis of the muscles of the shoulder, but more particularly of the del- toid, the result generally of external injury, as a blow or fall upon the part, is sometimes met with, and often proves exceedingly obstinate, if not irreme- AFFECTIONS OF THE SHOULDER. 1001 diable. Although the affection is ordinarily occasioned by direct injury, cases occur in which it is produced indirectly, through force applied to the elbow or head. A considerable number of cases have fallen under my obser- vation in which the attack was apparently due to the effects of cold. The immediate cause of the paralysis appears to be the contusion, com- pression, or laceration, or these different lesions combined, of the nerves of the affected muscles, and, doubtless, also of the fibres of the muscles themselves. However this maybe, the muscles, whose natural stimulus is thus cut off, soon fall into a state of atrophy, becoming thin and flabby, and partially, if not completely, powerless. By degrees, the morbid influence extends to the shoulder-joint, causing inflammation of the synovial membrane, followed by morbid adhesions between the contiguous surfaces, and eventually, in many instances, by complete anchylosis. The sensibility of the part is often, though not always necessarily, much impaired, and the patient usually expe- riences fixed or darting pains, resembling those of rheumatism. The para- lysis may be limited to the deltoid, or it may affect, either simultaneously or successively, the other muscles of the shoulder, as well as some of those of the arm and forearm, followed by a cold and withered condition of the entire limb. The general health is usually somewhat impaired ; occasionally very much. The prognosis of this affection is variable. In the milder cases, the parts, under judicious management, usually recover in from three to eight weeks, whereas, in the more severe ones, very little benefit is to be expected from therapeutic measures of any kind. The treatment of paralysis of the muscles of the shoulder must, in the first instance, be conducted upon strictly antiphlogistic principles; by rest, leeches, and soothing applications, as weak solutions of lead and opium, spirituous lotions, or arnica and laudanum, with a view of subduing the inflammation which must necessarily follow whenever the disease is of traumatic origin. Subsequently our main reliance must be upon the hot and cold douches, fric- tions, stimulating liniments, passive motion of the shoulder-joint, shampooing of the muscles, and electricity. The general health must not be neglected. In most cases, the patient will be immensely benefited by a course of tonics, alterants, change of air, and sea-bathing. In obstinate cases I have some- times derived marked benefit from the repeated application of a blister. Anchylosis of the shoulder-joint may be caused by injury, or by want of use in consequence of paralysis of its muscles, eventuating in effusion of plastic matter. Such cases generally admit of cure, simply by breaking up the morbid adhesions under chloroform, and then instituting a regular sys- tem of passive motion, aided by the use of the douche, sorbefacient liniments, and dry friction. When the anchylosis is osseous and not too extensive or old, an effort may be made to destroy the connections with the perforator employed subcutaneously; or, this failing, resection may be performed. Injury and rheumatism of the shoulder-joint are soraetimes followed by contraction of the soft parts in its vicinity, seriously interfering with the restoration of its functions. Passive motion will do much for such cases, and the knife can only be required when there is marked shortening of the pectoral muscle, pinioning the arm to the side. In making the section of the muscle, regard must be had to the safety of the axillary vessels and nerves. In consequence of burns and scalds giving rise to vicious cicatrices, the arm is sometimes pinioned to the side of the chest, thus restricting the move- ments of the shoulder-joint, and rendering the limb in great degree useless. Unless the attachments are very broad and extensive, a very simple operation, consisting, in the division of the fibrous or cutaneous bands will generally suffice to afford relief, especially if care be taken during the healing process to 1002 DISEASES AND INJURIES OF THE EXTREMITIES. keep the arm away from the trunk. Occasionally it will be found necessary to aid the cure by the division of some of the fibres of the pectoral muscle. 4. AFFECTIONS OF THE AXILLA. The axilla is liable to wounds, inflammation, abscess, tuberculosis of the lymphatic ganglions, encysted tumors, and malignant disease, especially encephaloid and scirrhus. Aneurism may also occur here, but as this dis- ease has been described elsewhere, it is not necessary to repeat what was then said. Wounds in this situation acquire their chief importance from involvement of the axillary vessels and nerves. They may be of various kinds, as incised, lacerated, punctured, or gunshot, and must be treated upon the same general principles as similar injuries in other regions. Bleeding from the axillary artery must be checked with the ligature, applied both to the cardiac and distal side of the vessel, thoroughly exposed for the purpose, the wound serving as a guide to the knife. A good deal of embarrassment frequently attends the operation on account of the infiltrated and discolored condition of the areolar tissue, which, from its great laxity, admits of the ready diffusion of the blood. The subclavian artery should never be tied for such an accident. It is not often that the division of the axillary artery is followed by gan- grene of the hand, but such an occurrence will be very likely to ensue when the lesion co-exists with a wound of the axillary vein, or of some of the principal nerves of the limb. In the latter event, indeed, mortification may arise without any injury whatever of the vessels. Wounds of the axilla, from their peculiar valve-like shape, and the move- ments of the shoulder, are occasionally followed by emphysema, even when there is no injury of the lung. As such a phenomenon might cause great alarm in the mind of an ignorant surgeon, it deserves to be remembered as one of the possible contingencies of a traumatic lesion in this situation. The cicatrization of wounds of the axilla will be materially expedited, if, after their edges have been properly drawn together, the arm be carefully fastened to the side, so as to insure perfect quietude to the parts. Inflammation, of a common, phlegmonous, or erysipelatous character, not unfrequently makes its appearance in the axilla, and is liable to cause great suffering, besides occasionally terminating in extensive abscesses. Terrible attacks of inflamraation of the lymphatic ganglions, attended with fatal results, sometimes follow the absorption of poison, such, for example, as that received in dissecting. The virus appears to be arrested in these bodies, which, in consequence, soon become swollen, tender, and exquisitely painful, the tumefaction generally rapidly spreading over the whole limb, and occasion- ally even over the corresponding side of the trunk. Acute abscesses of the axilla are sufficiently common. The matter may be confined entirely to the areolar tissue, or it may at the same time be disse- minated through the lymphatic ganglions. When the suppuration is at all profuse, the fluid may burrow freely among the surrounding parts, pass- ing, perhaps, forwards beneath the pectoral muscles, backwards under the scapula, up into the neck, or even into the anterior mediastinum, although such an event must necessarily be very uncommon, and should always be guarded against by a timely outlet for the pent-up fluid. In performing the operation, the surgeon must not lose sight of the close proximity of the axillary vessels, otherwise he might produce a frightful, if not fatal, hemor- rhage. The most prudent plan will be, unless the matter is very superficial, first to incise the skin, and then to divide the tissues, layer after layer, with the knife, guided by the grooved director. AFFECTIONS OF THE AXILLA. 1003 Chronic abscesses of the axilla are by no means uncommon, especially in young, strumous subjects, the matter, which is often very abundant, evidently forming in connection with diseased lymphatic ganglions. The progress of the swelling is generally very slow, and the phenomena of ordinary inflammation are frequently entirely absent, although occasionally the skin over the affected ganglions is abnormally hot, red, tender, and painful. The pus is always characteristic. The treatment must be by free incision, followed by sor- befacient applications, and by a course of alteratives, or alteratives and tonics. Tuberculosis of the lymphatic ganglions of the axilla is soraetimes met with, generally as a chronic enlargement, these bodies being aggregated together in such a manner as to form a hard, circumscribed, nodulated mass, easily distinguishable by its history, its consistence, the absence of pain, and its gradual tendency to suppuration. It is most commonly found in young sub- jects, in association with tuberculosis of other parts of the body, particularly of the lymphatic ganglions of the neck and supra-clavicular region. The disease is tardy in its progress, but the resulting tumor may, in time, acquire a very large bulk. The general health, at first unimpaired, ultimately suffers, and the patient may finally fall into a state of marasmus, although, in most cases, he will be likely to make a good recovery. The most common cause of the disease is cold acting upon a debilitated constitution. Occasion- ally it is dependent upon caries of the ribs or disorder of the mammary gland. The treatment of this affection must be conducted upon general anti-strumous principles, iodine and bichloride of mercury constituting the more important internal remedies ; leeches, blisters, and sorbefacients the most reliable topical ones. If matter form, it should be promptly evacuated, disorganized ganglions being destroyed with escharotics. If the disease prove obstinate, the altered mass should be extirpated. The encysted tumor occasionally occurs in the axilla; generally as a congenital affection, of a round- ed, semiglobular form, soft, fluctu- ating, free from pain, and filled with a watery, coagulable fluid. An interesting case of this kind, in a stout and otherwise healthy child, six months of age, was sent to my clinic at the Jefferson Col- lege last November, by Dr. Conry, of Manayunk. The sac, which contained about four ounces of limpid serum, was laid freely open, and its inner surface thoroughly mopped with a weak solution of iodine. The operation was fol- lowed by a speedy cure. Malignant growth of the axilla, as a primary affection, is most common in elderly subjects, and the form in which it usually ap- pears is that of encephaloid, com- mencing as a small, nodulated tumor, which often, in the course of a few months, acquires an im- mense bulk. The mass feels hard, Scirrhus of the axilla. 1004 DISEASES AND INJURIES OF THE EXTREMITIES. or hard at one place, and soft at another, and, although movable at first, soon becomes firmly fixed in its position, filling up completely the hollow between the arra and chest. The subcutaneous veins gradually increase in size, and the morbid mass at length breaks and gives way, forming a fungous, bleeding ulcer, the seat of a more or less copious, fetid discharge. The general health, in the meantime, is greatly impaired, and the corresponding limb is swollen, stiff, and painful. Scirrhus of the axilla is generally the result of secondary involvement in connection with carcinoma of the breast; as an independent disease, it is very uncommon. The tumor, which sometimes acquires a large bulk, as in fig. 676, frora Erichsen, usually extends further down the chest than in en- cephaloid, and is always the seat of sharp, lancinating pain, which, together with its history, its form, consistence, and the absence of enlargement of the subcutaneous veins, serves to distinguish it from soft cancer. The only remedy for this disease is extirpation. The operation, however, besides affording only the most temporary relief, is one of great delicacy, from the fact that the axillary vessels and nerves are often seriously involved in the morbid mass. In performing operations upon the axillary region, special care must be taken not to wound the axillary vein, inasmuch as such an accident might be followed by fatal consequences frora the introduction of air, as in a case under the care of the late Dr. John C. Warren, of Boston. 5. BANDAGES FOR THE SUPERIOR EXTREMITY. Bandaging of the fingers is a very nice operation ; it is particularly called for in inflammation after fractures of the radius and ulna, and in cases of burns and scalds, with a view to the prevention of adhesions. The roller should be from three-quarters of an inch to an inch in width, and should be carried up, by circular and reversed turns, as far as the root of each member, Fig. 677. Fig. 678. Bandages for the hand and fingers. when the extremity should be stretched across the back of the hand, which, when all the fingers are enveloped, should be surrounded with a broad band- BANDAGES FOR THE SUPERIOR EXTREMITY. 1005 age, extending from the knuckles a short distance beyond the wrist, as ex- hibited in fig. 677. For retaining dressings on the hand, the bandage represented in fig. 678 is usually employed. It consists of a roller, an inch in width, and several yards in length, carried, first, round the wrist, and afterwards across the car- pus, in front and behind, in such a manner as to embrace the root of each finger. The most suitable bandage for the forearm and arm is the ordinary roller, fig. 679. The application, commenced at the fingers, is gradually continued Fig. 679. Roller for the superior extremity. up the limb as far as the elbow, and thence up as high as the axilla, where the end is fastened with a pin. Sometimes, as when it is desired to secure the arra to the side, the bandage may be carried horizontally round the trunk. The hollow of the hand may, if necessary, be filled up with cotton, lint, or old muslin. Great care must be taken in carrying the bandage round the elbow, otherwise it will be apt to lose its hold or to produce undue compression. The usual length of the roller for the upper extremity is from six to eight yards, its width being about two inches and a quarter. In cases of fractures and other injuries, likely to be followed by severe swelling of the hand, the thumb and fingers should be put up in separate bandages. For confining dressings in the treatment Fig. 681. of wounds, abscesses, and other affections of the axilla, the most simple and efficient contrivance that can be used is a large handkerchief, folded cornerwise, the centre being placed under the arm, and the ends, Fig. 680. Bandage for the axilla. Spica for the shoulder and the upper part of the arm. 1006 DISEASES AND INJURIES OF THE EXTREMITIES. crossed over the shoulder, carried round the chest, and tied onder the oppo- site axilla, as illustrated in fig. 680. The spica bandage for the shoulder and the upper part of the arm, repre- sented in fig. 681, consists of a roller from eight to ten yards in length by two inches and a half in width, with compresses for the axilla of the affected side. Leaving about two feet and a half of the end of the bandage pendent at the posterior part of the arm, the application is commenced by several spiral and reversed turns round the limb, passing from its outer towards its inner surface. The bandage is then carried up over the outer aspect of the shoulder, obliquely across the anterior part of the chest, to the axilla of the sound side, and thence across the back to the affected shoulder. In this manner one turn after another is made, each succeeding one partially over- lapping the preceding one, until the roller is consumed, when the initial extremity at the back part of the limb is brought round under the axilla, and thence over the front of the shoulder and round the back of the neck to the sound side, where it is secured by a pin. SECT. II__INFERIOR EXTREMITY. 1. AFFECTIONS OF THE FOOT AND TOES. The foot and toes, like the hand and fingers, are liable to various affec- tions, either congenital or acquired. Among the former are supernumerary, webbed, and hypertrophied toes, flat-foot, and club-foot; among the latter, corns, bunions, podelkoma, pododynia, and certain affections of the toes. CONGENITAL AND OTHER DEFORMITIES OF THE TOES. It is very seldom that we meet with congenital absence of the toes; super- numerary toes, on the contrary, are not very uncommon, the additional mem- ber being usually connected with the large toe, which it closely resembles in shape, but does not equal in bulk. The anomaly sometimes occurs on both feet, and cases are met with where it co-exists with an additional thumb. The supernumerary member is not only unseemly, but, by increasing the width of the foot, may seriously interfere with the patient's comfort and convenience. Hence, it should always be removed soon after birth. The operation is very simple, the only care required being to take away the whole of the anomalous toe, and to leave a sufficient amount of integument to afford a good covering for the exposed surface. A webbed condition of the toes is uncommon, and rarely affects raore than two or three of these pieces. I have never seen more than two cases in which all the toes were thus united. The remedy is the same as for webbed fingers. Hypertrophy of the toes is still more uncommon than hypertrophy of the fingers. It is usually congenital, and the affected parts may acquire a very large bulk, thus greatly interfering with the comfort and convenience of the foot. The proper remedy is removal of the offending structures, as it would be worse than useless to waste time upon compression and other sorbefacient means. Deformity of the toes occasionally arises from the effects of rheumatism, from paralysis, or from the wearing of a tight shoe, causing them to project in an unseemly and inconvenient manner, either above or below the natural level, as in fig. 682, or producing an incurvated, claw-like appearance. The immediate cause of the distortion is a contraction of the tendons of the flexor muscles, which should accordingly be divided, as they pass beneath the first CORNS. 1007 phalanx, by subcutaneous section, the faulty toes being afterwards treated in the extended posture by splint and bandage, until they are completely straight. When the great toe is mainly involved, as generally happens when the affec- tion is induced by paralysis, or by inflammation of the metatarso-phalangeal joint, as in fig. 683, it may be necessary to divide the long flexor in the sole Fig. 682. • Fig. 683. Deformity of the second toe. Deformity of the great toe from inflammation of the metatarso-phalangeal joint. of the foot; but, in doing this, proper care must be taken to keep the knife close to the affected tendon, made previously as tense as possible, otherwise the internal plantar artery might suffer. CORNS. Corns consist in an indurated and hypertrophied condition of the cuticle, caused by inflammatory irritation of the superficial portion of the dermis, and a consequent effusion of lymph. They affect different parts of the toes and feet, and are generally produced by wearing tight shoes and boots, whereby these organs are habitually compressed and even forced out of their normal position. Corns are very variable in regard to their size, form, and consist- ence. They are usually distinguished into hard and soft. Hard corns are dry, scaly, insensible callosities, occurring mostly on the dorsal surface of the toes, opposite the middle joints. All these structures are occasionally affected, but the great and little toes suffer much more fre- quently than any of the rest. These bodies are met with also in the sole of the foot, in the hollow or arch, and on the under part of the heel. Occa- sionally a very hard corn is found under the nail of the big toe, or between the nail and the fleshy flap of the toe. A hard corn, when fully developed, is lamellated, firmer at the centre than at the periphery, and furnished with a sort of nucleus, of a whitish, horny appearance, not unlike the eye of a fowl. A small, but distinct burse, con- taining a minute quantity of serous fluid, and sometimes a drop of blood, is almost always interposed between it and the dermis. The hard corn fre- quently consists of three or four layers ; it is commonly of a circular shape, is either fixed or movable, and varies iu size from the head of a pin to that of a dime. In many cases it has a sort of radiated root. The hard corn, from a continuance of the pressure by which it is pro- duced, becomes gradually a source of pain and tenderness, which are much increased by exercise, and are often accompanied by heat and swelling of the whole foot. In time the burse under the horny cuticle inflames, and pours out an unusual quantity of fluid, which distends the sac, and thus greatly aggravates the suffering. When matter forms, the pain becomes excruciat- 1008 DISEASES AND INJURIES OF THE EXTREMITIES. ing, the slightest touch is intolerable, and the patient is unable to use the limb. In such cases the lymphatic vessels are sometimes inflamed as high up as the groin. Soft corns are always situated between the toes, usually opposite a joint or at their angle of union, and derive their characteristic feature frora beiii" in a constant state of moisture, frora the perspiration which collects between these parts; they are usually superficial, and are produced by wearing very narrow-soled shoes, by which the toes are habitually squeezed together, bent at their articulations, or forced over or under each other. For this reason ladies are raore subject to this variety of corn than men or the poorer classes of females. The soft corn is of a circular or oval figure, of a whitish, yel- lowish, or grayish color, with a radiated or horny-looking nucleus, and seldom larger than a split-pea or half a dime. Occasionally it is broad, ob- long, flat, and of a dark color, frora the presence of extravasated blood. In some instances, especially in old people and in cases of long standing, the corn is very hard at the centre, has a small synovial burse, and consists of several distinct layers. Frora being constantly compressed, it is very pain- ful, and remarkably prone to inflammation, suppuration, and even ulceration. The treatment of corns consists in scraping away the thickened cuticle, and lightly touching them with nitrate of silver, or tincture of iodine, which may be repeated occasionally until the cure is completed. This may be greatly expedited by washing the feet night and morning with cold water and soap, and afterwards rubbing thera well with a soft, dry towel. The shoe, which should have a low, broad heel, should- be accurately adapted to the shape of the limb, and all undue pressure carefully avoided, even from the seam of the stocking. When the toes are much deformed, or incurvated, they are to be kept apart by pledgets of lint, a piece of soft sponge, or adhesive plasters passed from one to the other. When this cannot be done from their fixed position, amputation may become necessary. In some instances it is useful to make the patient wear a stocking constructed on the principle of a glove, each of these organs having a separate stall. A shoe or boot made of buck- skin or cloth sometimes affords great relief. When corns are very tender, they should be frequently scraped with a blunt knife, and kept constantly covered with a piece of soap plaster, or a bit of linen spread with simple cerate to prevent them from becoming hard and dry. In some instances the pressure may be warded off by letting the corn project through a hole in the plaster, which ought then to be very thick, or consist of several layers. When the corn is seated in the sole of the foot, and this treatment is employed, it must be first covered with a piece of adhe- sive plaster, otherwise the weight of the body will cause the flesh to bulge into the opening, and thus produce severe pain in walking. Occasionally it is necessary to cut a hole in the boot or shoe, or to wear a felt sole with a hole in it, to protect the corn from pressure and friction. All these means, however, are merely palliative, and, when they fail, nothing short of complete eradication will answer. The operation, which is seldom painful, is performed with a small narrow-pointed scalpel and pair of forceps, care being taken not to injure the sensitive skin beneath, and to soften the corn by previous im- mersion in warm water. When an abscess forms, it should be opened as speedily as possible, after which the offending part may be removed, or this may be postponed to another day. Sometimes the matter escapes by ulcer- ation, leaving a fistulous sore with thick, irregular edges, and constantly bathed with a thin, ichorous fluid. In such a case nitrate of silver consti- tutes the best remedy. When corns are inflamed, they cannot be treated with too much care, since, when neglected, they may give rise to serious mischief. The foot should be kept perfectly at rest, and it may even be necessary to resort to leeches and BUNIONS—INVERSION OF THE NAIL OF THE GREAT TOE. 1009 medicated fomentations. The knife should be used raost cautiously. Several instances have fallen under my observation in which the cutting of an inflamed corn was followed by violent erysipelas and mortification ; and numerous cases are recorded in which these diseases, thus occasioned, have caused death. BUNIONS. A bunion is a corn on a large scale, caused in a similar manner, having a similar structure, and requiring a similar treatment. It consists in a thicken- ing and induration of the common integument over the first metatarso-phalangeal joint, ac- companied by a malposition of the great toe, which is usually forced inwards, either against, over, or under the adjoining one, thus occasioning a sharp, angular projection on the outside of the articulation. These appearances are well shown in fig. 684, from a female patient. The whole difficulty is originally dependent upon the wearing of a short, narrow-soled, high-heeled boot, by which the whole weight of the body is thrown upon the anterior part of the foot in pro- gression. A similar tumor sometimes forms over the first joint of the little toe. Heredi- tary malformation, preternatural laxity of the ligaments, and a gouty or rheumatic state of the system, may be mentioned as so many predisposing causes of the complaint. The cuticle, when the disease is somewhat advanced, is thick, scaly, or lamellated, hard, brawny, and at times studded with superficial corns ; the subjacent burse, which is often of large size, contains a considerable quantity of synovia; and the corresponding joint of the toe is always chronically in- flamed and hypertrophied, if not partially anchylosed. Exercise is painful, and never fails to aggravate the disorder, not unfrequently occasioning ery- sipelas of the foot, and abscess in the sac of the bunion. The treatment of this complaint is palliative and radical. The first thing to be done is to procure a proper shoe, in order to diffuse the pressure over the footj instead of concentrating it upon the toes. Pain, tenderness, and inflammation are best relieved by rest and elevation, aided by leeching, blis- tering, and cold water, medicated with laudanum and acetate of lead. If matter form, an early and free incision is made down to the bones. A radical cure may be effected by excision of the sac, but, unless the part and system have been well prepared, the operation may prove dangerous from its liability to be followed by erysipelas. A much safer plan is to divide the sac subcu- taneously with a delicate tenotome, cutting it up into numerous fragments, and then pencilling the surface of the swelling several times a day with tincture of iodine. I have practised this procedure in numerous cases with highly gratifying results. Amputation through the metatarsal bone may become necessary when the parts are hopelessly crippled, and the seat of constant suffering. INVERSION OF THE NAIL OF THE GREAT TOE. The big toe is subject to the inversion of its nail, consisting, as the name implies, in an ingrowing of its edges into the common integuments. The affection is productive of severe suffering, and is, therefore, as well as on account of the frequency of its occurrence, deserving of particular attention. VOL. II.—64 Fig. 684. Bunion. 1010 DISEASES AND INJURIES OF THE EXTREMITIES. It is not peculiar to the big toe nail, although it is most common here, and it is here, also, that it has been best studied. It is most frequent in young adults, and occasionally exists in several members of the same family. Several cases have come under my observation where it began very early in life, and under circumstances which induced me to believe that it might have been hereditary. Thus, I know two instances where a mother and two of her children are all afflicted with the disease. The affection consists essentially in a vicious formation of the nail, in con- sequence of which its edges become incurvated, and pushed down into the skin at the margin of the toe, which thus overlaps them. This often happens with the hardest as well as with the softest nail. The incurvation generally exists on both sides, though rarely in an equal degree, and we sometimes meet with cases where both the big toes are involved. When the affection is fully developed, the edge of the nail dips into the flesh almost vertically, leaving a well-marked gutter upon the removal of the offending part. Long, however, before it has attained this height, it becomes a source of severe suf- fering, on account of the pressure which it exerts upon the soft structures at the side of the toe, which at first inflame and swell, and afterwards ulcerate, the sore discharging a foul, fetid fluid, and being usually covered with ten- der, fungous granulations. In some cases, the inflammation involves nearly the whole toe, which is then proportionately painful, and thus greatly aug- ments the distress ; so that, at length, the patient is in constant misery, and hardly able to wear a shoe or take any exercise. The habitual use of a tight, narrow^ shoe, causing severe lateral pressure, no doubt often contributes to the production of this affection, but most commonly it arises from the vicious manner in which the nail is cut down at the edges, thereby allowing the thickened and indurated integument to rise above the level of the nail, which always grows more slowly than the other structures, in which, consequently, it is ultimately buried. Once formed, it is extremely difficult to get rid of it. Great convexity of the nail no doubt acts as a powerful predisponent. Various remedies have been suggested for the cure of this affection, most of which can hardly be regarded even as palliatives. Paring the inverted portion of the nail occasionally with a sharp knife, and removing the callous skin by its side, will always afford marked relief, and will, if steadily persisted in, sometimes eradicate the evil, but, in general, it wik soon return, and ulti- mately call for a more decisive procedure. Scraping the back of the nail, so much lauded by certain surgeons, is commonly useless, as it is hardly pro- ductive even of transient comfort. Dr. Robert Campbell, of Georgia, has recently recommended systematic compression with a small compress and roller, but the operation, without being by any means free from pain, is trou- blesome and tedious, from six to eight weeks being required to effect a cure, and even then it is seldom, if ever, permanent. When the affection is fully formed, and the patient's time is valuable, the best plan is at once to excise the offending portion of the nail, chloroform being given to prevent suffer- ing, which will otherwise be excessive. With a stout, narrow and very sharp scalpel, the nail is divided through its whole length, down almost to the bone, on a line with the incurvated edge, which is then rapidly detached, root and all being embraced in the dissection. Yery little bleeding attends the ope- ration, which is over in a few seconds. Warm water-dressing is applied, and the foot is kept at rest until the wound is measurably healed. I generally excise both margins at the same time. By this procedure, a large portion of the nail is left for the protection of the toe, and a radical cure effected. Everything else is merely palliative, the patient being at last obliged, per- haps after long suffering, to submit to the knife. The barbarous practice, formerly so fashionable, of removing the entire nail for the relief of this affec- tion cannot be too much condemned. EXOSTOSIS OF THE GREAT TOE — CLUB-FOOT. 1011 EXOSTOSIS OF THE GREAT TOE. The last phalanx of the great toe, as seen in fig. 685, is sometimes the seat of an exostosis, so large as to cause serious inconvenience and pain in walk- ing. It may appear at various points of the bone, but generally it is seated on its upper surface, partly under the nail, which, in time, it lifts up and partially destroys by ulceration. Its form is spherical or pyramidal, and in size it varies from that of a millet seed to that of a hazelnut, its structure and consistence resembling those of the natural osseous tissue. Arising generally without any assignable ., ... ~u •!_ j j. 11 7 ,i Exostosis of the dis- cause, its origin is usually ascribed to a blow, or to the tal phalailx of great pressure of a tight shoe; it is most common in young toe. adults, is slow in its progress, and is amenable to excision with a stout knife, aided, if necessary, by the saw. Amputation of the phalanx is not to be thought of, unless the whole bone, nail, and soft parts are involved in destructive ulceration. CLUB-FOOT. Club-foot consists in a peculiar distortion of the foot, attended with a de- viation from its natural direction, and also, generally, with a diminution of its proper length. Presenting itself in various degrees, the deformity to which it gives rise is sometimes so great as to occasion the most disagreeable disfigurement and the raost painful inconvenience, rendering the individual an object of constant attention and remark, as well as sadly interfering with the function of progression. Hence it is not surprising that it should always have attracted the notice and enlisted the sympathy of medical men, inducing them to investigate its nature and causes, and to devise means for its suc- cessful relief. For a long time, however, the whole subject was involved in almost impenetrable obscurity, notwithstanding the numerous attempts that had been made to elucidate it, and it was not until about thirty years ago that anything like substantial light began to be shed upon it. Since that period the etiology, anatomy, and treatment of club-foot have received an ex- traordinary degree of attention, and it is perhaps not going too far to affirm that these topics are as well understood now as they probably ever will be. At all events, however this may be, it is perfectly certain that there is hardly a solitary case of club-foot, bad as it may be, that does not admit of com- plete relief, if attended to in time. Club-foot is for the most part a congenital affection. It may, however, be developed after birth, and even at an advanced period of life, from the foot being accidentally placed in a constrained position, and so retained until the soft structures, particularly the muscles and ligaments, are moulded into a new shape, or thoroughly fixed in their new relations. Various mechanical causes may give rise to it, as splints and bandages, by which the parts to which they are applied are injuriously compressed, or forced out of their normal position. Similar effects are produced by convulsions, dentition, nervous irritation, contusions, sprains, fractures, partial luxations, and pre- ternatural laxity of the ligaments. Sometimes the defect is occasioned by the presence of a corn, an ulcer, or some other disease which induces the person to walk on one side of the foot, the tip, or the heel, to ward off pres- sure from the tender parts. A vicious habit is thus established which, if continued for any length of tirae, as it frequently is inevitably leads to irre- gular action of the muscles, and to distortion of the bones into which they are inserted. 1012 DISEASES AND INJURIES OF THE EXTREMITIES. Etiology.—The etiology of congenital club-foot has never been satisfac- torily explained. The hypothesis of arrested development, so warmly advo- cated by some modern pathologists, is altogether untenable, being essentially contrary to the facts of the case in every particular. The imperfect growth, if any such really exist, is not congenital, as this doctrine teaches, but acquired, being the result of causes which are brought to bear upon the child during its intra-uterine life, leading to shortening and contraction of certain muscles, and not to a want of development, properly so called. It must be acknow- ledged, however, that instances occasionally do occur, although rarely, which strongly favor the doctrine under consideration. Thus, I have, in my own practice, seen two infants born at the full term, but who died immediately after birth, who had each well-marked hare-lip, cleft-palate, and club-foot, the result evidently, so far at least as we can judge of such an occurrence, of an arrest of development. Another hypothesis of the formation of club-foot, that has met with con- siderable notoriety, is that the distortion is caused by the pressure of the uterus upon the feet of the infant during gestation, in consequence of a defi- ciency of the amniotic fluid. But, the question may be asked, if such an effect may be exerted by this organ upon the feet, why should it not be exerted also upon the hands, head, nose, chin, legs, and knees? Such a coincidence, supposing the doctrine to be true, ought to be of constant occurrence, yet it is so rare that it is probably not noticed once in a hundred cases of the affection. Besides, it remains to be proved that women who bear club-footed children have always a deficiency of amniotic liquor. The most plausible view, perhaps, that can be framed, in the present state of the science, of the formation of club-foot, is that it is produced by a defect of nervous influence, leading to a permanent contraction of certain muscles, with a corresponding retraction and incurvation of the bones into which these muscles are inserted. This hypothesis, for it is nothing else, derives corroboration from what occurs in strabismus, in which the straight muscles of the eye, frequently almost in an instant, simply from irritation, or an attack of convulsions, lose their parallelism, without the ability afterwards to regain it except by an operation. Here the contraction of the muscles must be the direct result of a lesion of innervation, or perverted nervous action ; for the effect is generally too rapid to justify the conclusion that it can pos- sibly be due to inflammation, which has sometimes been invoked as its exciting cause. How a lesion of the nerves can be produced in the foetus in the womb is of course inexplicable; but that it does occur, in various forms and degrees, is a fact clearly established in pathology. It is worthy of remark, in connection with this hypothesis, and as strikingly confirmatory of it, that congenital club-foot has been repeatedly met with in the embryo as early as the third and fourth month. Moreover, it is not unfrequently associated with imperfect development of the cerebro-spinal axis, or of certain classes of nerves, and with an atrophied and contracted state of the muscles in dif- ferent portions of the body, especially of the back, shoulder, and hand. The congenital variety of club-foot often affects both feet, though rarely in an equal degree. The relative proportion, however, of double to single club-foot has not been determined; and the probability is, judging frora re- corded facts, that it varies materially in the practice of different surgeons. In my own hands the number of cases of single club-foot has considerably exceeded—perhaps in the proportion of three to two—the number of double cases. In 167 cases, reported by Dr. Detmold, of New York, the distortion occupied both feet in 93. At the Orthopaedic Hospital, London, the two affections are said to occur almost with equal frequency. When the distor- tion is single, it involves the right foot a little oftener than the left. Both sexes are liable to club-foot, but males suffer raore frequently than females, CLUB-FOOT. 1013 probably, if I may judge from my examination of the subject, in the propor- tion nearly of two to one. Some very remarkable cases have been recorded of the occurrence of this distortion in different members of the same family. In one instance, observed by Held, all the children, six in number, were the subjects of congenital club-foot; and its history renders it probable that the affection was hereditary, since one of the parents was laboring under a similar infirmity. The transmissibility of this variety of deformity has been insisted upon by most writers on club-foot, and there are certainly just grounds for such an opinion ; still, the occurrence is extremely uncommon. Varieties of Form.—Club-foot presents itself under several varieties of form, of which there are four principal ones, differing frora each other not only in regard to the character of the distortion and the accompanying phe- nomena, but likewise in relation to the frequency of their occurrence, and the nature of their treatment. These may be respectively denominated the in- verted, everted, phalangeal, and calcaneal varieties of club-foot, each name having reference to the manner in which the limb touches the ground in standing or progression. Thus, in the inverted club-foot the inner margin of the foot is inclined upwards, while in the everted it is turned downwards ; in the phalangeal variety the heel is elevated, and in the calcaneal it is de- pressed, the toes in the former case being, of course, turned down, and-up in the latter. Besides these varieties there are several subdivisions, depend- ing upon a combination of two of the principal forms, as, for instance, the inverted and phalangeal, which is extremely common, and the inverted and calcaneal, which is more rare. The most common form of club-foot by far is the inverted, usually denomi- nated varus, figs. 686 and 687, in which the patient walks upon the outer Fig. 686. Fig. 687. Varus. ankle, the great toe being directed inwards and upwards. The muscles of the calf and the adductors of the foot are contracted, and hence there is not only elevation of the heel, but a peculiar inward twist of the foot, analogous to supination of the hand. This alteration occasions the raost serious impedi- ment to tfroo-ression, and when it reaches its highest point imparts a most disagreeable'aspect to the affected limb. In the more severe grades of the disorder the sole of the foot is literally scooped out, as it were, as well as deeply furrowed; the instep, on the contrary, is unusually convex and promi- nent- the small toes generally present in a vertical position, while the big one, separated frora the rest, looks upwards and inwards; the outer margin 1014 DISEASES AND INJURIES OF THE EXTREMITIES. of the foot, which, in conjunction with the corresponding malleolus, chiefly sustains the weight of the body, is alraost semicircular in its shape, rough, and callous; and the tendo Achillis, forced obliquely towards the inner side of the leg, forms a tense, rigid cord beneath the skin. When, as not unfrequently happens, both feet are affected with varus, their points may forra an acute angle with the leg; or they may approach so nearly as to touch, and even overlap each other. In the majority of cases the thio-h and leg retain their natural conformation, being merely somewhat atrophied- occasionally, however, the knees project slightly inwards or outwards, in consequence of the contraction of the hamstring muscles. The second variety of this deformity, anciently called valgus, fig. 688, may be regarded as the opposite of varus, the patient treading on the internal margin of the foot, while the external is entirely removed from the ground. The sole is directed outwards and slightly backwards, the toes are more or less elevated, and the outer ankle is in a state of serai-flexion. The heel is drawn upwards and somewhat outwards, the internal malleolus is uncommonly prominent, the instep is flatter than natural, and the muscles of the calf, together with the abduc- tors of the foot,. are permanently contracted. When the disease has attained its highest point, the patient has an unsteady, vacillating gait, from the difficulty which he expe- riences in preserving his centre of gravity. Yalgus is comparatively rare; like the first variety of the distortion, it may affect one or both limbs. It is seldom a congenital affec- tion, but is almost always produced by some local injury, as a sprain, blow, or contusion. The most simple form of the affection constitutes what is called flat-foot. The phalangeal variety of club-foot, figs. 689 and 690, the pes equinus of the older writers, is caused by a shortening of the gastrocnemial and soleal muscles, aided, in some cases, by the flexor of the toes. It is nearly always a non-congenital affection. In this species of the deformity the individual walks upon the ball of the foot, the toes, or the metatarso-phalangeal articulations, without the heel or any other part of the sole touching the ground. The distance to which the heel is raised varies in different cases, frora six lines to four or five inches, according to the extent of the contraction upon which the distortion depends. Considerable diversity is observed in regard to the manner in which the per- son treads on the ground ; most commonly the ball of the little toe bears the brunt of the pressure, but in some instances the weight is thrown upon the great toe, or it is diffused over the whole of the forepart of the plantar sur- face. In the worst grades, the heel is so much elevated that the foot forms nearly a straight line with the leg, the toes are much deformed, and perhaps retracted, if not doubled under, the instep is unnaturally convex, from the projection of the astragalus, the plantar aponeurosis is greatly contracted, and the skin above the heel is thrown into large, dense wrinkles. Phalan- geal club-foot, without any complication with the other forms of the affection, is exceedingly rare. Fig. 688. Valgus. CLUB-FOOT. 1015 Fig. 689. Fig. 690. Equinus. In the fourth variety, the calcaneal, fig. 691, the limb rests upon the heel, the toes being drawn upwards, towards the anterior surface of the leg, with which they sometimes form an acute angle. The immediate cause of the Fig. 691. deformity is a contraction of the an- terior tibial muscle and of the extensor of the great toe, assisted occasionally by that of the common extensor of the foot. The tendons of these muscles form an evident protuberance under the skin, where they present the appear- ance of tense, rigid cords, which power- fully resist the flexion of the limb. The inner margin of the foot, as seen in the cut, is sensibly elevated above the outer, and there is always considerable atrophy of the leg. The distortion, which is almost always congenital, is exceedingly rare. I have seen only one case of the non-congenital variety. The patient was a young female, who, in consequence of an ulcer ou one of the toes, had got in the habit of walk- ing on her heel, until at length the parts became rigidly fixed in their ab- normal position. Occasionally the foot inclines slightly outwards, owing to the inordinate contraction of the common extensor muscle. The changes which the bones, ligaments, and muscles undergo, vary, not only in the different species of club-foot, but in the different stages of the same case. The greatest alteration appears to exist on the part of the tarsal bones, which, although they are rarely completely dislocated, are generally somewhat separated frora each other, twisted round their axes, variously dis- torted, atrophied, or marked by irregular spicules or exostoses. Calcaneus. The cal- caneum, cuboid, scaphoid, and astragalus always suffer more than the other 1016 DISEASES AND INJURIES OF THE EXTREMITIES. bones; which, however, as well as those of the metatarsus and of the toes, usually participate, more or less, in the deformity. The ligaments, in recent cases of club-foot, do not present any material changes, but in those of long standing, or in the higher grades of the affection, they are invariably stretched in the direction of extension, and relaxed in that of flexion. In some instances the original structures are partially replaced by bands of new formation, of a dense, fibrous character, the volume and resistance of which vary accord- ing to the duration of the disease and the pressure of the parts which they serve to connect. The muscles also are not much altered in the first instance, except that they deviate from their natural direction, and that, like the liga- ments, they are elongated on the one hand, and shortened on the other. In ancient cases the whole limb is always considerably wasted, and many of the muscles are remarkably thin and pale, or even transformed into soft, fatty bundles. The cellular substance is condensed and diminished in quantity; the fat is absorbed; and even the vessels and nerves supplying the affected parts are reduced in volume. The skin of the foot, which receives the prin- cipal brunt of the pressure in standing and walking, is generally very much thickened and indurated, and large synovial burses are often formed beneath it, which are apt to inflame, and thus add to the suffering of the patient. Treatment.—The treatment of club-foot should always receive early and efficient attention, for the longer it is deferred the more difficult it will be, other things being equal, to effect a cure. This is equally true of the con- genital as of the accidental form of the affection. The bones in early life, and in recent cases of deformity, are much more easily restored to their nor- mal position than in youth and adolescence; and the muscles also regain much sooner, as well as more completely, their native power. In the worst grades of the lesion, it is generally extremely difficult, if not impossible, when treatment has been neglected until after the age of puberty, to make a satisfactory cure without the division of a great number of tendons, and the necessity of compelling the patieut to wear, for a long time, various kinds of apparatus. The precise period at which the treatment should be commenced has been variously defined by different authorities. Provided the infant is healthy, my custom has long been to begin it as early as the end of the second month, and, unless the case is very bad, I have rarely found it necessary, at this early period, to do more than confine the limb in a well-adjusted apparatus, worn steadily day and night. If the distortion is considerable, I invariably employ the knife as a preliminary measure, and this may always be done with the most perfect safety, even within the first four or five weeks. Different kinds of apparatus are in vogue for the cure of club-foot, and it is, therefore, not always easy for the practitioner to determine which is the best, or which should be employed to the exclusion of others. Every orthopaedic surgeon, almost, has some peculiar notions upon the subject, which induce him to adopt such measures as whim, fancy, or experience may dictate. This very circumstance, however, goes to show that the same end may be attained by different means. Whatever plan be adopted, the great caution to be observed, on the part of the surgeon, is that the extension be raade in a slow and gradual manner, that the skin be protected from friction and unequal pressure, that the dressing be worn day and night, and, finally, that the limb be frequently washed, and immediately afterwards rubbed with some mild sorbefacient lotion. The object of these instructions is self-evident, and must be constantly borne in mind in our curative procedures. During the first few days, the apparatus should be applied rather loosely, until the limb has become accustomed to its presence, when it must be gradually tightened. If the skin becomes chafed, hot, and tender, measures must immediately be adopted to moderate or shift the pressure, or the apparatus must be left off CLUB-FOOT — TREATMENT. 1017 altogether for a few days. In young children, the integument is so delicate that, unless the greatest caution is used, the foot may be seriously injured before any one is aware of what is going on. By inattention to this rule, I have soraetimes seen deep ulcers produced, which greatly interfered with the subsequent management of the case. The time required for restoring the limb to its normal position raust neces- sarily vary in different cases, and must depend upon so many circumstances as to render it impossible to lay down any specific rule. .From two and a half to six months, however, may be regarded as a fair average, though occa- sionally a much longer period will elapse, and that too when the most unre- mitting attention is bestowed. The division of the faulty tendons generally materially expedites the cure, and should always be promptly resorted to the moment it is found that the case is likely to prove obstinate. Indeed, I am not sure whether it would not be well, in almost every case, however simple, to resort to tenotomy as a preliminary step. In the milder forms of varus, or the inverted variety of club-foot, I have often succeeded in effecting complete cures, in a very short time, by the use of adhesive strips, aided by a long splint for the outer part of the leg, arranged on the plan of that of Dupuytren for fracture of the fibula. The strips should be from an inch to an inch and a quarter in width, and long enough to reach as high up as the knee, or even to the lower third of the thigh. Cut in the direction of the length of the cloth, they should be well stretched, to prevent their relaxation, when they should be applied so as to extend from the inner margin of the instep spirally or vertically up the limb, the foot being the while forcibly bent upon the leg by an assistant. Five or six strips will generally suffice, but occasionally I have found it necessary to employ as many as ten or twelve. They should be laid down as smoothly as possible, and be con- fined at suitable distances by cross slips, extending partially round the limb, otherwise they may embarrass the circulation. A narrow roller is next ap- plied from the toes upwards. A broad cushion, filled with cotton, bran, or horse hair, and considerably thicker inferiorly than above, is now stretched along the outside of the limb, frora the middle of the thigh to the ankle, and over this a tight splint, projecting from an inch and a half to two inches below the level of the sole of the foot. The dressing is completed by secur- ing the apparatus with a bandage, passed round the instep and ankle in the form of the figure 8, and thence by circular and reversed turns up the limb. This apparatus, which is exceedingly simple and easy of construction, causes, when carefully used, neither pain nor inconvenience. The strips should be renewed as often as they become slack, which will be about the sixth or seventh day, when the limb should be well washed, and rubbed with some gently stimulating lotion. When the child is not more than a few months old, or the distortiou is inconsiderable, a cure may generally be effected in this way in ten or twelve weeks. As a preliminary step, I commonly divide the tendo Achillis, and also, if necessary, the plantar aponeurosis. When the apparatus is laid aside, the foot should be placed in a strong boot, made of undressed sole-leather, carefully moulded to the limb, and constructed so as to lace in front in its whole length. Although the contrivance here described will often answer extremely well, yet its use is hardly advisable when it is practicable to obtain a properly constructed club-foot apparatus. This can, of course, always be readily done in large towns and cities; but in remote situations cutlers are seldom to be found and it is then that the surgeon is obliged to tax his ingenuity to pro- vide means necessary for the accomplishment of his purpose A great variety of club-foot apparatus has been constructed during the last twenty-five years, all based upon the original shoe of Scarpa, so well known 1018 DISEASES AND INJURIES OF THE EXTREMITIES. to surgeons. The adjoining sketches, figs. 692 and 693, afford a good idea of what such a contrivance ought to be, and, under the superintendence of Fig. 692. Fig. 693. Club-foot apparatus. that excellent cutler, Mr. Kolbe, of this city, it can be readily made with the aid simply of a plaster cast, which can now be sent from any part of the country by express. The essential elements of the apparatus are a shoe and two side-pieces, extending as high up as the lower third of the thigh, the whole being so arranged by means of screws as to permit the angle of flexion to be regulated at pleasure. The shoe, which is composed of soft leather, well padded, and laced in front, has a steel sole, consisting of two pieces, moved by a concealed screw, the spring of which projects at the side. In this way the foot may readily be turned to one side or the other, according to the exigencies of the case, while it is depressed or elevated by'an oblique screw at the ankle, connecting the shoe with the leg-piece of the apparatus, and worked by a key, as seen in the accompanying drawing. The steel rods which extend along the sides of the limb are so constructed that they can be lengthened or shortened at will, and are secured in their proper position by means of well-padded straps, each inclosing a semicircular piece of steel behind, in order to afford proper support to the limb in that situation. They are united, opposite the knee, by a hinge-joint, with a view of permitting the full play of that articulation. There is an apparatus, differing from the preceding chiefly in having only one side-piece, and in being worked by an endless screw, situated opposite the ankle. Its great value consists in the facility which it affords for depress- ing the displaced margin of the foot. The division of the faulty tendons requires more care and attention than is usually imagined. Every tyro in surgery thinks he can perform it; but this is a great mistake. To do it well requires skill, judgment, and a competent knowledge of the anatomy of the foot and leg. It is this presumptuous inter- ference that has brought so much obloquy upon this operation in this country. In general, very little preliminary treatment is necessary; often, indeed, not any. If the child, however, is several years old, and has been accustomed to CLUB-FOOT — TREATMENT. 1019 much exercise, it will be well to keep him at rest for a few days before the operation, to wash the foot repeatedly with cold water, and to enjoin a light diet. The operation may then be commenced, chloroform being given or not, according to circumstances, and every faulty muscle being divided at one sitting. The position of the patient must necessarily vary according to the exigencies of each particular case. The number and nature of the tendons requiring division vary with the extent and character of the distortion. Thus, in simple equinus or phalan- geal club-foot, the tendo Achillis alone being concerned in producing the affection, the operation must accordingly be restricted to that cord, and the effect is generally such that, if the patient is able to walk, no apparatus will afterwards be needed to bring down the heel. Pure, uncomplicated varus requires the division of the tendon of the anterior tibial muscle, or of this muscle and of the long flexor of the toes. In the more simple forms of valgus, the tendons of the peroneal muscles are mainly concerned; while in calcaneal club-foot the distortion depends upon the contraction of the anterior tibial and common extensor muscles of the toes. In equino-varus, and in the worse forms of club-foot generally, more or less extensive division of the plantar aponeurosis is required. Age is no bar to tenotomy. I have repeatedly performed the operation within the first two months after birth, and I should not object to it, if the child were perfectly well, and the distortion very great, within the first fort- night, though, as a general rule, it is always best to wait a much longer time. Young adults are often immensely benefited, and sometimes entirely relieved by the operation; and cases have been reported of excellent results in persons of forty and even fifty years of age. The knife which I am in the habit of using in tenotomy is represented in fig. 694; it is nearly six inches in length, of which one inch and Fig. 694. three-quarters are occupied by ___ the blade. The cutting portion *—"_____^==r^^—^—'ZZ=S?^$V^^^ of the blade is spear-shaped, very Sss""^s^ sharp, thin, and a little more than Tenotome. five-eighths of an inch in length by two-thirds of a line in width at its widest part. The instrument, of course, makes a mere puncture in the skin. In dividing the tendo Achillis, the patient is placed upon his abdomen, and the limb, extended upon the table, is firmly held by an assistant. The opera- tor, sitting in a chair, then grasps the foot with his left hand, and, bending it over the edge of the table, brings down the heel as far as possible. The necessary tension being thus given to the tendon, the knife is entered flatwise between it and the deep-seated structures, a full inch above the calcaneum, and pushed on until it reaches the opposite side, care being taken that the point does not pierce the integument. The instrument is now turned in such a manner as to bring the edge of the blade against the anterior surface of the cord, which is then completely severed by pressing the handle steadily and firmly backwards, with a kind of sawing motion. The division of the parts is generally indicated by a distinct snap, and by the immediate cessation of their resistance. The operation, which is soon over, is attended with hardly any pain, and with the loss of only a few drops of blood. The only danger is the wounding of the posterior tibial artery, but this raay be easily avoided simply by keeping the knife in close contact with the anterior surface of the tendon, and cutting frora before backwards. The puncture may be made on the inner or on the outer side of the limb, as may be found most convenient. Professor Pancoast, instead of severing the tendo Achillis, prefers, in most cases attended with retraction of the heel, the division of the inferior portion 1020 DISEASES AND INJURIES OF THE EXTREMITIES. of the soleal muscle, on the ground, not only that the procedure is free from danger, but that it admits of the raore rapid rectification of the deformity. The operation, which he has performed upwards of fifteen times, is, however applicable only when there is marked tension of the soleal with relaxation of the gastrocnemial muscle. The tendon of the posterior tibial muscle is cut most conveniently about an inch and a quarter above the inner ankle, the patient lying on his side, with the inner surface of the leg looking upwards. The operation is conducted upon the same principles as in dividing the tendo Achillis, and the only pre- caution necessary is to avoid the posterior tibial artery and nerve, which might be endangered by carrying the knife too deeply. The tendon'of the long flexor muscle may be severed at the same point. In the slighter cases of distortion, the tendon of the posterior tibial muscle may be cut below the ankle, in its passage to the scaphoid bone, but in the raore aggravated forms such a procedure is impracticable on account of the concealed situation of the cord. The tendon of the flexor muscle of the great toe may be divided in the sole of the foot, where, when it interferes with the rectification of the limb, it will be found to form a tense, prominent cord. The raost favorable situation for dividing the tendon of the anterior tibial muscle is in front of the ankle-joint, where it may usually be easily felt, form- ing a tense cord, lying somewhat nearer to the internal malleolus than in the natural state. The patient rests on his back during the operation, and care is taken not to wound the anterior tibial artery. The tendons of the peroneal muscles are most conveniently divided a short distance above the outer ankle, as they run over the fibula. The operation will be facilitated if, as the knife is carried outwards towards the surface, the foot be rotated downwards and inwards, the cords being thus rendered more tense. Section of the plantar aponeurosis is to be effected upon the same princi- ples as that of the tendons, the knife being inserted flatwise beneath the skin, and made to cut from before backwards, the patient lying upon his back, and the foot being put on the stretch. As the aponeurosis is extremely dense and firm, its division generally requires a very sharp, well-tempered knife, worked with a kind of sawing motion, the finger resting the while on the skin imme- diately over it, to prevent it from cutting through. It is seldom necessary to divide more than two bands, one in the posterior part of the sole, and the other at the inner margin of the foot, corresponding with the metatarsal bone of the great toe. All the faulty structures having been thoroughly divided, the foot is well flexed and extended, in order to break up any morbid adhesions that may exist, and separate as widely as possible the ends of the tendons, as much force being used for this purpose as may seem to be compatible with the safety of the limb. The advantage gained in this way is generally very great, and it is remarkable how tolerant the parts are of manipulation. The little puncture made in the operation is covered with a strip of adhesive plaster, and usually closes by the next morning. The limb being bandaged from the toes up, is immediately placed in the apparatus provided before the operation. This plan has been constantly pursued by me for many years, and I have never had any cause to regret it; on the contrary, I believe it to be decidedly preferable to waiting three or four days, as usually recommended by authors; for at the end of this time the parts are often so tender as to be quite intole- rant of pressure and extension. It is only in cases of an extraordinary cha- racter that this rule should be deviated from. There need be no apprehension of a want of reunion of the ends of the divided tendon when this course is adopted. I have myself never seen such a case, nor heard of one that was entitled to credence. The apparatus must, of course, be applied rather CLUB-FOOT — TREATMENT. 1021 loosely at first, and be gradually tightened as the limb becomes more tole'rant of its presence. It should be taken off regularly every other day, in order that the limb may be well washed and rubbed with some mild sorbefacient lotion, as well as subjected to passive motion ; a circumstance of great im- portance in respect to the welfare of the ankle-joint, and the restoration of the muscles of the limb. For the first five or six days after the operation, the limb is kept at rest in an elevated position ; but after that tirae the patient may go about on his crutch or stick, as he may find it most convenient. The apparatus must be worn day and night, for a period varying from three to twelve months, according to the severity of the case. If the treatment be properly conducted, the patient and surgeon carefully co-operating, there will seldom be any necessity for a redivision of the tendons. In simple equinus, occurring in childhood and young persons, I have never found it necessary to apply any apparatus, the heel readily coming down under exercise, which the patient may safely begin within a few days after the ope- ration. The interval between the ends of the divided tendons is gradually filled up with plastic matter, while the blood poured out in the operation is rapidly removed by the absorbents. As in other subcutaneous procedures, so in this, the plasma soon becomes organized, and is finally converted into a firm, dense substance, analogous to the original structure, which it now replaces. Ob- servation shows that it is already quite firm and unyielding by the end of the first fortnight; a circumstance which proves how important it is to give due heed to the management of the extending apparatus. The operation for club-foot is occasionally attended with the puncture of some of the arteries, especially the anterior and posterior tibial. Should such an accident unfortunately occur, the proper plan is to cut the vessel completely across, and to apply graduated compression over the wound. Finally, whatever mode of treatment may be adopted, it is of paramount importance that it should be carried out under the personal superintendence of the surgeon ; to delegate this office to the parent or nurse or to the patient himself, is only a waste of time, and what no sensible surgeon should ever do. I never, in fact, like to intrust the management of a case of club-foot even to an intelligent physician, for there are so many points to demand attention that, unless the greatest possible care is exercised, some- Fig- 695- thing will be sure to go wrong, and mar the beauty of the cure. The adjoining sketch, fig. 695, illustrates the effects of the divi- sion of the tendo Achillis and plantar aponeurosis, in a case of equino-varus, attended with bad deformity. The cure was perfect. The operation for club-foot, as stated in a previous chapter, was first satisfactorily performed in 1831, by Dr. Stromeyer. The tendo Achillis, however, was di- vided as early as 1784, by Lo- renz, a surgeon at Frankfort, at the suggestion of Dr. Thilenius. The case was one of equino-varus, in a youno- lady who had suffered from birth. The operation was not performed subcutaneously, but by direct incision. The heel descended two inches; and, although the cure was tedious, the patient finally obtained a good use of the Effect of the operation for club-foot. 1022 DISEASES AND INJURIES OF THE EXTREMITIES. limb. A similar operation was performed not long afterwards by Sartorius; he made his incisions still larger than Lorenz, and it is, therefore, not sur- prising that he should have signally failed. Michaelis, at a still later period, modified the procedure by dividing the shortened tendon partially, and im- mediately bringing down the foot by mechanical appliances. His first opera- tion was performed in 1809. In 1816, Delpech, of Montpellier, whose name is indelibly associated with this department of surgery, conceived the idea of performing the operation subcutaneously, and he accordingly carried it into effect in a case of varus Conjoined with retraction of the heel. What is remarkable, however, and what greatly marred the success of the result, was that he should have made, as a preliminary step, an incision an inch in length through the skin and deep-seated structures on each side of the tendo Achillis, evidently with the view of facilitating the division of the cord from behind forward. After much trouble and not a little suffering the patient ultimately made a tolerably good recovery, but Delpech was so much dis- couraged that he never ventured to repeat the operation. Such was the state of tenotomy when Stromeyer, fifteen years later, entered the field, and, perceiving the errors of his predecessors, laid down the proper principles which should guide the surgeon in the execution of his task. FLAT-FOOT. This deformity, which is most common in young adolescents, occurs in both sexes and in all classes, usually from some inherent congenital defect in the structuresof the foot, aggravated by overwork, by the use of imperfectly constructed shoes, or by vicious eversion of the foot, in attempts at polite walking. It is often associated with disorder of the general health, and is most frequently met with in persons of a strumous predisposition, with a tendency to rachitis. Although it sometimes begins very early in life, it seldom becomes a source of serious Fig. 696. deformity until after the age of four- teen. Both feet commonly suffer simultaneously, but not in the same degree. The affection, as seen in the an- nexed sketch, fig. 696, essentially consists in a loss of the arch of the foot, so that, when the individual stands up, the sole rests flat upon the ground, instead of upon the heel and the ball of the toes. The external malleolus is uncommonly prominent, the foot inclines outwards, as in the milder forms of valgus, and the ankle is remarkably large and full. In the worst forms of the affection, there is par- tial displacement of the scaphoid, astragalus, and internal cuneiform bones, the convexity of the dorsum is lost, the toes are everted, and the foot is con- siderably elongated. The ankle-joint, at all times weak, eventually loses its mobility, and the patient is permanently crippled and deformed, progression being difficult, awkward, and painful. The internal lateral ligament is at- tenuated and relaxed, while the peroneal, tibial, and extensor muscles are shortened, and not unfrequently affected with the fatty degeneration. The treatment, in the earlier stages of the complaint, consists in the use of the cold douche, followed by friction with some stimulating liniment, and aided by mechanical support of the ankle, as a shoe or boot with side pieces and a screw for inverting the foot. The sole should be considerably thicker on the inner than on the outer side. The general health is amended, if necessary, PODELKOMA—PODODYNIA. 1023 by tonics and change of air. Absolute rest of the limb is sometimes of para- mount importance, in order to afford the weakened structures an opportunity of becoming invigorated, exercise being taken, in the mean time, in a carriage or swing. In the more serious forms of flattening, attended with great eversion and more or less elevation of the toes, recourse must be had to tenotomy, with the subsequent employment of a rectifying apparatus. The treatment, in fact, must be very similar to that of valgus. The muscles whose tendons require division are the peroneal, the anterior tibial, and the long extensors of the toes. PODELKOMA. A peculiar ulcerous affection of the foot, known under the name of podel- koma, first bestowed upon it, I believe, by Professor Miller, of Edinburgh, is occasionally met with. Its precise nature is not well understood, some regarding it as of a scrofulous, others as of a syphilitic, character. It occurs in both sexes and in different classes, and is most frequent in persons of middle life, of a broken-down constitution. Commencing usually about the toes, the disease is characterized by the occurrence of numerous small sores, separated by thickened and indurated skin, their edges being steep and abrupt, and their surface incrusted with aplastic lymph. Their shape is generally oval or circular ; sometimes, though rarely, several run together, or are connected merely by narrow, undermined bridges of integument. The discharge is foul, fetid, sanious, and irritating. The Fig. 697. pain is usually very severe, and there is always serious constitutional involvement, the patient being thin, wan, weak and fretful. In cases of long standing, the disease is not limited to the soft parts, but affects the other structures also. The nails ulcerate and drop off; the phalanges of the toes are rendered carious ; and the calcaneum and metatarsal bones ulti- „ , „ c „ . , „a . ,, . , . . ., e , mi Podelkoraa; a, the toes, much altered; 0, mately experience a similar fate. The the outer side of ^e foot, in some parts show- frightful Changes Which this disease is ing Beatrices; c, the line of amputation, at Capable Of producing in the foot are Well the ankle; d, the astragalus. The swelling illustrated in the annexed CUt, fig. 697. 1b often much greater than here represented. In the treatment of this disease great advantage will be derived from a regular and persistent course of iodide of potassium along with iodide of iron and bichloride of mercury. Quinine and brandy will be required if much debility exist. The best topical remedies will be the warm water-dressing or emollient cataplasms, with the free use of the chlorides to allay fetor and promote cicatrization. The nitric acid lotion will also prove useful; and many cases will do well under the applica- tion of calomel, or calomel and tannin, with dry lint. In the worst cases nothing short of amputation will answer. PODODYNIA. This disease, hitherto undescribed, although not peculiar to tailors, is so common among them that it might very properly be called after their name. It is most frequent among cutters, in consequence, apparent y, of their being compelled to maintain for many successive hours every day the erect posture, after they have been accustomed to sit for years upon the board. The feet, being thus suddenly exposed to great hardship, are unable to bear the con- 1024 DISEASES AND INJURIES OF THE EXTREMITIES. tinual pressure imposed upon thera by the weight of the body, and the con- sequence is that they become exceedingly tender and painful, if not, in time, entirely disabled. The soreness is generally most severe in the sole of the foot, over the calcaneum and the ball of the great toe, or in the line of the metatarso-phalangeal joints, parts which are particularly subject to pressure during the erect posture. The hollow of the foot, however, occasionally participates in the suffering. The pain and tenderness are deep-seated, and are always aggravated by the pressure of the finger, and by walking and standing, which the patient is often obliged to forego in consequence. Little swelling attends the disease, and there is seldom any marked discoloration of the skin. Both feet often suffer simultaneously. The general health is sel- dom materially, if, indeed, at all, affected. What the pathology of pododynia is, I have not been able to determine, as no opportunity has been afforded me of dissecting the parts. The proba- bility is that it is a forra of inflammation, situated chiefly in the periosteum, or the periosteum and plantar aponeurosis, attended with an inordinate de- termination of blood and a slight tendency to effusion. In the cases which have fallen under my observation, it has not been in my power to trace any connection between this disease and gout or rheumatism. The subjects are, for the most part, young men. The treatment which I have found most reliable in pododynia has been a succession of blisters, with rest and elevation of the foot, and some attention to the diet and bowels. Medicated lotions, tincture of iodine, and leeching, have exerted no special influence upon the progress of the disease. In a few cases I have tried, but without any material benefit, subcutaneous scarifi- cation of the affected parts. 2. AFFECTIONS OF THE LEG. VARIX. Varix of the lower extremity is a very common disease in both sexes, and often entails much suffering. In general, it involves both the leg and foot, while not unfrequently it extends even into the thigh, being particularly con- spicuous along the course of the saphenous vein and its branches. An excel- lent illustration of this affection will be found in fig. 275, in the chapter on the diseases and injuries of the veins, to which the reader is referred for a full account of it. The treatment is palliative and radical. In the milder cases, very little is generally required beyond attention to cleanliness of the parts, the avoidance of all constriction of the limb, and the exhibition, now and then, of a purgative, especially in pregnant females. If the patient be very plethoric, much benefit will be expe- rienced by an occasional bleeding. The limb should be frequently washed with cold water, or sponged with some alcoholic lotion, and be kept, as much as possible, at rest in an elevated posture. With the aid of these measures, and the use of a laced stocking, fig. 698, or a well-applied bandage, the milder cases will generally be sufficiently manageable. For the radical cure, various remedies have been sug- gested, the safest, as well as the raost effectual, of which are the caustic issue, subcutaneous ligation, and injections of the persulphate of iron. Excision and direct exposure of the diseased vessels are dangerous, and should never be Laced stocking. practised. AFFECTIONS OF THE LEG — VARIX. 1025 The treatment by the caustic issue has been eminently successful in my hands, and I, therefore, give it a decided preference. It consists in making a number of eschars with equal parts of caustic potassa and quicklime, con- verted into a consistent paste with alcohol. Of this, a portion of the size and shape of a three-cent piece, only much thicker, is placed directly upon the enlarged and tortuous vessel, at intervals of three, four, or five inches, and allowed to remain on for fifteen minutes, by which time the skin and cellular tissue will have been thoroughly destroyed. The paste is now re- moved, and the part, carefully washed with vinegar, to neutralize any of the alkali that may still adhere to the surface, is covered with an emollient poul- tice, for the purpose of promoting, first, the separation of the eschar, and, secondly, the development of granulations. The cure is usually somewhat tedious on account of the length of time required to heal the issues, but it possesses the great advantage of being entirely free from danger and always perfectly successful. Ligation of the diseased vessels may be performed by passing underneath them, at different points, long, ordinary suture pins, aud drawing tightly around each of thera a stout, well-waxed thread, so as to arrest at once the circulation both within the veins and also in their tunics, as delineated in fig. 699. Some surgeons interpose a piece of wax bougie between the skiu Fig. 699. Fig. 700. Obliteration of varicose veins by ligation. Twisted suture. and ligature, as in fig. 700, but I do not believe that this adds anything either to the comfort of the patient or the success of the operation. Great care must be taken that the pins are carried fairly behind the vein, for, if they transfix it, very serious phlebitis may arise, whereas, if the procedure be properly executed, it will generally prove harmless, although, as already ob- served, less so than the operation by caustic. The pins should not be removed until considerable ulceration has taken place, which will rarely be before the end of the sixth or eighth day. Instead of using pins, a much better and safer plan is to ligate the enlarged vessels subcutaneously by means of a metallic wire, fig. 701, as practised by Dr. R. J. Levis, of this city. The operation is performed with a straight needle, from two and a half to three inches in length, with a sharp, angular point which perforates without cutting. The instrument is carried across the tissues with the same precautions as in the ordinary method, and in such a manner as to bring out at the same orifices both ends of the thread, which are then firmly twisted together, and cut off about half an inch frora the surface. Spontaneous removal of the sutures will generally occur in from two to three weeks, especially if they be occasionally tightened. Dr. Levis informs me that he has performed this operation successfully in vol. n.—65 Subcutaneous ligation of a varicose vein with sil- 1026 DISEASES AND INJURIES OF THE EXTREMITIES. thirty-eight instances, without any accident or unfavorable result, his first case having occurred in 1859. Dr. Bozeman effects subcutaneous ligation of the enlarged vessels with his button suture. A cure of this disease has occasionally been effected by the injection of the enlarged vein with a solution of the perchloride of iron, as recommended by Mons. Pravaz. The most suitable instrument for the purpose is the one depicted in fig. 255, in the chapter on aneurism; the vessel is firmly com- pressed, as a preliminary step, by means of the finger, or a pad and roller, and a few drops, generally not more than three or four, of the solution are slowly thrown into its cavity, the contents of which are immediately coagu- lated. The great objection to this mode of treatment is that, while it is not always successful, in consequence of the gradual absorption of the clots, it is occasionally followed by serious accidents, as violent erysipelas and even pyemia. A solution of the persulphate of iron has lately been employed in this affec- tion writh a similar view as the perchloride, but whether it possesses any advantages over it is questionable. Dr. James M. Minor, of Brooklyn, in 1860 published the results of five cases of varix successfully treated by this means, without any dangerous symptoms following the procedure. The solu- tion was prepared with one part of the salt to four of water, and the blood was usually firmly coagulated in less than a minute. Whatever mode of treatment may be adopted, the case should receive every possible attention until all danger of erysipelas, phlebitis, and pyemia is passed. The limb, invested with a roller, is placed in an easy, elevated posi- tion, and is kept constantly wet with water-dressing, simple or medicated, the diet and bowels being at the same tirae thoroughly regulated. Premature exercise must be avoided, and the leg must be for a long time supported with a bandage or laced stocking. ANEURISMAL VARIX. This rare form of disease is occasionally observed in the leg or leg and foot. The most remarkable example of the kind I have ever seen, in any part of the body, came under my observation in 1858, in a woman, aged forty-three years, an in-patient of the Jefferson College Clinic. The varicose enlargement ex- tended from the base of the toes as high up as the knee, affecting both the superficial and deep vessels. Pulsation was perceptible both to sight and touch, and a well-marked aneurismal thrill, most distinct over the posterior tibial region, was readily detected by auscultation. The internal saphenous vein was enormously distended in various parts of its course, being in some places nearly an inch in diameter, and the circumference of the limb was much greater than that of the sound one. The foot had a soft, spongy feel, and a deep, exca- vated ulcer, of the size of a ten cent piece, with a foul bottom and everted ed°-es, existed upon its dorsal surface. The toes were distorted and enlarged, and near the instep a congenital nevus was found. As the limb had been for years the constant seat of severe pain, and as the poor woman had long ceased to be able to walk without crutches, I ampu- tated the leg a short distance below the knee. A large number of arteries and also the internal saphenous vein required ligation, the latter vessel being greatly enlarged, patulous, and unable to retract. The case went on tolerably well for eighteen days, when erysipelas and pyemia ensued, followed by an enormous abscess, extending from the stump to the crest of the ilium. She expired, completely exhausted, at the end of the fourth week. A full report of this interesting case, with an account of the dissection of the body and limb, frora the pen of Dr. S. W. Gross, may be found in the Transactions of the Pathological Society of Philadelphia for 1861. AFFECTIONS OF THE KNEE —ANCHYLOSIS. 1027 LACERATION OF THE TENDO ACHILLIS. This accident is always the result of the sudden and violent contraction of the gastrocnemial muscles, consequent upon inordinate exertion It is most common in actors, beyond the middle age, and is probably generally connected with fatty Fig. 702. degeneration of the substance of the tendon. The seat of rupture varies ; but in most cases it is rather low down towards the heel bone. The occurrence of the injury is commonly de- noted by an audible snap, and by a sensation as if something had suddenly given way, the patient at the same time falling down, or finding it difficult to maintain himself on'his limbs. The pain is very severe, and, on exa- mining the parts, a distinct gap is discovered at the site of the laceration, similar to that which occurs in the operation for club-foot. In the treatment of this accident, the indi- cation is to maintain perfect apposition of the ends of the ruptured tendon until complete consolidation has been effected. Unless this be carefully met, a certain degree of lameness will almost be inevitable. The apparatus that is usually employed for this purpose is that devised by Monro, and sketched in fig. 702. It consists, as will be perceived, of a slipper and a thigh-strap, connected by a cord, the object being thorough flexion of the limb, and consequent relaxation of the gastrocnemial muscles. Should the strap have a tendency to slip, it must be secured to the pelvis. The indication may also be fulfilled by applying a splint along the front of the leg and foot, as in fracture of the heel-bone, the leg having previously been bandnged from the knee downwards so as to con- trol the action of the flexor muscles, and the limb being afterwards placed in an easy, relaxed position, over a large pillow. A cure usually follows in about five weeks, but the patient must be very careful for some time after, otherwise the connecting bond will either give way, or, at all events, become injuriously elongated. Monro's apparatus for maintaining flexion in ruptured tendo Achillis. 3. AFFECTIONS OF THE KNEE. ANCHYLOSIS. Anchylosis of the knee-joint is of frequent occurrence, and may depend, first, upon contraction of the hamstring muscles; secondly, upon disease of the ligaments and bones of the joint; and, thirdly, upon adhesions of the articulating surfaces, the union being either of a fibrous or osseous character. However induced, the limb will be sadly in the way of usefulness when the leg is straight, or flexed at a right angle with the thigh. When the anchylosis is caused by permanent contraction of the hamstring muscles, a cure may generally be readily effected by the division of their tendons, passive motion of the joint being afterwards regularly maintained to prevent relapse. The operation is sufficiently simple, but requires some care to avoid 1028 DISEASES AND INJURIES OF THE EXTREMITIES. Fig. 703. the nerves and vessels in the neighborhood of the affected structures. Forci- ble extension with the hand should be practised immediately after the section has been completed, and the subsequent treat- ment should be conducted by means of a hol- low splint, composed of sheet iron, worked by a screw, and applied to the posterior surface of the joint. The treatment must necessarily be tedious, demanding both patience and skill, but by proper perseverance a good cure may be effected. The best apparatus for keeping up the requisite extension is that sketched in fig. 703, which may be readily manufactured by any respectable cutler. When the ligaments and bones are at fault, as when there has been serious disease, resec- tion will probably be required. Fibrous an- chylosis, even when of long standing, may usually be effectually overcome by forcible flexion under chloroform, the procedure being generally well borne both by the part and system, the slight pain and inflammation con- sequent upon it commonly disappearing in a few days. When the connection is osseous, either Barton's operation will be necessary, or, what I should prefer, as more safe, that of Dr. Brainard, described at page 86. In the case of a young man, aged 20, recently under my care at the Jefferson College Clinic, I broke up subcutaneously, though not without considerable difficulty, by means of perforators and other instruments, the most firm and ex- tensive osseous adhesions of the knee-joint, without the occurrence of a solitary untoward symptom. The anchylosis, caused by a wound, had existed for nine years, and the natural structures of the articulation had been com- pletely annihilated. The leg was flexed nearly at a right angle with the thigh. I believe that such an operation will always be perfectly safe when a joint has been deprived of cartilage and synovial membrane, and care is taken not to inflict serious injury upon the soft parts. Apparatus for treating deformities of the thigh and leg. KNOCfK-KNEE. Knock-knee is an affection in which, as the name implies, the knee is turned inwards in such a manner as to touch its fellow of the opposite side, the leg being at the same time inclined outwards. When both knees are involved, and the deformity exists in a high degree, the lower extremities, when the individual stands up, represent pretty accurately the outline of the letter £ inverted, the upper part corresponding to the thighs, and the lower to the legs, as seen in the accompanying cut, fig. 704. The feet are widely sepa- rated from each other, and are often so much everted as to corapel the person to support the weight of his body principally upon the inner margin of the limb. The deformity thus occasioned is not only very unseemly, but, what is worse, produces a limping, awkward gait, which greatly interferes with pro- gression. Knock-knee is always a non-congenital affection, though it is occasionally KNOCK-KNEE. 1029 noticed at so early a period of life as to have led to the opinion, at one time sufficiently common, but now obsolete, that it is now and then an intra- uterine lesion. It occurs chiefly Fig. 704. Knock-knee. in weakly, delicate subjects frora the age of two years to that of eighteen or twenty. Children of a scrofulous habit and a rachitic predisposition are particularly obnoxious to it. So far as my experience enables me to judge, lam inclined to believe that the affection is considerably raore frequent in males than in females, although some allowance must certainly be made for the fact that the difference in the clothing of the two sexes renders the for- mer, when laboring under knock- knee, a subject of much greater attraction than the latter, many of whom, simply in consequence of the petticoat, entirely escape detection both in the house and in our public thoroughfares. The worst cases of this affection that have ever come under my observation occurred in negroes. The immediate cause of this affection is a relaxed and enfeebled state of the internal lateral ligament, which allows the external hamstring muscle, one of the flexors of the thigh, to drag the head of the tibia gradually out- wards, away from the inner condyle. Whether the internal hamstring mus- cles, the semi-membranous and the semi-tendinous, as they are termed, are originally involved in this partial displacement is not easily determined ; but, however this may be, it is certain that they too become very soon re- laxed and elongated, thus losing their antagonistic influence, and permitting their fellow on the opposite side to fall into a shortened and contracted con- dition, which, if not timeously remedied, only tends to a still further increase of deformity. The existence of this state of the parts has been verified by dissection, and may be readily ascertained by carefully examining a person laboring under knock-knee, in the recumbent posture. The limb being turned in various directions, an opportunity is afforded of determining where the structures at and around the knee are most relaxed and most resistant. In the more aggravated forms of the affection, the crucial ligaments always par- ticipate in these changes in the natural relations of the parts; the bones of the leg are liable to be curved and otherwise altered, and the feet are either very much flattened, or more or less inverted, as in valgus. In such cases, the ankle-joint also usually becomes involved, the internal ligaments being attenuated and stretched, and the peroneal muscles more or less contracted. The treatment of knock-knee, in its more simple forms, admits of relief by mechanical means, such as a long, hollow, and well-padded splint, applied along the inner surface of the thigh and leg, so as to counteract effectually the contraction of the outer hamstring muscle, which is the active agent in the displaceraent. The use of the apparatus should be assisted by a course of tonics the shower bath, and the cold douche, followed by stimulating lotions to' the affected limb. In short, no pains should be spared to invigo- rate the general health, and impart tone to the nervous system, which are so 1030 DISEASES AND INJURIES OF THE EXTREMITIES. frequently at fault under such circumstances. The apparatus must be worn for a long time, inasmuch as the tendency to relapse is, in almost every case of the kind, remarkably great. When the affection is obstinate, or exists in a high degree, the best plan is at once to divide the tendon of the two-headed flexor muscle ; an operation which is not only very simple, but extremely valuable in furthering the cure. In performing the operation, the patient is placed upon his abdomen, when, the limb being slightly flexed, a delicate tenotome is entered flatwise at the outer margin of the tendon, from an inch to an inch and a half above the knee, and passed on until it reaches the opposite side, when, the cutting edge being directed forwards, the division is easily effected in the usual manner. No vessel is in danger of being injured, but the peroneal nerve is occasion- ally cut, followed by slight paralysis, which, however, seldom lasts longer than a few months. Should the femoral aponeurosis be involved in the contrac- tion, any hard and resisting bands that may present themselves may now be severed by a cautious use of the knife. The little punctures made in the operation being covered with bits of adhesive plaster, the limb is wrapped in a bandage, frora the toes up, and placed in an easy posture over a pillow; or, what I prefer, the extending apparatus may be applied at once, as the resulting inflammation is generally so slight as not to require any special attention. An affection the reverse of the preceding sometimes occurs, either in association with it or by itself. In the latter case, one knee is inverted, the other everted. The causes and treatment are the same in both disorders. housemaid's knee. An enlargement of the burse over the patella occasionally takes place, con- stituting an inconvenient and unsightly tumor, interfering with comfort and progression. It is most common in ser- vant girls and persons who habitually exert much pressure upon this part, and is popularly known as the housemaid's knee. The immediate cause of the affec- tion is inflammation, usually chronic, bnt now and then acute. The swelling is soft and fluctuating, semi-globular in shape, and unaccompanied by discolora- tion of the skin and enlargement of the subcutaneous veins. Some degree of soreness is usually present, but seldom any decided pain. The appearances of the parts are well shown in fig. 705, from one of my clinical cases. The treatment of this disease consists in evacuating the contents of the sac, and injecting it immediately after with a small quantity of equal parts of tincture of iodine and alcohol, the fluid being well pushed about, and permitted to remain until it is productive of some pain. Or, instead of this, a small seton may be inserted. The after-treatment consists Housemaid's knee. of perfect repose of the parts and the ordinary antiphlogistic measures. affections of the ham and thigh. 1031 4. affections of the ham. A large synovial burse sometimes forms in the popliteal region, in connec- tion with one of the tendons of the hamstring muscles, giving rise to a swell- ing which eventually seriously impedes the movements of the knee-joint. The tumor is characterized by the tardiness of its progress, by a sense of fluctuation, or peculiar puffiness, by an absence of pain, and by a freedom from discoloration of the skin. If any doubt exists as to its real nature, re- course is had to the exploring needle. The treatment is by seton or injection with iodine. No judicious surgeon exsects such a tumor. In several instances in which the operation was practised, violent erysipelas ensued, necessitating amputation of the thigh. A bloody tumor occasionally forms in the ham, being generally caused by external violence, as a blow or fall, eventuating in a rupture of some of the smaller vessels in the connective tissue. It is tardy in its growth, semi-elastic, and productive, when of large bulk, of pain and stiffness of the joint. It is distinguishable from aneurism by the absence of pulsation and thrill, and by the history of the case. A section of the tumor reveals the existence of organized coagula, differing in consistence and color, some being hard and pale, others soft, almost semifluid, and dark. The inclosing cyst is composed of condensed cellular tissue. The proper remedy is excision. Solid tumors of various kinds, as the fibrous, fatty, and encephaloid, are liable to occur in the ham, but they do not exhibit any peculiarities requiring special notice. Their progress and consistence generally afford sufficient evidence of their true character. Abscess of the ham is occasionally met with ; generally as a result of injury, or as a consequence of the extension of disease frora the knee. The matter is commonly very deep-seated, and, therefore, slow in reaching the surface ; the symptoms, both local and general, are unusually severe, and the fluctua- tion, especially in the early stage of the affection, is always very indistinct. The limb soon becomes stiff, the swelling is extensive, and the existence of pus is eventually indicated by an cedematous and erysipelatous state of the skin. The absence of pulsation will usually distinguish it from popliteal aneurism. Still, the surgeon must be upon his guard, not neglecting, in case of doubt, the use of the exploring needle. The proper treatment is a free and early puncture. 5. affections of the thigh. The thigh is sometimes drawn remarkably inwards, in a very awkward and constrained position, by the permanent contraction of the short adductor and pectineal muscles. Several cases of this kind have fallen under my obser- vation, chiefly in young boys from five to eight years of age, without my having been able to trace the affection to any assignable cause, none of the subjects having suffered from rheumatism. The contraction sometimes exists simultaneously on both sides, and, under such circumstances, the person usually walks with great difficulty, the gait being very unseemly and crippled, the limbs during progression tending to cross each other. The remedy con- sists in dividing the faulty muscles freely by subcutaneous section, care being taken to keep the tenotome as closely as possible to the affected structures. The thighs should be forcibly abducted immediately after the operation, and in three or four days, the patient may be permitted to run about. The cure will be expedited by exercise on the hobby-horse, and by whatever has a tendency to keep the limbs apart. The thigh is occasionally rigidly flexed upon the pelvis by the contraction 1032 diseases and injuries of the extremities. of the straight muscle, or of this muscle and the femoral. Such an occurrence may be the result of rheumatism, of accident, or of disease of the hip-joint, and is often readily relieved by very simple measures, as sorbefacient and anodyne liniments, the hot and cold douches, shampooing, and gradual ex- tension of the limb. When the contraction, however, is of long standing, the only reliable remedy is the subcutaneous division of the affected muscles, an operation which is generally sufficiently simple, as it does not involve any large vessels. The thigh, in consequence of injury or disease, occasionally stands off in a very constrained and unseemly manner from its fellow, owing chiefly, if not solely, to the inordinate contraction of the tensor muscle, which forms a hard firm cord at the upper and outer part of the limb. The femoral aponeurosis often participates in the lesion, and, in that event, requires to be divided along with the tensor muscle. In hip-joint disease, whether the result of rheumatism, aecident, or tubercu- losis, the attempts at rectifying the deformity of the thigh are frequently very seriously counteracted by the contraction of the adductor and flexor muscles, the division of which is absolutely necessary, as a preliminary measure, to success. Among the more serious effects growing out of this faulty condition of the muscles of the thigh is permanent anchylosis of the hip-joint, the danger of which is generally in proportion to the duration of the contraction, and the consequent inactivity of the limb. It is, therefore, an object of great im- portance that early and efficient measures should be adopted for the relief of the parts, before the articulation has been deprived of its normal structure. 6. AFFECTIONS OF THE NATES. The gluteal region is liable to various affections, as wounds, abscesses, aneurism, and tumors. Wounds of the nates require no special notice, as their treatment is gene- rally quite simple. Unless they are very deep, or complicated with lesion of the gluteal or ischiatic artery, fracture of the innominate bones, or injury of the pelvic viscera, they usually heal very kindly under simple dressing, aided by rest and recumbency. In the event of serious hemorrhage, the bleeding vessel must at once be searched for, and effectually ligated at both extremi- ties, access being, if necessary, facilitated by freely enlargiug the original opening. Abscesses, phlegmonous and chronic, occasionally form here, and, when deep-seated, may not only cause excessive suffering, but great embarrassment in regard to their diagnosis. In general, however, the history of the case, a careful examination of the parts, aud the use of the exploring needle, will dispel all doubt upon the subject, and lead to the adoption of the proper treatment. If the abscess be not soon opened, its contents may burrow extensively among the neighboring structures. La Motte relates an instance in which the pus of an abscess of the buttock travelled down the limb as far as the ankle, and cases have also occurred where it found an outlet through the rectum. Aneurism of the gluteal and ischiatic arteries is extremely uncommon, and is always, or nearly always, the consequence of external injury, as a punctured or incised wound. The prominent symptoms are abnormal pulsation, and a peculiar whizzing, blowing, or bellows' sound, easily detected by the ear. The remedy consists in exposing the sac, and ligating the artery above and below. The operation, for the method of performing which the reader is referred to the chapter on aneurism, is generally a very bloody one, and demands great skill for its successful execution. AFFECTIONS OF THE NATES. 1033 Fig. 706. Of the various tumors that are liable to occur in this region the most com- mon are the encephaloid, enchondromatous, fibrous, fatty, and encysted, the latter of which is sometimes congenital. In their progress, these morbid growths may all extend into the pelvic cavity, or, originating there, they may gradually pass out at the sacro-sciatic notch, and thus place themselves under cover of the gluteal muscles. Their diagnosis is generally attended with great erabarrassraent, and hence, if the surgeon is not greatly upon his guard, very serious blunders may be committed. The congenital encysted tumor often acquires such a size as to interfere mate- rially with the delivery of the child. Its shape is usually somewhat globular or ovoidal, its attachment being effected by a pretty broad base, extending deeply among the muscles but not into the pelvic cavity. It is soft and elastic, and fluctuates distinctly under pressure. Its contents are serous, turbid, brown- ish, or sanguinolent, and readily coagulable by heat, alcohol, and acids. The skin is not materially discolored, though, in general, it is a few shades darker than that in its neighborhood. The inner surface of the tumor is usually smooth and polished, and pervaded by minute, tortuous vessels with tender, friable walls. In some cases the tumor is unilocular, in others, multilocular; and instances .occasionally occur in which a considerable amount of solid matter enters into its composition. A good idea of the situation and shape of the encysted tumor of the gluteal region may be formed by a reference to fig. 706, from a drawing of a speci- men in the possession of Dr. Keller, of this city, who has given an account of it in the Transactions of the Pathological Society of Philadelphia. The tumor, attached to the nates, immediately behind the anus, was nearly of the size of a man's head, and, on being punctured, on the eighth day after the child's birth, it was found to contain upwards of a quart of brownish fluid. Death occurred a few hours after the ope- ration from hemorrhage into the sac, the parietes of which were very dense, vascular, and studded internally with small, transparent cysts, filled with serum. There was no communication between the sac and the spinal canal, or the sac and pelvic viscera. In another case, of a similar character, Dr. Kel- ler was obliged to puncture the tumor before de- livery could be effected, the quantity of fluid drawn off being about a gallon. It was also of a brown- ish color. The child died six hours after its birth frora capillary hemorrhage into the sac, the inner surface of which was covered, in parts of its extent, by a soft tissue, exhibiting, under the microscope, a rich network of vessels, very similar to the villi of the intestine. The sac had its root between the anus and the extremity of the coccyx, soraewhat to the right of the middle line, without any commu- nication with the vertebral canal. Should the child be born alive with such a tumor, the best plan would be to wait a few weeks, and then draw off a part of its contents, the operation being repeated every six or eight days in the hope of gradual shrinkage and ultimate obliteration of its cavity. In the event of failure the injection of iodine might be tried, or, instead of this, the sac might be detached with the knife, particularly if it had a narrow pedicle. A growth of a more solid nature is sometimes seen upon the buttocks, pre- senting itself in the form of elephantiasis or hypertrophy and fibro-cystic degene- Congenital cyst of the nates. 1034 DISEASES AND INJURIES OF THE EXTREMITIES. Fig. 707. ration of the areolar tissue. In a remarkable case of this kind, under my charge at the Jefferson College Clinic, during last autumn, in a lad twelve years and a half old, the tumor, as seen in fig. 707, formed an enormous mass hanging off both buttocks down upon the upper part of the thighs, greatly impeding progression, and caus- ing much annoyance both by its weight, its peculiar position, and its unseemliness. It was nearly thirty inches in circumference, rounded at the extremity, and of a hard, firm consist- ence. Upon the surface of the tumor were two large ulcers, the seat of a copious discharge of thin, yellowish, fetid pus. The anus was drawn, at least, three inches beyond it natural situation, and exhibited a very irregular nodulated ap- pearance ; the perineum was hard and tumid, the scrotum was enlarged, and the penis was of extraordinary dimensions. The tumor, at its upper part, had a soft, fluctuating feel, as if the tissues around were iufiltrated with serum, as was, in fact, the case; for a very large quantity of this fluid was suddenly discharged at one of the ulcers soon after the lad fell into my hands, followed by great subsidence of the swelling. As the general health was progressively de- clining, the removal of the tumor was promptly decided upon. An elliptical incision being made, so as to include the ulcerated surface, the flaps were gradually raised, but such was the intimate adhesion between the skin and the substance of the morbid growth that it was impossible to make a clean dissection. The only place where satisfactory separation could be effected was at the upper part of the tumor previously alluded to as having been the seat of serous infiltration. Here the boundary line was well marked. The attachments were also very firm to the gluteal muscles, the fibres of which were yery pale, and intimately intermingled with the abnormal structures. Several small serous cysts were opened during the operation, which was, in other respects, unattended with any- thing remarkable. Some large veins were noticed, but they did not bleed much, and only a few small arteries required ligation. The lad, under chloroform, bore the operation well, and made a good recovery. The tumor, after removal, was found to weigh eight pounds, ex- clusive of the fluid lost during the Microscopic characters of a fibro-cystic tumor of the Operation. It Was of a whitish nates. color, and of dense,, firm consist- Fibro-cystic tumor of the nates. AFFECTIONS OF THE GROIN. 1035 ence, grating under the knife. Its microscopic characters, fig. 708, as ascer- tained by Dr. Packard, afford a beautiful illustration of the fibrous structure, all the cells being nucleated, and most of them having more than one nucleolus. 7. AFFECTIONS OF THE GROIN. The principal affections of the groin, requiring notice here, are wounds, inflammation, abscesses, and tumors. Wounds of the inguinal region, whether incised, punctured, lacerated, or gunshot, may be limited to the superficial structures, or they may extend deeply among the glands and muscles, in the latter event, perhaps, dividing important vessels and nerves, and thus leading to frightful, if not fatal, hemor- rhage, and other bad consequences. In general, the treatment is sufficiently simple, but, in order to effect a rapid cure, it is absolutely necessary that the patient should observe strict recumbency with the thigh slightly flexed upon the pelvis, as this affords the best opportunity for the maintenance of accurate apposition of the edges of the wound. All motion of the limb must be avoided. Any bleeding vessels are, of course, at once secured with the ligature, and, if the iliac or femoral artery be divided, whether partially or completely, it must be tied both above and below the wound, which should, if necessary, be freely enlarged to afford ready access to the parts. In most cases, such an injury will prove fatal before the surgeon can reach his patient. Mortifi- cation of the toes and feet is apt to follow the division of the principal artery and vein of the limb, especially if some of the anastomotic branches are in- volved in the mischief. Inflammation of the groin may be common or specific; more generally the latter, the exciting cause being the syphilitic poison. The disease, in either event, may be limited to the skin and areolar tissue, or it may be located principally in the lymphatic ganglions, either above or below Poupart's liga- ment. Syphilitic bubo nearly always occupies the former situation, whereas the swelling of the lymphatic ganglions, consequent upon the_ irritation of gonorrhoea and injury of the lower extremity, generally occupies the latter, and seldom proceeds to suppuration. In whatever manner the inflammation may have been induced, the object of the treatment should be to prevent suppuration, and this is best done by perfect quietude of the part, and the application of leeches, saturnine lotions, and tincture of iodine, aided by the usual constitutional remedies. If matter forms, an early and free incision, made in the direction of Poupart's ligament, will be indicated. The resulting sore should be treated upon general prin- ciples, the cure being greatly expedited by laying open sinuses and enjoining recumbency. .... Abscesses of the groin sometimes form in consequence of irritation in the caecum and sigmoid flexure of the colon, the raatter passing down towards Poupart's ligament, or, perhaps, even beyond it. Such collections, to which the term stercoraceous may very properly be applied, not only contain fecal matter, but also, at times, ingesta, pieces of bones, cherry-stones, and even gall-stones, the impaction of which in the bowel is often the starting-point of the disease. However this may be, the damage inflicted upon the parts is generally so great as to lead to the establishment of irremediable sinuses and fistules. , , -,., •,. ... Chronic abscesses occasionally occur here, and are always readily distin- guishable by their history and progress. Great care should be taken not to confound such collections with those attendant upon psoas abscess, which, as is well known often points in the groin, generally above, but sometimes 1036 DISEASES AND INJURIES OF THE EXTREMITIES. below, Poupart's ligament, forming, in the latter event, a tumor of variable size and shape, at the upper and inner part of the thigh. A troublesome form of eczema is sometimes met with in the groin, chiefly in young fat children and elderly women, with a pendulous abdoraen. The skin is chafed, red, inflamed, and the seat of a thin, watery discharge, at- tended with distressing itching. An occasional purge, the avoidance of stimulating food and drink, strict attention to cleanliness, and the use of Turner's cerate, or the dilute ointment of the nitrate of mercury, are gene- rally the most effectual remedies. Hypertrophy of the lymphatic ganglions of the groin, the result of tubercu- losis or ordinary inflamraation, is liable to occur, the enlarged structures forming a hard, irregular tumor, situated partly above and partly below Poupart's ligament, without any disposition, in many cases, either to advance or recede, owing, apparently, to some disorder of the general health or some local irritation. An occasional purgative and a mild course of alteratives, with the repeated application of tincture of iodine, blisters, and compression, will, in general, procure the gradual removal of the disease. Of tumors of the groin the most common are the fatty, encysted, and fibrous, to which may be added the enlargements produced by hydrocele of the spermatic cord, varicosity of the saphenous vein, and the undescended testicle. Scirrhus, encephaloid, and melanosis are also occasionally observed, sometimes as primary, but more frequently as secondary, affections. The fatty tumor is not always developed in the groin, but occasionally ex- tends into it from the abdomen, by a sort of migratory process. It may acquire a very considerable volume, and is generally easily distinguished by its pendulous character, and by its doughy, inelastic feel. When small and deep-seated, however, it might be mistaken for femoral hernia, especially if the patient should be seized with symptoms of intestinal strangulation. The two affections, in fact, might co-exist. The removal of such a tumor by the knife is usually easily effected, as it seldom adheres very closely, if, indeed, at all, to the sheath of the femoral vessels. An encysted tumor is sometimes found in the groin, but the occurrence is unusual. It varies in size from the volume of a hen's egg to that of the fist, is of a globular or ovoidal shape, and distinctly fluctuates under the finger. Its contents are generally serous. Desault removed from the groin of a girl a hydatid tumor, for which she had previously been advised to wear a truss, and a similar case occurred to Dr. Monro, the cyst in this instance being situated at the upper and inner part of the thigh, where it might readily have been mistaken for a hernia. Care should be taken not to mistake for a tumor of this kind the synovial burse which exists between the capsule of the hip-joint, the body of the pubic bone, and the tendon of the iliac and psoas muscles, and which is liable, in consequence of inflammation, to considerable increase of bulk. The prin- cipal sign of distinction is that the enlarged pouch generally follows the movements of the thigh, whereas the encysted tumor, properly so called, usually remains stationary. The fibrous tumor, which is also very uncommon, is, in general, easily recognized by its tardy progress, its firm consistence, and its close connec- tions with the surrounding structures, processes often extending deeply among the vessels, nerves and muscles. Hence, the extirpation of such a tumor is commonly attended with much difficulty. A hydrocele of the spermatic cord occasionally projects into the groin, form- ing a tumor of variable size and shape, but usually easily recognized by its softness, elasticity, and fluctuation, by its tardy progress, by the absence of disease of the skin, and by the unimpaired state of the general health. If AFFECTIONS OF THE GROIN—GENERAL DIAGNOSIS. 1037 any doubt exist in regard to the diagnosis of the case, recourse is had to the exploring needle. A considerable tumor is sometimes formed by the saphenous vein at its junction with the great femoral, in consequence of a varicose condition of its tunics. The tumor, which is raost frequently met with in old, fat subjects, in connection with similar disease of the leg, is commonly of an oblong shape, soft, and about the size of a large almond. It receives a distinct impulse on coughing, and is readily effaced by pressure upon the upper part of the saphenous vein, but promptly reappears when the pressure is removed. An undescended testicle is sometimes retained in the groin, forming a tumor which, especially if inflamed, might lead to the suspicion of the existence of hernia. The absence, however, of the organ from the scrotum, and the pecu- liar hardness of the inguinal tumor, together with the sickening sensation caused by compressing it, will always serve to distinguish it from all other affections. Scirrhus of the groin generally takes its rise in the lymphatic ganglions, for the most part as a secondary affection consequent upon malignant disease of the thigh, penis, testicle, or vulva. As an original malady, its character is seldom detected in time to admit of operative interference, as the lymphatic ganglions in the iliac region usually soon participate in the morbid action, and thus oppose an effectual barrier to the use of the knife. Encephaloid of the groin is occasionally witnessed. A very remarkable case of the kind fell under my notice in 1859, in a young lady, twenty years of age. It had commenced, apparently in the lymphatic ganglions, when she was sixteen, and gradually progressed until, several months before she expired, it occupied the entire circumference of the upper part of the thigh, and nearly the whole of the corresponding nates, forming an enormous mass, attended with excessive emaciation and great enlargement of the subcutaneous veins, some of which were almost the size of the little finger. A few weeks before dissolution, the tumor gave way at its summit, throwing out a large, bleeding fungus. Melanosis of the groin generally begins in the superficial lymphatic gan- glions, and is commonly, if not invariably, associated with similar disease in other parts of the body. It is easily distinguished, even in its earlier stages, by its black color, its firm consistence, and its tuberiform shape. General Diagnosis.—The surgeon, in contemplating the diseases of the groin, will not lose sight of the fact that he has to deal with a region which is often the seat of hernia, both inguinal and femoral, of psoas abscess, and of aneurism, the latter formed either in the course of the femoral artery or in that of the external iliac. He will, therefore, be slow in making out his diagnosis, and be particularly wary in the use of the knife. He will not forget, on the one hand, that a tumor not aneurismal may, if situated over the track of the femoral or iliac artery, readily receive an impulse from the vessel, so as to lead to a false suspicion regarding its true character, nor, on the other, that an aneurism may really exist, and yet be free from pulsation, or, perhaps, be even so soft as to simulate an abscess, especially if it be ac- companied with considerable oedema and discoloration of the integuments. The great danger of mistake, however, generally arises, not from tumors, but from hernia, which often coexists with various kinds of swelling of the groin, in- flammatory and other, and which, in the event of the supervention of symptoms of intestinal strangulation, might, therefore, occasion great embarrassment, both in regard to the diagnosis of the case, and the proper course of treat- ment to be adopted for its relief. The opening of an abscess of the groin overlyino- a knuckle of small intestine, has been followed more than once by an incurable fistule. How cautious, then, should the surgeon be in the use of his knife in a region of such vast importance to health and life! 1038 DISEASES AND INJURIES OF THE EXTREMITIES. 8. BANDAGES FOR THE INFERIOR EXTREMITY. Fig- 709. The ordinary roller for the foot and leg is represented in fig. 709. It will be seen that its application begins at the toes, and that it is continued, by circular and reversed turns, as high up as the knee. Its usual length is from five to six yards; its width frora two inches and a quarter to two inches and a half. A roller, of similar length and width, will answer for the thigh, the connection being uninterrupted. Care is taken not to make the .reverses over the shin, lest they should provoke ulce- ration. Particular care is also required in conducting the bandage across the ankle and knee. In general, compresses will be required to fill up the vacancies between the tendo Achillis and the mal- leolar processes. For retaining dressings on the knee, as in inflammation and wounds of the joint, an ordinary roller may be used; or, what is more neat and convenient, a piece of muslin, from eight to ten inches in width, and about a yard and a quarter in length, the extremities of which are split to within a short distance of its centre. The centre is then applied to the patella, and the ends, crossed behind the ham, are tied, re- spectively, above and below the knee, as exhibited in fig. 710. In dropsy Roller bandage applied to the foot and leg Fig. 710. K■ *\vv1' 'b ' Bandage for the knee. and loose bodies of this joint, a special contrivance, called a laced knee-cap, described at page 34, is sometimes employed. Bandages for the groin are rendered necessary in the treatment of various affections, as buboes, abscesses, and wounds, and also after the operation for strangulated hernia and the ligation of the external iliac artery. A very effective contrivance of the kind is a triangular piece of muslin, passed round the thigh, the base being fastened in front, and the apex behind, to a band encircling the abdomen, additional security being given by a side strip, as seen in fig. 711. Occasionally the bandage, depicted at fig. 712, may be advantageously em- ployed. It consists of an ordinary roller, from six to eight yards in length by tw7o inches and a half in width, which is carried round the abdomen and BANDAGES FOR THE INFERIOR EXTREMITY. 1039 the upper part of the thigh, by circular and reversed turns, until the object for which it is applied has been attained. In most cases, it will be best to Fig. 711. Fig. 712. Bandages for the groin. extend it round both limbs, as it will thus be less likely to slip and become useless. The spica bandage for the groin and thigh is now seldom employed. 1040 SPECIAL EXCISIONS OF THE BONES AND JOINTS. CHAPTER XXI. SPECIAL EXCISIONS OF THE BONES AND JOINTS. 1. TRUNK. EXCISION OF THE CLAVICLE. Extirpation of this bone may be required on account of caries, necrosis, morbid growths, and displacement in consequence of disease. Mr. Davie, of Bungay, many years ago, excised the inner extremity of the clavicle in a case of dislocation backwards from deformity of the spine, the luxated head caus- ing such a degree of pressure upon the oesophagus as to endanger life by inanition. Having made an incision frora two to three inches in length over the bone, in a line with its axis, and severed its ligamentous connections with the sternum, he divided the bone about one inch from its articular end, by means of a Hey's saw, the soft parts being protected by a piece of sole-leather. The patient speedily recovered, and survived the operation six years. In my private collection is nearly the whole of the left clavicle, which I removed, in 1849, on account of necrosis, from a lad thirteen years old. In 1813, Dr. Charles McCreary, of Hartford, Kentucky, amputated the right collar-bone at its articulations for scrofulous caries; the patient, a boy, aged fourteen, survived the operation many years, enjoying, it is affirmed, excellent use of the corresponding limb. A similar operation was successfully performed in 1852 by Dr. A. J. Wedderburn, of New Orleans, in 1856 by Professor Black- man, of Cincinnati, and in 1860 by Dr. Fuqua, of Richmond. In the latter case, however, the sternal end of the bone was saved. In 1828, Dr. Mott removed the entire clavicle, on the left side, on account of an osteo-sarcomatous tumor, of great hardness, conical in its shape, and four inches in diameter at its base. The operation was one of immense deli- cacy and difficulty, requiring nearly four hours for its execution, and more than forty ligatures for the suppression of the hemorrhage. The patient, notwithstanding, made an excellent recovery, and, by means of an apparatus contrived for the purpose, had perfect use of the arra, being able to move it in all directions. The history of the case, with a detail of the different steps of the operation, will be found at length in the American Journal of the Medical Sciences for 1828, and also in Dr. Mott's edition of Velpeau's Surgery. The entire clavicle has also been removed, on account of osteo-sarcoma, by Dr. Charles R. S. Curtis, of Chicago. His operation was performed in 1856, but the patient, a woman, aged twenty years, had a return of the disease at the cicatrice at the expiration of two months. Recently a similar, bnt more formidable, operation was performed by Dr. E. S. Cooper, of California. It is obviously impossible to lay down any definite general rules for the resec- tion of this bone. When its removal is required on account of caries, necro- sis, or displacement from disease, the operation is sufficiently simple, a single longitudinal incision, in the axis of the bone, affording ample space for its isolation and detachment. But the case is widely different when the clavicle EXCISION OF THE SCAPULA. 1041 is buried in a large mass of disease; when the circumjacent structures are all intimately matted together by morbid deposits; and when not only the great vessels of the neck, but likewise the phrenic nerve and the thoracic duct, are in close proximity to the affected bone, as in the instance of Mott. Under such circumstances, the operation must be one of extraordinary difficulty, demanding the greatest patience, skill, and anatomical knowledge for its suc- cessful execution. The surgeon must proceed with the greatest circumspec- tion, making constant use of the handle of the knife, keeping in close contact with the tumor, tying the arteries as they are divided, and guarding against the entrance of air into the veins, the danger of which is always considerable in the excision of morbid growths from the base of the lower cervical region. Trustworthy assistants must be at hand, and every emergency must be anti- cipated. EXCISION OF THE SCAPULA. Excision of this bone has now been so frequently performed as not only to establish its feasibility, but to prove that, when the cases are properly selected, it is comparatively devoid of risk. The cases of Mussey, McClellan, Gilbert, Ferguson, Schuh, myself, and others, in some of which the entire scapula was removed with the clavicle, or with the clavicle and superior extremity, clearly evince what the human body is capable of enduring under dissections of a character apparently the raost desperate. Dr. Mussey's first operation was performed in 1837 ; the patient had osteo-sarcoma of the scapula and clavicle, and both these bones were removed in their whole extent. The enormous wound healed almost completely by the first intention, and the man, when last heard from, fifteen years after the operation, was still well. In 1845, this distinguished surgeon successfully removed the entire scapula, with the outer-half of the clavicle and the upper extremity, also for osteo-sarcoma. In 1838, Dr. George McClellan exsected this bone along with the clavicle on account of encephaloid disease ; but the man died from a return of the malady six months after. In Dr. Gilbert's two cases, the excision was also performed for an encephaloid growth, and included in each the arm, the greater portion of the clavicle, and the neck and acromion process of the scapula. One of the patients survived the operation four months; the other only one week. In his last case, this excellent surgeon found that the performance of the operation was greatly facilitated by deferring the division of the clavicle until after the separation of the scapula, the weight of the arm drawing the tumor away from the chest and neck. Professor Schuh, of Vienna, removed nearly the entire scapula in 1860, on account of osteo-sarcoma, in a child eight years of age. If it be impossible to lay down any specific rules for the performance of excision of the clavicle, it would be still more futile to attempt such an under- taking for the scapula. The truth is, every case must provide its own rules. The following instance, in which, in 1850, I removed nearly the whole of the right scapula for an osteo-sarcomatous affection, will serve to convey a gene- ral idea of the procedure necessary under such circumstances. It may be premised that the patient was a man, aged forty years, and that the tumor, which had been first noticed nine years previously, was fifteen inches in length by fifteen and a half in breadth at-its widest part. The patient being placed recumbent, with the body inclining towards the abdomen an incision, sixteen inches in length, was made from the superior angle of the scapula to the inferior extremity of the tumor, its direction being obliquely downwards and inwards. Another, beginning about five inches below the upper end of the first, and terminating about the same distance from its lower end, was then carried, in a curvilinear direction, so as to include vol. ii.—66 1042 SPECIAL EXCISIONS OF THE BONES AND JOINTS. Fig. 713. a small oval flap of skin in its centre. The integuments, which were exceed- ingly dense and thick, especially at the superior part of the tumor, were then dissected off from the surface of the morbid growth, first towards the spine, and then towards the axilla. Having detached the elevator and trapezius muscles, I sawed through the acromion process of the scapula just behind the clavicle, and then divided the broad dor- sal and anterior serrated muscles. Carry. ing my fingers next underneath the tumor, and raising it up, I severed its connections with the ribs, cut the deltoid and other muscles of the arm, sawed the neck of the scapula, and thus removed the entire mass with comparatively little difficulty. Several vessels were divided in the early stage of the operation, at the posterior and middle part of the tumor; but these were easily controlled by the fingers of the assistants. Several arteries near the neck of the bone bled so freely as to demand the ligature after the reraoval of the mor- bid growth. About twenty-four ounces of blood were lost. The patient became very faint towards the close of the opera- tion, and cordials were necessary to revive him. The immense wound thus produced was dressed with three interrupted sutures and adhesive strips, and supported by a compress and a broad body bandage. No untoward symptoms of any kind occurred after the operation ; nearly the whole wound healed by the first intention ; and, at the end of three weeks, the patient went home, gradually improving in health and strength. From exposure to cold, however, he contracted pleuro-pneumonia, from the effects of which he died three months after the operation. The neck and glenoid cavity of the scapula were unaltered, but the remainder of the bone was completely disorganized. The tumor weighed upwards of seven pounds, and belonged to that class of structures usually, though vaguely, denominated osteo-sarcomatous. The external appearances of the tumor are exhibited in fig. 713. The entire scapula has occasionally been removed on account of necrosis, or long-standing caries. Such an operation was first performed by Mr. Syme, of Edinburgh, in 1856, and in 1858 it was repeated by ]\Ir. T. M. Jones, of Jersey, the disarticulation in both instances being effected at the shoulder-joint, with reraoval of the acromial extremity of the clavicle. The patient of the latter gentleman recovered with a good use of the corre- sponding limb, but with a decided falling of the shoulder. Encephaloid of the scapula. EXCISION OF THE RIBS. Caries and necrosis of the ribs, both from disease and accident, are by no means uncommon, and often lead to the necessity of excision. These pieces are also liable to carcinomatous degeneration, and to different morbid growths, which can only be removed by the interposition of the knife and pliers. The annals of surgery afford numerous examples of excision of the ribs, from a portion hardly an inch in length to nearly the entire bone. Operations of this kind were probably performed at a very early period of the profession, EXCISION OF THE RIBS AND STERNUM. 1043 and some very extraordinary cases have occasionally been published of their success. Thus, it is reported of Suif that he cut away from a man two of his ribs, making an opening into his chest capable of admitting the fist, and through which he removed, with complete success, a portion of diseased lung. Incredible as this case may at first appear, it has its analogue in one which occurred in the practice of Dr. Milton Antony, of Georgia. In this instance, the fifth and sixth ribs, which were extensively carious, were removed along with two-thirds of the right lobe of the lung, the patient surviving the ex- ploit nearly four months. The particulars of this remarkable case have been reported in the sixth volume of the Philadelphia Journal of the Medical and Physical Sciences. I have repeatedly excised considerable portions both of the ribs and of their cartilages; and at the Jefferson College Clinic, in 1857, I removed from a negro lad, aged seventeen, the central pieces of the sixth and seventh ribs, one of which was upwards of six inches in length, on account of scrofulous disease. During the operation, the apex of the heart could be plainly seen pulsating beneath the denuded structures. The boy rapidly re- covered, and has ever since been in good health. Formidable operations upon the ribs, affected with various kinds of tumors, for the most part of a carcinomatous character, have been performed by different American sur- geons, among whom it will be sufficient to mention the names of John C. Warren, George McClellan, and William Gibson. In caries and necrosis of the ribs, excision maybe performed with the greatest facility, as the diseased pieces are always more or less isolated by the morbid action, especially from the pleura, which is usually very much thickened and indurated, and, therefore, not at all in danger of being injured, unless great negligence is displayed. The intercostal arteries, too, are generally, under such circumstances, out of harm's way. In necrosis, a slight incision will commonly suffice to enable the surgeon to effect extraction, but in caries a more extensive incision, made in the axis of the affected bone, will be needed. If the attachments are firm, the knife must be kept close to the bone, and it is safer here, as elsewhere, in similar cases, to use the handle of the instru- ment than its point. When the ribs are involved in morbid growths, exci- sion will be environed with many difficulties, owing to the fact that the pleura generally retains its normal characters, and that it is then almost impossible to separate it from the affected structures without penetrating its cavity; moreover, such tumors are usually extremely vascular, and are apt to project to a considerable distance beneath the surrounding parts. As it respects the incisions necessary in such cases, the most eligible and convenient will be the T-shaped, semilunar, or elliptical. EXCISION OF THE STERNUM. The sternum has occasionally been excised, not wholly, of course, but in part, in consequence of caries, to which its substance is very subject in scro- fulous and syphilitic persons, and on account of necrosis, gunshot injury, and compound fractures. Its affections are liable to be complicated with abscess in the anterior mediastinum, thickening of the pleura, and lesion of the costal cartilages. The diseased portions may usually be gouged away or extracted without difficulty, exposure having been effected by a T-shaped, or crucial incision. When the bone is largely implicated, without any tendency to spontaneous separation, the removal will be expedited by perforating it with the trephine, to admit the introduction of the elevator. In general, how- ever, its substance is so soft that it raay be easily cut away with the pliers, or even a stout, probe-pointed knife. 1044 SPECIAL EXCISIONS OF THE BONES AND JOINTS. EXCISION OF THE PELVIC BONES. The bones of the pelvis are occasionally the seat of caries and necrosis, and there are few surgeons in extensive practice who are not occasionallv obliged to excise portions of them. I have, in one instance, been compelled to remove the tuberosity of the ischium ; in another, a large fragment of the iliac crest; and, on one occasion, a considerable piece of the posterior and lateral part of the sacrum. Exostoses sometimes form upon them, and may, unless deeply seated under the gluteal muscles, be easily removed with the knife and chisel. The coccyx is liable to caries, in consequence of the contact of fecal mat- ter in anal fistule; the same effect is occasionally produced by a blow or kick, or by injury inflicted by the pressure of the child's head in protracted partu- rition. Dr. Nott, of Mobile, as early as 1832, exsected this bone on account of severe and intractable neuralgia seated in its substance, its lower extremity being hollowed out into a mere shell. A vertical incision was raade behind, along the median line, when the bone was disarticulated at the second joint, and separated from its muscular and Jigamentous attachments. The patient was a female, twenty-five years of age ; the wound was long in healing, and a month elapsed before the pains disappeared frora their original site. Dr. Nott has repeated this operation several times, and it was also recently per- formed, with complete success, by Professor Simpson, and Dr. Godfrey, of Sonora, on account of a similar affection. 2. SUPERIOR EXTREMITY. EXCISION OF THE BONES OF THE HAND. Excision of the head of the phalanx of the thumb has sometimes been practised in compound dislocations and fractures, and the success attending the operation has afforded a warrant for performing it in case of caries of its substance. The joint is exposed by a free lateral incision, and the offending portion removed with the pliers. The cure will be more likely to be satis- factory if a small piece be clipped off from the contiguous bone, as the two raw surfaces, when brought together, will then unite more readily. It is never desirable to exsect any of the digital phalanges, except the distal one; such a procedure would only leave a useless finger, and could, therefore, never become general. When the last phalanx is rendered carious, or de- prived of its vitality, as so often happens in whitlow, the proper plan is to remove it through an incision extended along its palmar aspect; and it is well known that, when the periosteum is not destroyed, the bone, under these circumstances, is sometimes partially regenerated. Excision of all the carpal bones has occasionally been attempted, generally in connection with that of the articulating extremities of the radius and ulna, but I am not aware that it has ever, in a single case, been followed by any satisfactory results. On the contrary, the disease for which the operation was performed has nearly always returned, and eventually led to the necessity of amputation of the forearm. It is questionable, therefore, whether the opera- tion is worthy of repetition. It is different, however, when only a few of the carpal bones are in a carious state; then exsection of the affected pieces should be practised by all means, for if pains be taken to remove all the morbid structure, aud no serious injury be inflicted upon the soft parts, par- ticularly the sheaths of the tendons, there will be a very reasonable prospect of a good result, the hand not only preserving its usefulness, but also its symmetry. In several cases in which I adopted this method the effect was EXCISION OF THE WRIST-JOINT. 1045 most satisfactory. The site of the piece to be removed will usually be indi- cated by a fistulous opening; if any formal incision is necessary it should be made upon the dorsal surface of the hand. A gouge and mallet will be indis- pensable instruments in the operation. The metacarpal bones have frequently been removed in part, or in whole, for caries, necrosis, or external injury. The operation, which is sufficiently simple, consists in making a longitudinal incision along the dorsal aspect of the bone, in separating it from the soft parts by keeping the knife close against its surface, and in disarticulating it in the usual way. The carpal end of the bone, if sound, should be left, and in that case the division should be effected with the pliers. As the object is to preserve the finger, the extensor tendon is carefully drawn aside during the operation. The metacarpal bone of the thumb may be treated in a similar manner, the phalanges being retained; and, although the member may not, for a time, be of any material use, yet as the soft parts become consolidated it will be found to be quite serviceable, to say nothing of the important part which it plays in preserving the symmetry of the hand. EXCISION OF THE WRIST-JOINT. Excision of the wrist-joint has been practised much less frequently than that of the other articulations, and in the cases in which it has been done the result has not been at all encouraging. The operation, besides being awk- ward and difficult on account of the importance of the structures concerned in it, and the peculiar conformation of the joint, is extremely liable to be followed by permanent anchylosis of the wrist, and stiffness of the fingers. Another objection is that, when the carpal bones are involved in the disease, there is apt to be a return of the morbid action, eventually necessitating amputation of the forearm. Hence some surgeons prefer amputation in the first instance to the risk, pain, and inconvenience of excision without the certainty of a final cure. In opposition, however, to this decision, it may be urged that a stiff hand with the preservation of the mobility of even some of the fingers is very greatly to be preferred to no hand at all, both on the score of utility and seemliness, and that there are few persons who, if the matter were left to their own choice, would not rather submit to excision, if it afforded any reasonable prospect of success, than to the unconditional loss of so important and valuable a member. There are two methods according to which this operation may be practised; in one the incisions are made along the inner and outer margins of the limb, in the other over its dorsal aspect, in the form of a semilunar flap, with the convexity downwards. When the disease necessitating the operation is limited to the ulna and radius, the former plan is to be preferred, but the latter, as affording more room, when the carpal bones participate in the dis- organization. Whichever procedure be adopted, care is taken not to divide the extensor tendons of the thumb and fingers, as this would compromise their future usefulness, and thus frustrate the main object of the excision The ends of the radius and ulna are removed on the same level either with the pliers or with a narrow saw: in the flap operation it may be necessary, during the division of the bones, to protect the soft parts with a spatula or 8trThe°f sllttics of this operation are very limited Altogether there are accounts of about 30 cases, of which 9 proved fatal, or abou30 I er cent while the mortality of amputation of the forearm is only a little over 12 per cent. 1046 SPECIAL EXCISIONS OF THE BONES AND JOINTS. EXCISION OF THE BONES OF THE FOREARM. The bones of the forearm may require removal in part, or in whole, for caries, gunshot injury, or chronic enlargement. A case of excision of both the radius and ulna occurred, in 1853, in the practice of Dr. Compton, of New Orleans. The operation was performed on account of a compound, comminuted fracture, two months after the accident; both pieces being removed with the exception of the inferior extremity of the radius. The greater portion of the periosteum, which had been detached during the pro- gress of the resulting inflammation, was left in the wound. The patient, a boy, aged fifteen years, made an excellent recovery, having a very good use of the hand. The forearm was three inches shorter than natural, and flexed at a right angle with the humerus. Dr. Robert B. Butt, of Virginia, exsected, in 1825, the lower two-thirds of the ulna of the left side, in a man twenty-five years old, who, several years previously, had received a punctured wound in the wrist-joint, causing violent inflammation of the whole limb as far as the elbow, and ultimately terminat- ing in hypertrophy and caries of the ulna, with immense thickening of the periosteum. ' Three months after the operation, the man had so far recovered as to be able to pursue his occupation of a house-joiner, flexion, extension, and rotation of the joints being as free and uninterrupted as they had ever been. In 1853, Dr. Carnochan performed a similar operation, taking out the entire ulna, which, as in the case of Dr. Butt, was excessively enlarged from one extremity to the other, measuring, at the base of the coronoid pro- cess, five inches and a half in circumference, and weighing nearly eight ounces, His patient was a man, thirty years of age, of a strumous habit, and the dis- ease was supposed to have been occasioned by a sprain of the arm in splitting wood with a heavy axe. No untoward symptoms occurred during the after- treatment, and, with the exception of a depression, and the cicatrice along the inner aspect of the limb, no deformity was perceptible after the wound was healed. The functions of the forearm were preserved in a remarkable degree; the power of prehension was unimpaired ; the limb could be flexed and extended at the elbow and wrist as well as pronated and supinated; the hand could be moved from side to side, and the fingers could be used as before the ope- ration. Mr. Jones, of Jersey, has also excised the whole ulna. In 1849, the late Professor C. P. Johnson, of Richmond, Virginia, successfully re- moved the middle two-thirds of this bone, on account of scrofulous disease. In his Notes on the Wounded from the Mutiny in India, Dr. George Wil- liamson relates a case in which, on account of disease, he exsected the whole of the ulna, along with the head and neck of the radius and the lower end of the humerus, the patient regaining an excellent use of his arra, wrist-joint, and fingers. The entire radius was exsected by Dr. Carnochan, in 1854, on account of caries, hypertrophy, and eburnation, caused by a severe blow upon the upper part of the forearm, the patient, a man aged twenty, recovering with such an excellent use of the limb as to be able to write with ease and rapidity. When last seen, six years after the operation, the parts remained perfectly sound, but the hand was not quite in its natural axis, as it inclined a little outwards, while the styloid process of the ulna formed an abnormal prominence on the inside of the wrist. The bone was exsected from joint to joint. The ope- ration, which, so far as I know, was the first of the kind ever performed, is detailed at length in the American Journal of the Medical Sciences for April, 1858. An operation of a similar kind, with an equally fortunate result, was performed in March, 1859, by Professor Choppin, of New Orleans, upon a EXCISION OF THE BONES OF THE FOREARM. 1047 boy, aged fourteen years. In this case, however, the inferior articular ex- tremity of the bone was retained, as it was found to be free from disease. During the session of 1857,1 excised, at the Jefferson College Clinic, some- what raore than the upper half of the bone, along with the outer condyle of the humerus, for scrofulous disease of several years' standing, the patient being a young Irishman in dilapidated health. He recovered well from the operation, but of the ultimate result I am unable to give any account, as the case was soon after lost sight of. The appearance of the limb, prior to the operation, is exhibited in fig. 714. Fig. 714. Caries of the elbow-joint, as seen before excision. Mr. Erichsen states that he has resected the whole radius, with the excep- tion of its articular head, which was sound, and that a useful arm was left. Excision of the lower four-fifths of this bone was performed by Professor Carnochan, in April, 1857, his patient, a woman, aged thirty-one years, making an excellent recovery, the functions of the hand being so little im- paired that she was able to perform her household duties nearly as well as before the operation. The bone was greatly diseased and enlarged. Excision of the entire radius is performed by making a longitudinal inci- sion along the posterior and outer aspect of the forearm, from the wrist to the elbow, and in detaching the bone carefully from its connections, with the precaution of inflicting as little injury as possible upon the surrounding struc- tures. In caries, the bone is occasionally so slightly adherent that the peri- osteum may readily be peeled off from it by means of the handle of the knife, as happened in my case of partial excision. When the attachment is very firm, the rule is to keep the knife as closely against the bone as possible. Removal of the ulna is effected upon the same principle, but in this case the incision is carried along the posterior and inner aspect of the limb. In neither operation is it necessary to divide any of the principal arteries of the forearm, and hemorrhage from the smaller branches may be moderated by compression of the brachial by the fingers of an assistant. When the entire ulna or radius is removed, the proceeding will be facilitated by giving the wound, at each extremity, a curvilinear direction, or a short transverse cut may be extended from it at these points, either outwards or inwards, according to the nature of the bone concerned. . Resection of the bones of the forearm has occasionally been practised on account of gunshot injuries; but, hitherto, with no very encouraging results. The operation was-performed in the Schleswig-Holstein wars in seven cases, and although they all ultimately got well, their recovery is said to have been much slower and less satisfactory than those cases which were left entirely to nature, the splinters being, for the raost part, removed as they became detached. 1048 SPECIAL EXCISIONS OF THE BONES AND JOINTS. EXCISION OF THE OLECRANON. Exsection of the olecranon has been practised, in a few instances, for caries, or caries and necrosis. A T-shaped incision being made over the posterior part of the elbow, the process is detached from the tendon of the extensor muscle, and divided with the pliers or a narrow saw. The wound is accu- rately approximated by suture, plaster, and collodion, the limb is maintained at rest in the straight position, and, in due time, passive motion is instituted, to preserve the use of the joint. Dr. Buck, of New York, exsected the olecranon, in 1842, on account of hypertrophy of its substance from external injury, followed by total loss of flexion and extension, although pronation and supination partially remained. The patient recovered frora the effects of the operation, but the limb, instead of being benefited, became permanently stiff. EXCISION OF THE ELBOW-JOINT. Excision of the elbow-joint has been practised more frequently than that of any other articulation in the body, and such has been the success attending it, that no doubt can any longer be entertained respecting its propriety. The operation was first performed by the elder Moreau, in 1797. In 1828, it was introduced into Great Britain by Mr. Syme, of Edinburgh. It is usually required on account of caries, or caries and necrosis, of the heads of the con- tiguous bones, and should always be preferred to amputation of the arm, whenever it is possible to preserve a sufficiency of osseous matter to leave a good limb. Experience has proved that the danger of excision of the elbow- joint is, in general, very slight, when the operation is limited to the articular extremities of the bones; when the medullary canal of the humerus is ex- posed, there is always risk of diffuse suppuration and pyemia, and the same is true, although not in so great a degree, of the medullary canal of the radius and ulna. Besides, the shorter the excised pieces are, the greater, other things being equal, will be the probability of a serviceable limb. In regard to the mode of operating, surgeons have hitherto failed to agree Fig. 715. Excision of the elbow-joint. upon any particular standard, for the reason, doubtless, that no one method is applicable to all cases. Mr. Park, by whom the procedure was originally EXCISION OF THE ELBOW-JOINT. 1049 suggested, although never practised, thought the object might be attained by a single longitudinal incision along the posterior part of the elbow, and the excision has often been effected in this way. Moreau used an H-like cut, by means of which he obtained two large flaps, which, being reflected in op- posite directions, exposed the parts very freely. Some, again, as Erichsen, avail themselves of a En-shaped incision, as seen in fig. 715 ; and I am my- self an advocate for a semilunar one, the convexity looking downwards, on the ground that the wound made by it is more favorably situated for the escape of the discharges. In partial excision, a simple vertical incision will usually be quite sufficient for the purpose. In performing the operation, the patient should incline somewhat towards his abdoraen, but not to such an extent as to endanger the breathing during the exhibition of chloroform. Whatever plan of procedure be adopted, the incisions should be sufficiently ample to give the surgeon free room for the accomplishment of his main object. An assistant is ready to compress the brachial artery, in the event of there being any likelihood of much hemor- rhage, which, however, will rarely be the case, unless the articular vessels, which will necessarily be divided, have become much enlarged from pro- tracted irritation. Care is also taken not to injure the ulnar nerve, as it courses along the inner margin of the olecranon. If we adopt the semilunar incision, the knife should be drawn across the back part of the limb, from the superior extremity of one condyle to that of the other, for a distance of about two inches and a half; the flap being then raised, the ligaments, if still remaining, are severed by a cautious use of the knife, and the tendon of the three-headed extensor muscle separated at its insertion. The instrument is next passed closely round the olecranon, and this process removed with the pliers. The joint being now fairly exposed, the heads of the radius and ulna are liberated from their connections, and thrust through the wound by for- cibly bending the joint and pushing the forearm upwards. The saw is now applied, and the diseased structure excised, care being taken not to interfere, if possible, with the attachment of the two-headed flexor and anterior bra- chial muscles, as this would seriously compromise the future usefulness of the extremity. The articular end of the humerus is removed in the same manner. In cutting off the bones the ulnar nerve is drawn to one side with a blunt hook ; but it is not necessary to protect the parts in front of them, as the brachial artery lies securely under cover of the anterior brachial muscle. It has been suggested that, when the articular ends of the bones of the elbow are only partially affected, the operation should be performed pre- cisely in the same manner as when they are more extensively involved, and I heartily concur in this injunction; but such a procedure would certainly not be proper when the disease is limited to one of the bones of the forearm, as the radius, and the outer condyle of the humerus. Under such circum- stances, common sense, as well as humanity, would dictate that the excision should be limited to the disorganized parts, the sound being left undisturbed, in the hope that they will, at least partially, preserve the functions of the joint. In several cases in which I have adopted this procedure, the result was highly gratifying. During the after-treatment the limb is placed in an easy, flexed posture, in a tin case, with an opening opposite the elbow, to facilitate draiuage, upon an angular splint, or, what is better than either, upon Heath's apparatus, delineated in fif. 716. By means of this contrivance, which is furnished with screws and a central hinge, the forearm can readily be maintained at any desired length and angle. The ends of the bones should, therefore, be kept in tolerably close proximity with each other; for, as they are destined to 1050 SPECIAL EXCISIONS OF THE BONES AND JOINTS. unite by fibro-ligamentous tissue, it is important that this substance should be as short as possible. As the cure progresses, the forearm is gradually Fig. 716. Heath's splint, in the excision of the elbow. flexed, until, at length, it is brought to a right angle with the arm, passive motion being frequently practised to prevent permanent anchylosis. When the"after-treatment is judiciously conducted, there is not only usually no danger from the operation to the patient's life, but every reason to hope for a good result as it respects the use of the limb. Many of the persons subjected to this operation were afterwards able to pursue, with great satis- faction, their former occupation. Mr. Cock, of London, in 1857, operated upon a man whose elbow had been excised, eighteen years previously, by the late Mr. Key, on account of scrofulous caries. He had enjoyed, throughout the whole interval, very excellent use of the limb until a short time before his admission, when, in consequence of an attempt to work with it in a new position, disease again appeared, requiring a slight operation, which pro- mised to be followed by further relief. The case affords a beautiful illustra- tion of the triumphs of conservative surgery. Statistics.—Excision of the elbow-joint on account of gunshot injuries has lately engaged much attention among military surgeons. Dr. Esmarch, whose work comprises the details of all the cases of this operation that occurred during the Schleswig-Holstein campaigns, states that of 40 upon which it was performed, only 6 died; in one the forearm became gangrenous, and had to be amputated, aud in another the treatment was still progressing when last heard frora. The remaining 32 cases all recovered perfectly, with a more or less useful limb. In the Crimean war, there were 22 resections of the elbow-joint among the British surgeons, with 5 deaths, of which 2 occurred after secondary amputation. In the Russian army, during the same period, the operation was performed 20 times with 15 recoveries. Thus, of the whole number, 82, 16 died, or 1 in about 5. Mr. Barwell, in his recent Treatise on Diseases of the Joints, refers to 149 cases, including most of those here mentioned, with 33 deaths, or a little over 22 per cent. In 470 amputations of the humerus, 157 proved fatal, or in the ratio of about 33 per cent. It will thus be perceived that the results of these statistics are decidedly in favor of excision of the elbow. The time at which resection is performed in gunshot injuries of the elbow- joint exercises an important influence upon recovery. Thus, of 11 cases in the Schleswig-Holstein campaigns, in which the bones were removed within the first twenty-four hours, only 1 proved fatal; whereas of 20 cases operated upon when the parts were in a high state of inflammation, that is, from the second to the fourth day, 4 died. Of 9 resections performed from the eighth to the thirty-seventh day, only 1 ended fatally. These facts are, practically, of the deepest interest, as showing the bad effects which may be expected from interference after the occurrence of severe inflammation with incipient suppuration. EXCISION OF THE HUMERUS AND SHOULDER-JOINT. 1051 EXCISION OF THE HUMERUS. Excision of the shaft of the humerus is sometimes required on account of gunshot injuries, or fractures caused by severe falls, railway accidents, or ma- chinery in rapid motion. Unfortunately, however, we are not in possession of sufficient statistical information to enable us to form a correct opinion respecting the real value of the procedure. In the first two Schleswig- Holstein campaigns, resection of the ends of the fragments was practised for the cure of gunshot lesions in 9 cases, of which 4 died, while of the remaining 5 several had very defective limbs. Subsequently resection was abandoned, the surgeons limiting themselves for the most part to the immediate removal of the splinters, and of 32 cases thus treated only 5 died, the others making excellent recoveries, with useful limbs, although in many the humerus had been terribly shattered by cartridge shot. EXCISION OF THE SHOULDER-JOINT. Excision of this articulation is frequently rendered necessary on account of caries and necrosis of the head of the humerus, or of this bone and of the contiguous surface of the scapula. It has also been done, in numerous in- stances, in consequence of gunshot injury of the shoulder, attended with laceration of the soft parts and comminution of the upper extremity of the humerus. The operation was first performed on account of disease of the humerus in 1769, by Mr. White, of Manchester, although a nearly similar procedure had been executed "as early as 1740, by Thomas, of Pezenas, in Languedoc. No analysis, upon an extended scale, has yet been made, so far as I know, of the published cases of this excision, and it is, therefore, impos- sible to give anything like a definite opinion respecting its real value ; enough, however, is ascertained to satisfy me that it is incomparably more safe than amputation at the shoulder-joint, and that it ought to rank among the estab- lished operations of surgery. When properly executed, as it respects the selection of the cases, and the mode of the procedure, I believe that it will rarely, if ever, be followed by any bad effects, while the patient, in the great majority of instances, will have a very good use of his limb. Less impair- ment of function, other things being equal, will necessarily ensue when a small portion of bone is removed than when the reverse is the case. In a case in which Lentin excised the entire humerus except two inches of the lower ex- tremity, the arra remained permanently stiff. Various methods have been proposed and executed for the removal of the shoulder-joint; thus, some content themselves with a vertical incision, ex- tending from the acromion process down through the belly of the deltoid, nearly as far as the insertion of this muscle ; some, again, prefer a V-shaped cut, the base looking upwards ; Moreau, who performed the operation a num- ber of-times, made a quadrilateral flap with the base below ; Morel fancied that the easiest way of accomplishing the object was to make a semilunar flap over the most prominent part of the shoulder, not unlike that made in ampu- tation ; finally, Mr. Syme employs two incisions, a perpendicular one through the middle of the deltoid, and an oblique one extending upwards and back- wards from the inferior angle of the first. It cannot be denied that some of these methods afford the surgeon most ready access to the joint, and enable him to effect excision of the humerus with the greatest facility ; but then they have the disadvantage, and a very serious one it is, of inflicting most severe injury upon the deltoid muscle, in consequence of the oblique and more ex- tensive division of its fibres, and of thus greatly protracting the cure. It is 1052 SPECIAL EXCISIONS OF THE BONES AND JOINTS. Fig. 717. for these reasons that I have limited myself, in the operations which I have performed upon the scapulo-humeral articulation, to the simple per- pendicular incision, as depicted in fig. 717 ; and I believe this will generally be found to answer every purpose, while it is entirely free from the objections here adverted to. In one of my cases, treated in this manner, I was enabled to remove, without difficulty, upwards of four inches of the humerus, and the recovery was most satisfactory. The operation is generally the more easy because, in caries of the joint, there is nearly always very considerable atrophy of the deltoid muscle and absorption of the subcutaneous adeps. The in- cision should begin just beneath the acromion process, and, descending nearly in a straight line through the cushion of the shoulder, should terminate within a short distance of the inferior attachment of the deltoid. The knife is carried down, at the first stroke, to the bone, which is then thoroughly liberated from its connections with the soft parts by means of a stout, blunt- pointed bistoury, passed closely round its neck, so as to sever the tendons of the subscapular Appearance of the wound after ex- and spinate muscles, the long head of the biceps cision of the head of the humerus, being left undisturbed. The capsular ligament is generally destroyed by the disease, but if any portion remain, it must be divided in the usual way. If more than the head of the bone requires removal, it will be necessary to separate any fleshy fibres Fig. 718. Fig. 719. Flap operations in excision of the head of the humerus. that may be attached to its shaft. This step of the procedure may be greatly facilitated by the use of the instrument exhibited at page 520, fig. 310. The EXCISION OF THE BONES OF THE FOOT. 1053 , bone is now pushed through the wound by depressing the elbow backwards. and the whole of the diseased portion sawn off, the soft structures being carefully protected from the teeth of the instrument If the glenoid cavity is involved in the morbid action, the affected substance is scraped or cut away ; the acromion process is dealt with, if necessary, in a similar manner. Sometimes it is necessary to remove the head of the humerus 'and a large portion of the scapula, as in the case which occurred to Mr. Jones, of Jer- sey. The bleeding vessels being secured, the cavity is next washed out with cold water, the sinuses, if any exist, are properly pared, and the edges of the wound are approximated by suture and bandage, the arm being secured to the side of the body, and the forearm supported in a sling. To favor dis- charge, a small tent should be inserted into the lower angle of the wound. The posterior circumflex artery is necessarily divided in this operation, and is frequently the only vessel that requires ligation. The axillary artery, vein, and plexus of nerves are entirely beyond the reach of the knife. In the flap operation, the incisions may be made so as to represent the shape of a U, as in fig. 718, from Erichsen, or the outline of a V, as in fig. 719. In either case, the deltoid muscle is extensively divided, and easy access afforded to the articulation. The procedure, however, is one of great severity, and must sometimes be followed by grave consequences. The diseased appearances of the head of the humerus, in one of my cases, are well illustrated in fig. 720. The bone was sawn off upwards of an inch and a half below its tuberosity. The specimen affords conclusive evidence of the im- possibility of a cure, under such circumstances, by ordinary measures. The patient was a sea- faring man, nearly forty years of age, sent to me by Dr. J. L. Pierce, of Bristol, Pennsyl- . J ' < J Canes of the head of the humerus. vania. Statistics.—Dr. George Williamson has reported 16 cases of resection of the shoulder-joint for gunshot injury, occurring in various parts of the world, of which 3 proved fatal. In the Schleswig-Holstein campaigns, the opera- tion was performed 19 times with a loss of 7, most of the deaths having been caused by pyemia. Of 27 cases operated upon by the British surgeons in the Crimea, only 2 died ; and of 14 cases resected by Baudens all, except 1, got well. These statistics afford thus a total of 76 cases of this operation, with a loss of 13, or a ratio, in round nnmbers, of one death to six recoveries. Here, as in the other joints, resection for the relief of gunshot injuries is most successful when performed immediately after the accident. 3. INFERIOR EXTREMITY. EXCISION OF THE BONES OF THE FOOT. The principal articulations of the lower extremity which require to be dealt with in this way are those of the hip, knee, and ankle ; excision is occasion- ally practised upon some of the tarsal and tarso-metatarsal joints, and the procedure not unfrequently results in a good use of the foot. But I am quite sure that such an operation should never be performed upon the metatarso- phalangeal articulations and upon the joints of the toes, for the reason that the anchylosed and abbreviated member could not fail to be sadly in the way of the patient's convenience and comfort when he comes to wear his boot. The rules which apply to excision of the bones of the metacarpus and fingers are altogether irrelevant here on account of the difference in the uses to which 1054 SPECIAL EXCISIONS OF THE BONES AND JOINTS. these parts are subjected. The hand is essentially a prehensile organ; hence, * even if only one finger, although that should be the little one, or the meta- carpal portion of the thumb, can be preserved, we shall render the possessor a most valuable service. The foot, on the contrary, is an organ of support, serving to receive and sustain the weight of the body during progression, and in the erect posture. The longer and broader, therefore, it is, the better it will be able to perform its important offices. But there is another view of the subject which must not be overlooked in a parallel of this kind; it is this, that, while the hand is perfectly free, the foot is constantly incased in a tight boot or shoe, a circumstance which renders it absolutely essential to the com- fort of the patient that the whole limb, but more particularly the toes, should be as free from prominences and cicatrices as possible. It is for these rea- sons that the toes, when fatally injured or diseased, are never removed at their articulations or in their continuity, but always at their metatarsal junctions; when the operation is practised at these sites, as it occasionally is by young and thoughtless surgeons, the stump is always in the patient's way, and usually requires secondary amputation. Moreover, it is not only important that the foot should be free from painful and inconvenient scars and promi- nences, but that it should be firm and solid, otherwise it cannot possibly serve the purposes of a basis of support. We may excise a metacarpal bone, and yet, if proper care be taken during the after-treatment, the corresponding finger will retain, not only its symmetry, but also, in a considerable degree, its usefulness. But the result is very different when we remove a metatarsal bone without the toe with which it is articulated; as soon as the support afforded by that bone is gOne, the member is unable to sustain itself, and, as a consequence, it constantly drops away from its fellows, to the great discom- fort and annoyance of the individual. I believe, then, that excision of the bones and joints of the toes and metatarsus ought, as a general rule, to be super- seded by amputation, as altogether more likely to leave a serviceable and symmetrical limb. Professor Pancoast was, I believe, the first to exsect the articular surfaces between the great toe and its metatarsal bone, the case being one of caries. Having raised a semilunar flap at the inner side of the joint, the diseased ends were removed with the saw, when the parts were approximated in the usual manner, the shortening being three-fourths of an inch. A good re- covery ensued. During the treatment, the extensors were disposed to pull the end of the toe upwards; an occurrence which, as Dr. Pancoast has sug- gested, might readily be counteracted by their subcutaneous division. Cases of this operation, followed by an excellent use of the big toe, have been re- ported by Regnoli, Fricke, Butcher, and others. Examples of the successful excision of the anterior extremity of the first metatarsal bone, in complicated dislocation, are mentioned by Kramer, Josse, and others, the first of these surgeons having performed the operation as early as 1826. Blandin, Roux, and Jobert have removed the anterior half of this bone for caries and cystic degeneration ; and the posterior extremity of the first phalanx of the great toe has been excised in two instances, with excel- lent results, by Champion. The objections that have been urged here against excision of the toes and metatarsus cannot apply to exsection of the bones of the tarsus; the utility of the operation has, in fact, been tested in numerous instances, and, although it is impossible to lay down any specific rules for its performance^ yet any surgeon of ordinary skill or anatomical knowledge may undertake it with a reasonable hope of success. The great difficulty of the procedure depends upon the close and intimate manner in which the different pieces of the tarsus are connected together, the thickness of the plantar tissues, and the course and depth of the plantar arteries. This, however, may generally be overcome EXCISION OF THE BONES OF THE FOOT. 1055 by attacking the bone to be removed either frora the margin of the foot, or from its dorsal surface, where the soft parts are comparatively sparse and un- important. A useful guide to the diseased bone is commonly afforded by one or more sinuses, the situation of which is nearly always indicated by a red papula of granulations, and more or less discharge of sanious fluid. Caries of the foot is the disease for which excision is most commonly re- quired, and experience long ago demonstrated that the tarsal bones are those which are most liable to suffer in this way. Not unfrequently, however, the heads of the metatarsal bones participate in the lesion, and occasionally, again, they are its exclusive seats. It rarely happens, according to my ob- servation, that only one bone, either of the tarsus or metatarsus, is affected; in general, at least two or three pieces are in a carious condition, and cases arise where every one suffers, the foot presenting a horribly swollen and de- formed mass, full of sinuses, and the seat of excessive pain. Under such cir- cumstances, of course, nothing short of amputation will afford any chance of relief, and the sooner it is performed the better. When the caries is limited to the cuneiform bones, to these bones and the heads of some of the metatarsal bones, or, lastly, to the cuneiform bones and the adjoining portions of the cuboid and navicular bones, excision deserves a decided preference over amputation, and I am satisfied that the operation, if properly executed—that is, in a bold and uncompromising manner, the surgeon removing all the diseased structure—will generally be followed by highly satisfactory results. I have repeatedly removed nearly the whole of the cuneiform bones, together with the heads of several of the metatarsal, and also considerable portions of the cuboid and navicular, and yet the patient had a most excellent and useful foot, answering all the purposes of the natural limb. Access is easily obtained by a large horseshoe flap, with the convexity downwards, upon the dorsum of the foot, care being taken not to injure the sheaths and tendons of the extensor muscles. The removal of the affected bones, whether in part or in whole, must be effected by the cautious use of the gouge and mallet, aided by strong, narrow, probe-pointed knives, and long-bladed, slender pliers. Several mops must be at hand for sponging out the deep cavities made in the operation; and the bleeding, which, how- ever, is seldom profuse, must be controlled, after the excision is completed, by compression, with or without styptics, according to the exigencies of the case. The calcaneum has been exsected in numerous instances, but for the most part only partially, on account of caries, necrosis, and fracture. Dr. Carno- chan, of New York, and Dr. Morrogh, of New Jersey, have each recently reported a case of successful excision of the entire bone. I have myself on two occasions removed the whole of the heel portion of the calcaneum for necrosis. When the entire bone requires excision, the best mode of proce- dure will be that recommended by Mr. Erichsen, inasmuch as we are thereby enabled to preserve the integrity of the sole, a circumstance of great conse- quence to the patient after his recovery from the operation._ In the various proceedings heretofore practised the incisions are carried into the plantar region, so that the cicatrices are afterwards subjected to the pressure and friction of the shoe during progression, and rendered liable to pain, indura- tion, and ulceration. In the case reported by Dr. Carnochan, the sole was not entered, but as the proceeding was somewhat more complicated than that suggested by the English surgeon, I feel inclined to accord the latter the preference The following description and drawing of Mr. Erichsen's operation are taken from the third edition of his Surgery, issued in 1861:—"The patient lying on his face, a horseshoe incision is carried from a little in front of the calcaneo-cuboid articulation round the heel, along the sides of the foot, to a 1056 SPECIAL EXCISIONS OF THE BONES AND JOINTS. Fig. 721. corresponding point on the opposite side. The elliptic flap thus formed is dissected up, the knife being carried close to the bone, and the whole under- surface of the os calcis thus exposed. A perpen- dicular incision, about two inches in length, is then made behind the heel, through the tendo Achillis in the raid line and into the horizontal one. The tendon is then detached frora its insertion, and the two lateral flaps dissected up, the knife being kept close to the bones from which the soft parts are well cleared, as in fig. 721. The blade is then carried over the upper and posterior part of the os calcis, the articulation opened, the inter- osseous ligaments divided, and then by a few touches with the point, the bone is detached from its connections with the cuboid, which, together with the astragalus, raust then be examined, and if any disease is met with, the gouge should be applied. By this operation all injury to the sole is avoided, and the open angle of the wound be- ing the most dependent, a ready outlet is afforded for the discharges." When the parts are thoroughly cicatrized the patient may walk about with the aid of a shoe with a high heel stuffed with horse-hair, but great care must be taken for a long time not to bear too much weight upon it. It is not easy, in the present state of the science, to determine whether the astragalus, when in- vaded by caries or necrosis, should be excised, or whether the case should be subjected to amputa- tion. The fact that the operation has occasionally been performed successfully, the patient not only escaping with his life, but having afterwards a good limb, does not, in my judgment, prove that it should, as a general rule, be employed under the circumstances here indicated. The operation has, unquestionably, terminated fatally in a ma- jority of the instances in which it has been resorted to, whether for the relief of disease, luxation, or fracture, and this fact affords of itself a strong argu- ment against its repetition; but the reason for its abandonment derives addi- tional force when we consider the great difficulty of its execution, and the liability, in the case of caries, of a return of the morbid action, or, in the case of accident, of causing disease in the neighboring bones, with which the astragalus is so intimately united, and which must necessarily be more or less severely injured during the exsection, however carefully it may be done. It is a good plan in every operation of this kind, for the surgeon to place him- self mentally in the situation of his patient, and to ask himself, whether, if he were the subject of grave disease of the astragalus, he would prefer excision to amputation? If he had all the facts on both sides of the question, on the one hand, the great danger of excision, the violent inflammation which would be sure to follow it, and the probability of a relapse of the disease; and, on the other, the comparative safety of amputation, the freedom from subsequent suffering, and the certainty of an excellent stump, one which might be readily adapted to an artificial limb, he would hardly hesitate as to the course he would pursue. He would unquestionably decide in favor of the removal of the leg above the ankle, or at the joint by Pirogoff's or Syme's method. Excision of the calcaneum. EXCISION OF THE BONES OF THE FOOT. 1057 When excision of the entire astragalus is performed for caries, limited to its own substance, the best plan will be to expose the ankle-joint at its ante- rior and outer aspect, by a semilunar flap, with the convexity downwards, taking care not to injure any of the more important soft parts. The bone is separated, first, from its connections with the tibia and fibula, then from those with the calcaneum, and finally from those with the navicular bone. After its lateral attachments have been severed, the disarticulation will be materially facilitated by inclining the foot forcibly backwards, at the same time that an attempt is made with a stout pair of forceps to draw the astragalus out of its bed in the opposite direction. The cutting must be done with a thick, nar- row, probe-pointed knife, kept close against the bone in order to avoid the plantar arteries, especially the internal, which would otherwise be in danger. The operation being completed, the calcaneum is'brought up into the gap between the two malleolar prominences, where it is carefully maintained by appropriate apparatus, the foot resting at a right angle with the leg. Great attention will be required during the after-treatment to prevent retraction of the heel by the action of the gastrocnemial muscles. Slight motion is occa- sionally procured between the contiguous surfaces, but, in general, there will be permanent anchylosis. The limb will necessarily be somewhat short- ened. I have in my possession a cast, kindly presented to me by Dr. James H. Hutchinson, of this city, which admirably shows the appearances of the foot and ankle after the removal of the entire astragalus. The patient was a boy, eleven years of age, on whom Dr. Peace performed the operation, at the Pennsylvania Hospital, in March, 1858. He had been hurt, about seven months previously, by a fall from a haymow, which was followed by severe inflammation, and soon after by ulceration of the integuments, leaving an opening large enough to admit the little finger. Several small pieces of bone came away before his admission, and the remainder of the mass was after- wards extracted without difficulty. When the lad went home, in September, the sore had closed, and he was in excellent health, as I ascertained by a personal examination. The foot, which had a tendency for a time to turn inwards, was nearly at a proper angle, but was found, on accurate admeasure- ment, to be three-quarters of an inch shorter than the sound one, while the difference in the length of the legs was only about three lines. Some motion existed at the ankle-joint, which has no doubt since increased. Partial removal of the astragalus may be effected by the gouge, and it will frequently be well, here a's elsewhere, for the surgeon, when he begins the operation, to take some sinus in the neighborhood of the ankle-joint as his guide, a slight enlargement of the opening being often sufficient to enable him to obtain ready access to the seat of the disease. In a case of caries of the astragalus and calcaneum, Mr. T. Wakley, of London, excised both these bones, together with the malleolar extremities of the tibia and fibula, and had the satisfaction of saving his patient, recovery taking place with a strong and useful foot. Excision of the cuboid and navicular bones does not require any particular notice. When both these bones are involved in disease, the other pieces of the tarsus, and even those of the metatarsus, are also very apt to suffer, and then the question will arise whether Chopart's amputation should not super- sede resection. When the cuboid alone is carious, it may easily be dug out with the gou«-e, but the operation will probably necessitate the removal of the fifth metatarsal bone with the little toe. Partial excision of the navicular bone may be effected in a similar manner. vol. ii.—67 1058 SPECIAL EXCISIONS OF THE BONES AND JOINTS. EXCISION OF THE ANKLE-JOINT. The ankle-joint not unfrequently suffers from scrofulous caries, as seen in fig. 722, from a clinical case ; it is also liable to necrosis, especially in cases Fig. 722. Fig. 723. Caries of the ankle-joint. of compound fractures and dislocations, followed by excessive inflammation. For the relief of these lesions the surgeon usually resorts to amputation of the lower part of the leg, and there can be no question that, as a general rule, it is by far the most expedient procedure, involving hardly any risk to life, and affording an excellent stump. In caries, however, of long standing, where the disease is limited to the articular surfaces of the joint, without any serious implication of the surrounding tissues, excision may be practised with a reasonable prospect of success, a strong and useful, although somewhat shortened, limb being left. The operation was first performed in 1792, by the elder Moreau, but, till lately, has not had a place in surgery, and even now professional sentiment is much divided in regard to it. It is done most con- veniently by making two vertical incisions, ex- tending along the inner and outer margins of the leg, from the level of the ankle to a height of from two and a half to three inches; the lower angle of each cut is then connected by a semilunar one carried across the upper part of the instep, and the flap thus marked off being dissected up, the joint is exposed, the soft structures carefully detached from the two bones, and the articular ends turned out, and sawn off, if possible, on the same level, as in fig. 723. If the astragalus is diseased, the affected part is now removed with the gouge or pliers, when the raw osseous surfaces are placed in accurate apposition, and so maintained until consolidation has occurred, passive motion being duly attended to in order to obtain a short fibro-ligamentous rather than a bony union. In detaching the soft parts from the tibia and fibula, and sever- Caries of the inferior extremities of the tibia and fibula. EXCISION OF THE KNEE-JOINT. 1059 ing their extremities, the utmost care raust be taken not to injure the tibial arteries or the tendons of any of the long muscles of the foot. EXCISION OF THE KNEE-JOINT. It is not a little remarkable, when we consider the great size of the knee- joint, the importance of the structures which surround it, and the intimate sympathetic relations which exist between it and the rest of the system, that it should have been the first articulation which was subjected to excision for the relief of disease. The only plausible explanation which can be given of it is the fact that it is so frequent a seat of white swelling, or scrofulous ulcer- ation, which, until after the middle of the last century, was never thought of being treated in any other manner than by the removal of the affected parts by amputation of the thigh. Exsection of this joint was first performed by Mr. Filkin, of Northwich, in Cheshire, in 1762; as, however, no account of it appeared in print, no attention was attracted to it until the publication of the famous case of Mr. Park, of Liverpool, in 1781. The news of this achievement having reached France, Moreau, the elder, of Bar-sur-Ornain, was induced to make trial of it, in 1792, upon one of his patients, a young man, laboring under white swelling. In 1809 the operation was performed by Mr. Mulder, of Groningen, in 1823 by Mr. Crampton, of Dublin, and in 1829 by Mr. Syme, of Edinburgh, the latter surgeon repeating it soon after in another case. From this period nothing of special interest occurred in regard to excision of the knee-joint until 1850, when it was revived by Mr. Fergusson, of London. Since then the operation has been practised in numerous instances ; and, although the results have been far from being uni- formly successful, yet enough has been done to show that the procedure, if properly executed, holds out great promise of a strong and useful limb, in a class of cases which were formerly regarded either as entirely hopeless, or as remediable only by amputation. One of the most able and zealous champions of the operation, at present, is Mr. Butcher, of Dublin, who has perhaps done raore than any one else to reduce it to rule. It is not, of course, every case of diseased knee-joint that is proper for excision. Theoperation should, as a general rule, be refrained from when there is very extensive structural change of the bones, rendering it necessary to go much beyond their articulating extremities; when the morbid action is of a strumous nature without well defined limits ; and when the patient is so young that interference with the shafts of the femur and tibia would inevitably be followed by an arrest of development of the limb. In all such cases ampu- tation should take the place of resection. In regard to the manipulations, various plans have been suggested, any one of which will afford ready access to the diseased bones, but they are all ob- jectionable, on the ground that, the most dependent part of the wound being closed, there is no outlet for the discharges. To remedy this difficulty it has been proposed to pierce the posterior wall of the wound, and to insert a gum- elastic tube to carry off the fluids as fast as they are secreted; a circumstance of paramount importance both as it respects the speedy restoration of the parts and the prevention of pyemia. There can hardly be any doubt that many, if not most, of the accidents that have followed this operation have been due, directly or indirectly, to the accumulation of pus in the bottom of the wound and its consequent injurious action upon the bones, irritating antl eroding their substance, and burrowing more or less extensively among the soft nart. Such however, is the character of the tissues behind the articu- lation a to render it impracticable to approach the femur and tibia in that Action or To leave the operator any choice in regard to the place of election. 1060 SPECIAL EXCISIONS OF THE BONES AND JOINTS. Mr. Park readily accomplished his purpose by means of a crucial incision, the centre of which corresponded with the superior extremity of the patella, the perpendicular cut being Fig. 724. nearly six inches in length, while the horizontal one reached almost half round the limb, which was in an extended posi- tion. Moreau, on the other hand, made an H-snaPed inci- sion, that is, a longitudinal in- cision along each side of the thigh and leg, between the vasti and flexor muscles, and a trans- verse one just below the patella. I prefer myself a large semi- lunar, U-shaped or horseshoe flap, as seen in fig. 724, made by carrying the knife across the upper part of the leg, from one condyle to the other; this being carefully raised, affords a suffi- cient opening for dividing the connecting ligaments, separat- ing the soft parts, and turning out and sawing off the ends of the bones. In general, not more than an inch of the femur, fig. 725, should be removed, and a still smaller slice should, if possible, be taken from the tibia, fig. 726 ; sometimes, however, it is necessary to cut off much more, the tibia, Excision of the knee-joint. Fig. 725. Fig. 726. Lower end of the feraur excised. Upper end of the tibia excised. for example, below its articulation with the fibula, and the femur above its condyles, and yet a useful limb be left. If any sinuses are found to extend into the substance of these bones, after they have been sawn off, they should be followed up with the gouge, and every particle of disease be scooped out, with the same care and patience that the dentist drills out the cavity of a tooth preparatory to the introduction of the plug. Any burses that may have been exposed in the operation should also be removed, lest they occasion suppuration, and so retard the cure. In raost cases of disease of the knee-joint requiring excision, the patella is implicated in the morbid process, and should, therefore, be removed along with the other bones ; this course, however, necessarily involves the division of the tendon of the four-headed extensor muscle, and consequently the oss of anv action which that mnscle might exert upon the movements of the leg, iu the" event of the formation of an artificial joint during the progress of the case. Hence the preservation of the tendon becomes a matter of great in- EXCISION OF THE KNEE-JOINT. 1061 terest, as tending to augment the strength and usefulness of the limb. This can only be accomplished, however, when there is but little disease of the tibia and the patella; for, when the tubercle of the former bone is obliged to be exsected, the tendon or ligament necessarily loses its attachment, and had, therefore, better be removed with the latter. All the ordinary proceedings contemplate the ablation of the patella, and I am quite satisfied that it is, as a general rule, the most judicious practice, even when this bone is perfectly healthy. When the patella is retained, its articular surface should be divested of its cartilage, to promote its union with the surface of the femur, also pre- viously rendered raw. If notwithstanding this precaution, consolidation fail to occur, and the patella be found to interfere with the cure, lying loose under the integuments, and thus keeping up irritation, no tirae should be lost in removing it altogether. It might be supposed that, during the sawing of the bones, the popliteal artery would necessarily be endangered, but this is not the case, the vessel lying altogether beyond the line of the instrument. The hemorrhage, indeed, is usually very slight, ligation of the articular branches being all that is generally required. During the after-treatment the limb should be retained in the extended position, if much substance has been removed, but slightly flexed under opposite circumstances, in order to place it in the most favorable condition for usefulness in the event of anchylosis, which is so liable to happen after excision of the joints, notwithstanding all the precautions that may be taken to prevent it. Among the more suitable contrivances for accomplishing this object is Mr. Butcher's box, fig. 727, the sides of which can be let down by hinges; it is Fig. 727. Butcher's box for after-treatment in excision of the knee. well padded with horsehair, and readily admits of the requisite degree of extension and counter-extension of the limb. Mr. Price's apparatus, delineated in fig. 728, also answers admirably well. It consists of a Mclntyre's splint, of thin tinned iron, with a foot-board, Fig. 728. Price's apparatus for after-treatment in excision of the knee. between which and the leg there is an open space, in order that there may be no pressure upon the heel and the tendo Achillis. The portion of the 1062 SPECIAL EXCISIONS OF THE BONES AND JOINTS. apparatus corresponding to the popliteal space is slightly convex upwards, with a view of insuring more accurate apposition of the ends of the bones. A short splint, well padded, should be applied in front of the thigh, while a long one, provided with a central iron hoop and a perineal strap, should be stretched along the outside of the limb. Occasionally the limb may be swung, with great advantage and comfort, in Salter's fracture apparatus, shown in fig. 729. Fig. 729.' An excised knee swung in Salter's apparatus. One of the most annoying occurrences to be guarded against is the tend- ency which the tibia has to be drawn outwards and backwards, in consequence of the action of the flexor muscles of the thigh. The best means of counter- acting this disposition is the bandage, applied from the hip downwards, the leg being invested in the usual way; or, this failing, the subcutaneous section of the tendons of the offending muscles. When osseous union is expected, the bones should be sawn off a little slopingly behind, so as to enable the parts to afford the degree of flexion essential to the production of a serviceable limb. In this case the extremity should be placed over a double- inclined plane, and be well supported with lateral splints, to prevent bowing of the leg. Statistics.—The statistics of this operation are of deep interest. In regard to the earlier cases, those of Filkin and Park completely recovered, the patient of the latter having obtained so sound a limb as to be able to go to sea and perform all the duties of a sailor. Moreau's patient died, several months after the operation, of dysentery; of Crampton's two cases, one recovered with a good limb, and the other perished at the end of three years and a half, exhausted by hectic irritation and repeated attacks of erysipelas. Of Mr. Syme's patients one got well and the other died. Mr. P_ C. Price, a few years ago, collected the particulars of 160 cases of excision of this joint, performed in Great Britain since 1850, on account of disease, deformity, and accident, and of these 32 proved fatal, or in the ratio of 1 to 5. In 8 death was caused by pyemia, in 6 by exhaustion, in 5 by irritation, in 4 by shock, and in the remainder by various affections. It is proper to add that, in many of the cases, the operation was performed as a dernier resort, on account of extensive and protracted disease of the arti- culation, attended with a worn-out state of the systera. In 18 of the 160 EXCISION OF THE KNEE-JOINT. 1063 cases, the results of the excision were so unsatisfactory as to require amputa- tion of the thigh. Of these 18 operations only one terminated fatally. Of 127 cases collected by Dr. Geraldes, 33 proved fatal. Of 19 cages subjected to resection, between 1762 and 1730, 12 died. Of 108 cases ope- rated upon since that period, only 21 proved fatal, thus showing an immense diminution in the mortality of resection, as performed in more recent times. Mr. Humphry, of Cambridge, England, a few years ago reported the par- ticulars of 13 cases, in which he had excised the knee-joint, on account of chro- nic disease, of which only one proved fatal, although four were subsequently obliged to submit to amputation. Mr. Jones, of Jersey, has performed the same operation fifteen times with only one death. In operating upon young persons, Mr. Humphry suggests the propriety of making the section through the epiphyses, and not through the shaft of the bones, lest, their growth being thus arrested, great de- formity from shortening should occur. These effects are strikingly illustrated in the adjoining cut, fig. 730, taken from a case of Mr. Pemberton, of Birmingham. The patient, at the time of the operation, was twelve years of age, and the amount of bone re- moved was rather more than three inches and a half, of which about two inches and a half be- longed to the femur. Six years after the operation the limb was found to be nine inches shorter than the other. A similar case has been reported by Dr. Keith, in a boy whose knee was excised at the age of nine. Five years afterwards the limb was seven inches shorter than the other, and looked, when compared with it, like a mere appendage to the body. It would thus appear that a useful limb cannot be ob- tained when this operation is performed through the shaft of the bone before the completion of the ossific process, the epi- physis being indispensable to its full development. The annexed cut, fig. 731, affords a good idea of the result of the operation in the adult. The drawing was taken two years after the operation, which was performed by Mr. Hancock, of London. Assuming that these data afford a fair average result, it will be perceived Shortening after excision of the knee. 1064 SPECIAL EXCISIONS OF THE BONES AND JOINTS. that the mortality from excision of the knee-joint is considerably less than that from amputation of the thigh, for which it raay, therefore, under favor- able circumstances, be employed as a Fig- 731. suitable substitute. Excision of the knee two years after the operation. EXCISION OF THE PATELLA. The patella, though not often diseased, is occasionally affected without the femur and tibia participating in the morbid action. In a man who was under my care, some years ago, the bone was com- pletely exposed, and almost entirely ne- crosed, from frost-bite, its surface being as black as charcoal, and its substance greatly softened. By means of the gouge I cut away nearly the whole thickness of the bone, leaving merely its inner table, 'pared the edges of the ulcer in the soft parts, and, using warm water-dressings, succeeded in effecting an excellent cure, the joint gradually recovering from the stiffness into which it had been thrown in consequence of its protracted disuse. A case in which the entire patella was removed on account of necrosis, the result ofafall,maybefound reported in the North American Medico-Chirurgical Review for 1860, by Dr. 0. B. Knode, of St. Joseph, Missouri. Although the interior of the joint was exposed during the operation, the patient, a man, aged twenty-one years, made an excellent recovery, followed by a good use of the knee-joint. EXCISION OF THE BONES OF THE LEG. Excision of the long bones of the lower extremity can be practised only to a certain extent, as the removal of any considerable portion would deprive the limb of its solidity, aud so render it useless as an instrument of progres- sion and support. Several inches of the shaft of the femur might be exsected, and yet, if osseous union occurred, the thigh wTould answer an excellent pur- pose. In badly-treated fractures the limb is often shortened to this extent, the patient walking well afterwards with the aid of a high-heeled shoe. A loss of several inches of the body of the tibia would be a serious accident unless it were accompanied by a corresponding loss of the fibula, in which case, solid union taking place, a good leg might result, while if the fibula retained its integrity, the limb would not be sufficiently firm for locomotion. To the above statements the fibula forms a striking exception. The loss of a portion of this bone, or even the whole of it, except its malleolar ex- tremity, does not, as is well known, materially affect the functions of the leg and foot. Exsection of the entire fibula, originally proposed by Desault, was first executed by Percy and Laurent; Seutin has also performed the operation, and other surgeons, as Beclard and Elliot, have removed consider- able pieces of it; generally on account of caries, caries and necrosis, or hypertrophy from syphilitic disease. A case of excision of the entire fibula EXCISION OF THE HIP-JOINT. 1065 for fibro-cartilaginous degeneration of that bone was reported, in 1858, by Dr. A. R. Jackson, of Stroudsburg, Pennsylvania. The patient, a female, aged thirty-seven years, made a good recovery with a useful limb. In performing the operation, the bone, exposed by a longitudinal incision, is carefully isolated at its superior extremity, and either disarticulated from the tibia or divided with the pliers. Taking now hold of this part, and using it as a handle, the operator cautiously detaches the remainder of the bone from its muscular connections, and, lastly, from the tibia and astragalus below, keeping all the while the point of his knife as closely against the osseous surfaces as possible. The exsection is usually attended with a good deal of hemorrhage, and, unless great caution be employed, the peroneal artery will be likely to be wounded. During the after-treatment care must be taken to prevent inversion of the foot, to which there is generally a decided tendency whenever the external malleolus is removed. EXCISION OF THE HIP-JOINT. Excision of the hip-joint, or, raore correctly speaking, of the head and neck of the femur, has occasionally been practised for gunshot injury and chronic disease; but the operation never met with much favor in the latter class of affections until recently, although nearly a century has elapsed since the attention of the profession was directed to the subject by Mr. Charles White, of Manchester, England, who was the first to suggest the feasibility of the procedure. It does not appear, however, that he ever put the idea to the test of experiment. This credit was reserved for Mr. Anthony White, of London, who performed the operation successfully in 1818. His patient was a lad, fourteen years old, affected with coxalgia, who, notwithstanding the loss of four inches of the femur, made an excellent recovery, living for a number of years after in perfect health. The operation was not repeated, anywhere, until 1823, when Mr. Hew- son, of Dublin, exsected the extremity of the bone above the small trochanter; the case, however, terminated unfavorably, the patient dying three months after from disease of the acetabulum, followed by abscess of the pelvis. A more fortunate result attended the undertaking of the German surgeons, Schlichting, KShler, and Heine, which took place a short time subsequently to that of the Irish practitioner, recovery ensuing in every instance. Although the operation has been performed rather frequently during the last fifteen years, chiefly through the influence and example of Mr. Fergusson, of London, yet such is the want of statistical information upon the subject that it is extremely difficult, if not impossible, to arrive at any well-founded conclusions respecting its value, or even its propriety. The great objection that has been urged against it is that, in coxalgia, the morbid action often extends to the acetabulum, if not also into the pelvic cavity; and some, indeed, have even gone so far as to assert that this is always the case in the more confirmed stages of the disease, which, however, is not true, as my dis- sections fully satisfy me. But granting, for the sake of argument, that it is, the fact would not, in my opinion, constitute a valid objection against the procedure, seeing how easy it would be, in most instances, to gouge out all the carious structure, and thus leave the parts in a condition for gradual repa- ration When the acetabulum is deeply involved, a circumstance, however, which cannot always be determined beforehand, either from the symptoms or an examination with the probe, the case will, of course, be proportionately raore unfavorable, but even then we need not despair of an ultimate cure, provided the operation be conducted with the requisite care and skill. Left to themselves such cases nearly always prove fatal, life being gradually worn out by hectic'irritation and profuse discharge. Assuredly, then, unless the 1066 SPECIAL EXCISIONS OF THE BONES AND JOINTS. patient is in an utterly forlorn condition, both science and humanity would dictate the propriety of interference in the hope of rescuing the individual from his impending fate. I am satisfied that conservative surgery has not yet had fair play in this class of cases of hip-joint disease; the objection, I conceive, ought not to lie against the operation, but against the time at which it is performed, which is often too late to afford the benefits which it would otherwise be capable of conferring. When the head and neck of the thigh- bone alone are diseased, excision, early and judiciously practised, will not only prevent much suffering, but be instrumental in saving many lives. When the disease has committed such ravages as are displayed in fig. 732, from a drawing of one of my clinical cases, it is im- Fig. 732. possible for any surgeon to produce a good result. In contemplating the manual part of the opera- tion, several plans suggest themselves to the con- sideration of the surgeon. In the first place, he may adopt the method followed by White, of mak- ing simply one longitudinal incision, in the axis of the head and neck of the bone, of which he was thus readily enabled to remove four inches; or, he Fig. 733. of hip-joint disease. Excision of the hip-joint. may give his incision a T, L, or Y-shaped appearance; or, finally, what is preferable to any of these procedures, he may form a semilunar flap of the gluteal muscles, with the Fig. 734. convexity downwards. This plan of incision has the ad- vantage not only of allowing free access to the joint, but also of affording a ready out- let for the discharges at the lower and outer angle of the wound. The superior extre- mity of the femur, being thus exposed, is thrust through the opening, as seen in fig. 733, from Erichsen, by car- rying the limb across the sound one, rotating it in- EXCISION OF THE HIP-JOINT. 1067 wards, and then pushing it up, when it is to be divided immediately below the limits of the morbid action, fig. 734, by means of a narrow saw, the soft parts being carefully protected from injury during the movements of the instrument. Any disease that may exist in the acetabulum, whether at its margin or in its bottom, is to be freely removed with the gouge. There is not much bleeding, but a few small arteries may require ligation. The wound is approximated in the usual way, a small tent being inserted at the external and inferior angle; and the limb, placed in the straight position, is supported with a carved splint, with a window opposite the joint, to admit of the necessary examination and dressing. Until the primary effects of the operation are over, all attempts at extension and counter-extension will be likely to prove extremely painful, if not positively mischievous; but by de- grees this must be rigidly attended to, lest the limb, when well, be too short to be either seemly or useful. The object may, in general, readily be at- tained either with a bracketed Desault's splint, or with the apparatus of Mr. Fergusson, depicted in fig. 735, the extension iu the latter case being made Fig. 735. Fergusson's apparatus for the after-treatment in excision of the hip-joint. from the opposite thigh by means of a laced socket having a band attached to the upper extremity. One of the difficulties experienced after the opera- tion is to keep the end of the femur in contact with the acetabulum. Statistics.—The statistics of this operation are of great interest. The most elaborate yet furnished are those by Dr. Lewis A. Sayre, of New York, in a paper on "Morbus Coxarius," published in 1860. They refer exclusively to operations performed for the relief of hip-joint disease, and embrace altoge- ther 110 cases, of which, however, 18 are doubtful, leaving thus 92 reliable ones. Of these 92 cases, 42 recovered, 37 died, and 13 were still under treat- ment at the time they were reported. In the American Journal of the Medical Sciences for July, 1861, is a paper on the same subject, by Dr. Charles K. Winne, of Buffalo, in which 49 cases of excision of the hip-joint on account of coxalgia are tabulated. Of these, 20 recovered, 15 died, 11 were doing well when reported, and of 3 the result had not transpired. It will thus be perceived that the mortality from this operation is immense, a circumstance which is not surprising when it is remembered that it is often performed, as a dernier resort, when all other means of relief have failed, and when life is rapidly ebbing away under the wasting effects of the disease. Doubtless, too, the results of the operation are much more favorable in the hands of some surgeons than in those of others. As a proof of this, it may be stated that, of 7 cases in the practice of Mr. Erichsen, not one proved fatal; 3 completely recovered, 2 were lost sight of after they had left the hospital, and 2 died from constitutional disease, one eleven months and the other two years after the operation. In some of the fatal cases in Dr. Sayre's table, as well as in that of Dr. 1068 SPECIAL EXCISIONS OF THE BONES AND JOINTS. Winne, death occurred within the first week, ten days, or a fortnight after the excision, either from the violence of the resulting inflammation, excessive suppuration, secondary hemorrhage, erysipelas, pyemia, or phlebitis. In others the patient recovered from FiS- ?36- the immediate effects of the opera- tion, but fell a victim, at a variable period, to intra-pelvie abscesses, ca- ries or necrosis, phthisis, Bright's disease, enlargement of the liver, tubercular meningitis, or some other accidental malady. In not a few of the cases the operation seems to have been performed im- perfectly, or when the disease had made such progress as to render recovery absolutely impossible. The appearances of the limb after excision of the hip-joint for coxalgia are well illustrated in fig. 736, from a case of Mr. French, of London. The drawing was taken twelve years after the ope- ration. Dr. George Williamson has col- lected the histories of 11 cases of excision of this joint for gunshot in- jury, of which only one recovered, the patient being a man, twenty- five years of age, and the femur being sawed off below the trochan- ter. Of these cases six occurred in the Crimean war. EXCISION OF THE GREAT TRO- CHANTER. Excision of the great trochanter is occasionally required on account of caries of its substance. Profes- sor Willard Parker, a few years ago, performed an operation of this kind with very gratifying re- sults, and it has also been done several times by others. Mr. Fer- gusson has had two cases, one of which proved fatal at the end of the first week, in consequence of an attack of erysipelas. The operation itself is not difficult of performance, the carious prominence being easily exposed by a longitudinal or slightly cur- vilinear incision, and removed with a small saw, the gouge, or the pliers. The hemorrhage is usually inconsiderable. The two circumflex arteries are only endangered when we are obliged to carry the knife deeply and extensively around the base of the trochanter. The excision of the bone will be greatly facilitated if the limb be thoroughly inverted during the operation. When more room is required than usual, the surgeon may make a T-shaped incision, with the base downwards, to afford a better outlet for the discharges. Appearance of the limb twelve years after excision of the hip. AMPUTATIONS OF THE HAND. 1069 CHAPTER XXII. SPECIAL AMPUTATIONS. 1. SUPERIOR EXTREMITY. AMPUTATIONS OF THE HAND. The fingers may require removal either in their continuity or at their articulations. When the distal phalanx alone is involved, as when it is in a carious or necrosed condition, the operation should, if possible, be limited to the bone, the nail and soft parts being preserved. In disease of the bone from whitlow, such a procedure is nearly always feasible, and, when the peri- osteum has not been destroyed, is not unfrequently followed by a reproduction of the phalanx, although rarely in a perfect manner. It is only, therefore, when the parts have been crushed by machinery or some other cause, that, as a general rule; the finger should be cut off at the last joint. The operation is performed by making a short, semilunar incision from one side of the finger to the other, on its dorsal surface, the convexity presenting towards the nail, * as seen in fig. 737. Turning back the integument, the knife is inserted into Fig. 737. Amputation of the finger, at the distal articulation. the articulation, and, the ligaments being divided, it is drawn forwards, in close contact with the palmar aspect of the bone, so as to form a large con- vex flap, which is then retained by several points of suture. In amputation of the finger in the continuity of the second phalanx, the operation may be performed either by the circular method, or by two flaps taken laterally or from the dorsal and palmar surfaces, the bone being divided with a sharp pair of pliers. It is hardly necessary to add that it is always desirable to save as much of the member as possible, both on account of utility and seemliness. Excepting the index finger, amputation should never be performed at the first phalangeal articulation, as the stump thus left would not only be dis- figuring but inconvenient. Hence, when the operation is required, it is much better to remove the bone at its junction with the metacarpal bone. This 1070 SPECIAL AMPUTATIONS. raay readily be done by making two lateral flaps by circumscribing the pos- terior extremity of the first phalanx by two long, semilunar incisions, fig. 738, commencing at the centre of the knuckle of the metacarpal bone behind, and terminating at the middle of the palmar aspect of the member on a level with the web of the contiguous fingers. During the disarticulation, the finger is Fig. 738. Fig. 739. , Amputation of the finger at its metacarpo-phalangeal joint. Removal of the bone with the pliers. forcibly flexed, so as to afford an opportunity of severing the extensor tendon above the joint, as it would otherwise be in the way of the stump. Before approximating the flaps, the projecting portion of the knuckle of the meta- carpal bone should be cut off with the pliers, as in fig. 739, in order to give the part a more seemly appearance. Generally, two small arteries require the ligature. During the cure, the fingers must be confined upon a carved splint, otherwise they may overlap each other, and thus become, in great measure, useless. In amputating the index finger, a very useful stump may be formed by disarticulating the middle joint, especially in laboring subjects, or in those engaged in mechanical pursuits. In the rich, on the contrary, the hand will present a better appearance if the finger be removed at its connection with the metacarpal bone. ■,,-,. It is seldom that all the fingers are simultaneously affected by disease, so as to require removal at the metacarpo-phalangeal joints, but such a proce- dure may become necessary on account of accidents crushing the bones and extensively bruising and lacerating the soft parts. The operation, which is sufficiently easy of execution, is performed by making two flaps, one on the dorsal, and the other on the palmar aspect of the hand, by two incisions, slightly convex in front, the posterior extending over the roots of the fingers, about half an inch in front of their junction with the metacarpal bones, while the anterior one is carried across the hand on a line with the web of the fingers The best plan is to form the dorsal flap first, and then, after having reflected it back, and divided the tendons and ligaments, to fashion the other by cutting from above downwards, and from behind forwards. The appear- ance of the stump will be greatly improved if the projecting portion of each knuckle of the metatarsal bones be sloped off a little with the pliers A useful and not unseemly, stump may be formed by amputating the meta- carpal bones in their continuity, leaving, perhaps, the thumb or one of the AMPUTATIONS OF THE HAND. 1071 fingers, the principal flap being taken from the substance in the palm of the hand. In case of accident, crushing the bodies of these pieces, the opera- tion might be performed through their posterior extremities, from a third of an inch to three-quarters of an inch in front of their junction with the second row of carpal bones, or even at the carpo-metacarpal articulations, although, from the irregularity of the contiguous surfaces, the task would by no means be an easy one, nor would the resulting stump be as smooth as it ought to be, either for usefulness or seemliness. Cases occur, both of accident and disease, demanding the removal of one of the metacarpal bones along with the corresponding finger. The opera- tion is executed by making a triangular incision over the back of the hand, the apex of which is directed towards the wrist, while the base extends round the root of the finger in front, hardly any integument being removed. The extensor tendon being cut far back, the bone, isolated from its muscular con- nections, is either separated at its carpo-metacarpal articulation, or divided in its continuity, in a sloping manner, by means of the pliers. Amputation of the thumb at the distal joint, or in the continuity of its first phalanx, may be performed in the same manner as amputation of the fingers, and does not, therefore, require any particular notice. When both its bones are fatally implicated, whether by disease or accident, the hand will exhibit a much more seemly appearance if the member be removed at the carpo- metacarpal joint. For this purpose, a triangular incision is made along the radial aspect of the hand, beginning about one inch in front of the styloid process of the radius, one line extending to the centre of the web between the thumb and index finger, while the other passes round Fi#- 740. the outside of the head of the metatarsal bone, a little behind the joint, both meeting in front of the palm, as represented in fig. 740. The muscles being now detached, and the exten- sor tendons severed behind, the disarticulation is readily effected by bending the thumb forcibly inwards towards the ulnar margin of the hand. In performing the operation, the hand is placed in a state mid- way between pronation and supination, the fingers being fully extended and the thumb abducted. Care must be taken not to include too much integument in the incisions. When the flaps are properly shaped, they usually unite by the first intention, and leave a very insignificant cicatrice. The little finger is sometimes removed along with the metacarpal bone, at its junction with the unciform bone. Two incisions are made over the back of the hand, extending from the carpo-metacarpal articulation forwards, along each side of the root of the finger, and terminating at the centre of its pal- mar aspect on a line with the web which connects it with the ring finger. The soft parts are now carefully detached from the bone, which is then for- cibly flexed and disarticulated by inserting the knife into the back of the joint Unless this rule be closely followed, the operation will prove difficult, on account of the peculiar conformation of the articulating surfaces of the two bones. Amputation of the thumb and metacarpal bone. 1072 SPECIAL AMPUTATIONS. AMPUTATION AT THE "WRIST. Disarticulation at the wrist should always be preferred to amputation of the forearm whenever it is practicable, inasmuch as the mutilated extremity affords a much longer lever, which may afterwards be used with great advan- tage for various purposes, at the same time that it is more easily adapted to an artificial hand. I have repeatedly seen persons who, after this operation, enjoyed an amount of action in the limb that was truly astonishing, and who expressed very great satisfaction at having so good a weapon of defence in accidental pugilistic rencounters, the long stump enabling them to deal'a most powerful blow. The operation is performed by making two flaps, an anterior and posterior, about an inch and a half long, the convexity looking forwards towards the hand, as shown in fig. 741. They should be formed by cutting from without inwards, as we are thus enabled to give thera a much better shape. The incision should extend from the styloid process of the ulna to that of the radius, which should be previously felt for, and then taken as guides to the knife. The disarticulation is effected by inserting the instru- ment into the posterior part of the joint, the hand being forcibly flexed, and held perfectly prone at the time. This step of the operation will be greatly facilitated if the surgeon bear in mind the peculiar conformation and arrange- ment of the two surfaces of the joint, as seen in fig. 742. The hand being Fig. 741. Fig. 742. Amputation at the wrist. Wrist, carpal, and metacarpal joints. removed, the styloid processes are cut off on a level with the cartilaginous incrustation of the ulna and radius, when, the arteries of the wrist being tied, - and the extensor and flexor tendons, if necessary, properly retrenched, the flaps are approximated and retained in the usual manner. AMPUTATION OF THE FOREARM. The forearm may be removed in its continuity in any portion of its extent, but when the surgeon has his choice, the operation should be performed as low down as possible, for the reason that, as stated in the preceding para- graph, the longer the stump is the more useful it will be. The flap method is the one which I usually prefer, but the circular also answers exceedingly AMPUTATION OF THE FOREARM AND ELBOW. 1073 well, and is regarded by many as altogether superior to the other. When the limb is very fleshy, it is best to forra both flaps by transfixion, one on the anterior, and the other on the posterior surface of the forearm, as in fig. 743; Fig. 743. but, under opposite circumstances, one should be fashioned by cutting from without inwards, and the other by cutting from within outwards, as we are thus enabled to give thera a more suitable shape and size. The extremity is held in a state midway between pronation and supination, the brachial artery is compressed by a tourniquet or the fingers of an assistant, the interosseous structures are divided on a level with the retracted flaps, and the saw is worked in such a manner as to sever both bones simultaneously, or, if prac- ticable, the ulna a little before the radius, as the latter, from its more direct connection with the hand, affords a better support during the operation, and thereby prevents splintering of the osseous tissue. This occurrence, however, may, in general, be effectually obviated if the surgeon, during the sawing of the two bones, takes care to apply his thumb and fingers strongly to the interosseous space. In performing the circular operation, it is advisable, on account of the smaller quantity of tissue, to draw the soft parts forcibly back by means of a three-tailed retractor, but such a procedure is never necessary when the amputation is done FiS- 744. as here described. The radial, ulnar, and in- terosseous arteries alone generally require ligation. I have seen some cases of amputation of the forearm only about two inches, or two inches and a half below the elbow, with a most excellent result, the stump being rounded off and well shaped, perfectly movable, and quite Short stump of the forearm. serviceable. The annexed drawing, fig. 744, taken from the parts several years after such an operation, exhibits the appearance of the limb. AMPUTATION AT THE ELBOW. Amputation at the elbow is performed but seldom, a circumstance which is the more surprising wheu we consider what an admirable stump it leaves, VOL. n.—68 1074 SPECIAL AMPUTATIONS. what little risk it involves, and how promptly the parts usually heal. Besides these advantages, which experience has fully established, the operation is one of the most easy in surgery, and may, therefore, be performed by any one having a competent knowledge of the anatomy of the joint. Two flaps are formed, the principal one in front of the elbow, at the expense of the muscles in that situation, and the other, which is entirely cutaneous, behind, the leugth of the former varying from two and a half to three inches, accordino- to the diameter of the limb. The forearm being slightly flexed, so as to bring the sharp edge of the coronoid process on a line with the articular sur- face of the humerus, the surgeon transfixes the structures in front of the joint, on a level with the two condyles, and, carrying the knife downwards in close contact with the bones, thus forms the anterior flap, taking care not to give it too great a degree of convexity. The posterior flap is then raade by draw- ing the knife across the back part of the limb, in a somewhat semilunar direc- tion, the ends of the incision connecting themselves with those of the pre- ceding one. The next step of the operation consists in dividing the ligaments which unite the radius and ulna to the humerus, and in sawing the olecranon process from before backwards, leaving all that portion which lies above the level of the joint, and which receives the insertion of the three-headed ex- tensor muscle. It is not necessary to interfere with the articular cartilage of the humerus, but it will improve the shape of the stump if we cut off the inner trochlea of that bone on a line with the other surface, as may usually be readily done in severing the olecranon. AMPUTATION OF THE ARM. In amputating the arm, the same general rules are applicable, as it respects the point of election, as in the reraoval of the forearm, already described. The stump should be as long as possible; and the best covering for it is obtained by taking two Fig. 745. flaps, one from the anterior, and the other from the pos- terior aspect of the limb, the former being usually formed last, as it contains the brachial artery. The soft parts being firmly grasped, and held away from the bone, the trans- fixion is effected in the usual manner, the knife be- ing carried downwards for a distance of from two and a half to three inches, accord- ing to the dimensions of the limb, as shown in fig. 745. When the muscles are very large and firm, the surface of the flaps should be rather concave, to prevent redundance of substance. The bone being sawed, the brachial artery and its branches are secured, and the flaps approximated by suture and plaster. The circulation in the limb, during the operation, is con- trolled by compression of the axillary artery, or of the subclavian above the clavicle. Statistics of this operation are detailed in a previous chapter. It would seem that amputation of the upper arra in gunshot wounds is much raore dis- Amputation of the arm. AMPUTATION AT THE SHOULDER. 1075 astrous than resection of the elbow-joint for similar lesions. Of 54 cases of the former, mentioned by Esmarch, 19 proved fatal, while of the latter only 6 out of 40 died. The British surgeons in the Crimea amputated the upper arm in 162 cases, with a loss of 25, or a mortality of 15.4; 96 of the cases being primary. Of the 6 secondary cases, 3 perished. AMPUTATION AT THE SHOULDER. Of the numerous plans that have been devised for amputating the shoulder- joint, I shall content myself with an account of the following, an acquaint- ance with which will enable the surgeon readily to meet any emergency that raay arise in practice, whether civil or military. In performing these opera- tions, the circulation in the limb must be controlled by compressing the sub- clavian artery above the clavicle, either by means of the handle of a large key, or, what will answer much better, the compressor, described and delineated in the chapter on amputations, vol. i. p. 548. The head and chest should be well elevated by pillows, and the shoulder should be brought over the edge of the table, so as to allow the knife the most perfect freedom. Amputation at the shoulder-joint is one of the most easy operations in surgery. Richerand long ago remarked that it might be performed with the same celerity with which an adroit carver separates the wing of a partridge, and nothing is more true, although I have occasionally seen a case in which the surgeon consumed time enough not only to cut up the whole bird, but also to devour it. 1. One of the best methods of performing this operation is that of Baron Larrey, which consists in making two oval flaps, one in front and the other behind, as in fig. 746, each being frora three to three Fig- 746. inches and a half in length. The limb being held hori- zontally, away frora the body, with the hand in the prone position, the knife is introduced immediately be- neath the acromion process of the scapula, and carried down through the centre of the belly of the deltoid muscle, for about two inches and a half, when, changing the line of direction, it is drawn round the upper extremity of the humerus, as far down as the centre of the axilla, the flap thus formed exhibiting a well- marked convexity in front. A similar flap is then made on the opposite side, when the elbow is carried forcibly backwards, behind the level of the trunk, to facilitate the disarticulation, which is effected by cutting closely from above downwards, round the margin of the glenoid cavity as in fig 747. Instead of forming the flaps as here directed, they may be made by trans- fixion, or cutting from within outwards, although the former is, on the whole, the better method. . , , ... 2 SiiDDOsine the left shoulder to be the subject of amputation, the knife is introduced at the inferior margin of the axilla, and brought out about half an inch beneath the clavicle, just beyond the acromion process. By now Amputation at the shoulder. 1076 SPECIAL AMPUTATIONS. drawing the instrument downwards, in close contact with the humerus, a largo flap is formed, at the expense, mainly, of the deltoid and broad dorsal mus- Fig. 747. Amputation at the shoulder, the joint being exposed. cles. The capsular ligament being put upon the stretch by carrying the elbow across the front of the chest, disarticulation is readily effected, and the other flap formed by cutting the soft parts on the antero-internal portion of the limb. If the right shoulder be the seat of operation, the transfixion must be commenced above. 3. Lastly, an excellent stump may be formed by making the flaps at the outer and inner aspects of the joint. The elbow being elevated so as to depress the head of the humerus, and the cushion of the shoulder raised, the knife, supposing the left side to be the subject of operation, is thrust in at the posterior margin of the deltoid and brought out at the anterior, the flap being formed almost exclusively of the substance of that muscle. The soft parts being held up, the exposed joint is entered in the usual manner, and the other flap made at the expense of the structures in the axilla, by cutting from above downwards. The statistics of this amputation exhibit a less flattering result than one might have been led to anticipate from a consideration of the size of the arti- culation and the nature of the structures concerned in its execution. From the tables of Dr. Stephen Smith, published in 1853, it appears that, of 71 cases occurring in various American and European hospitals, 34 proved fatal, thus showing a mortality of nearly 50 per cent. The advantages of primary over secondary amputation at the shoulder-joint, in military practice, are well illustrated by the facts furnished by the late Mr. Guthrie. Thus, of 19 cases in which the operation was performed soon after the receipt of the injury, all save one recovered; whereas, out of 19 others, which underwent secondary amputation, 15 died. In the Crimean war, the British surgeons removed the arm at the shoulder-joint in 39 cases, with a fatal issue in 13, or 33.3 per cent., 33 being primary, with 9 deaths, and 6 secondary, with a fatal issue in 4. The tables of Dr. Smith embrace 39 cases of disarticulation of the shoulder-joint in American practice. Of these 18 were fatal, and one doubtful, being a mortality of nearly 45 per cent. AMPUTATION OF THE FOOT. 1077 2. INFERIOR EXTREMITY. In performing the more iraportant amputations of the inferior extremity, the circulation is usually most effectually controlled by compression of the femoral artery, in the upper portion of its course, by means of the tourniquet; or, if the patient be very thin, by the fingers of a trustworthy assistant. In removing the foot and lower part of the leg, the compression may be applied to the popliteal artery. In describing amputation at the hip-joint, special mention will be made of the manner of preventing hemorrhage iu that opera- tion. When recourse is had to the tourniquet, the surgeon takes care, before applying the instrument, to elevate the limb, and press the blood out of the superficial veins from the heel upwards. This precaution is particularly im- portant in weak, anemic subjects, in whom the loss even of a few ounces of blood is often followed by the most serious consequences. AMPUTATION OF THE FOOT. The toes are never removed in their continuity or at the phalangeal arti- culations, inasmuch as the stump thus left would only be in the way of the patient, and thus occasion serious inconvenience, if not positive suffering, from being constantly impinged upon by the shoe or boot. It is for this reason that the operation should always be performed at the metatarso-pha- langeal joints ; and this may be readily done when all the toes are involved, as, for example, in gangrene and frost-bite, by taking the principal flap from the plantar aspect of the foot. The amputation is commenced by making an incision across the back of the limb, from one side to the other, immediately in front of the metatarso-phalangeal articulations, which, the integuments having been dissected up, are then entered with the knife, an ordinary narrow-bladed scalpel, and successively divided from above downwards, the operation being finished by carrying the instrument forwards to a level with the web of the toes, in order to obtain a sufficiently large covering from the sole of the foot. There is no necessity for cutting off the ends of the meta- tarsal bones. Any bleeding vessel that may exist being ligated, the plantar flap is stitched in place, and maintained by adhesive strips, aided by an ap- propriate bandage. When only one of the smaller toes is to be removed, the operation should be performed with oval flaps, represented in fig. 748, as in amputation of the fingers at the metacarpo-phalangeal articulation. The disjunction will be facilitated by forcibly flexing the toe. The extensor tendon should be divided above the joint. When the great toe requires removal, the operation should be performed through the continuity of the metatarsal bone, and not at the metatarso-phalangeal articulation, as in this case the large head of the me- tatarsal bone would sadly interfere with the wearing of the boot. Two incisions are made along the dorsum of the foot, commencing at an acute angle a short dis- tance in front of the internal cuneiform bone, passing round each side of the toe anteriorly to the joint, and terminating at the centre of the web which connects the big toe with the adjoining one. The soft struc- tures Seine carefully detached, the metatarsal bone s awn through in a sloping direction, including fully Amputation of the toe at its onfallof"5si length. The sesamoid bone is removed metatarsophalangeal J0lnt. 1078 SPECIAL AMPUTATIONS. along with the extensor tendon of the toe. The wound usually heals very promptly, and the cicatrice, corresponding with the dorsum of the foot, is seldom productive of inconvenience when the patient begins to walk, espe- cially if proper attention has been paid, during the operation, to the pre- servation of the integument. The appearance of the parts is well shown in fig. 749, representing the approximation of the wound by suture. Fig. 749. Fig. 750. Appearance of parts after amputation of Amputation of the great toe at its junction with the the big toe with its metatarsal bone. cuneiform bone. When the whole of the metatarsal bone requires removal, the operation is performed with a large flap, extending from a little in front of the metatarso- phalangeal joint to a few lines beyond the internal cuneiform bone. The whole process will readily be understood by a reference to fig. 750. The foot is sometimes removed at its tarso-metatarsal junction. The ope- ration, however, is seldom practised, owing to the fact that it is rare that the diseases and accidents requiring such a procedure are confined entirely to the metatarsal bones; besides, such is the manner in which these pieces are con- nected to each other, and to the tarsal bones, that it is one of unusual diffi- culty. When deemed necessary, it should be executed according to the plan originally suggested and described by Mr. Hey, of Leeds, in his Practical Observations on Surgery. The operator, taking the tubercle of the fifth metatarsal bone and the projection of the scaphoid as his guides, forms a large convex flap on the surface of the foot, by carrying his knife as far for- wards as the ball of the toes. In order to give more precision to his inci- sion, a line may previously be traced in ink across the foot, along which the knife is then passed in the transfixion; or, what is preferable, the flap is made by cutting from without inwards, and from before backwards. The latter is the method which I generally adopt, because it enables us to give the flap a rounder and smoother shape, thereby avoiding the necessity of trimming it after the operation is completed, as is usually the case when performed in the AMPUTATION OF THE FOOT. 1079 ordinary way. The dorsal flap, represented in fig. 751, is comparatively small, and is composed entirely of integument; it is slightly convex, and is Fig. 751. Hey's amputation. Fig. 752. Fig. 753. easily made with a large scalpel. The soft parts being dissected up, each joint is entered separately, the disarticulation being expedited by bending the anterior extremity of the foot forcibly backwards. In executing this step of the operation, it is important to remember the oblique shape of the fifth me- tatarsal bone, at its articulation with the cuboid, and the peculiar manner in which the head of the second metatarsal bone is locked in between its fellows, as exhibited in fig. 752, as well as the distance to which it projects behind the level of the tarso-metatarsal junc- tion. Owing to these circumstances, it is generally extremely troublesome to disengage it; and hence it is always best to leave it, by sawing through its body on a line with the other joints. The stump, after removal of the parts, in Hey's operation, is seen in the an- nexed cut, fig. 753. The plantar and dorsal arteries being secured, the flaps are carefully adjusted, and the limb is supported, in an easy and relaxed posi- tion, upon its outer surface, to coun- teract the action of the gastrocnemial muscles, which might otherwise draw the foot out of place. In caries, as well as in injury of the metatarsal, cuneiform, cuboid, and scaphoid bones, the foot may occasion- ally be removed in such a manner as to leave merely the astragalus and cal- caneum, the principal flap being ob- tained from the sole. The operation is usually known as ChoparVs amputation, but the name of Mr. Syme is also generally associated with it, that gentleman having been the means of reviv- ing it by recalling to it the attention of the profession in Great Britain and this country Of the utility of this procedure in the class of cases under consideration, there can no longer be any doubt; I have employed it several times in my own practice, and I have seen it repeatedly executed by others, and in every instance that has come within my notice, the result has been Articulations of the foot. Stump after the re- moval of the parts, in Hey's operation. 1080 SPECIAL AMPUTATIONS. most satisfactory. The sturap, although short, is extremely useful, affording an adrairable support for the limb, the person generally walking well without the assistance of a cane. In one of my cases, the individual, a young coun- tryman, was able, in less than six months after the operation, to plough and do all the usual work of a farm hand with the greatest facility and comfort. In performing the operation a short flap is made in front of the foot, by an incision extending round its dorsal surface, from one side of the member to the other, in a curvilinear direction, the convexity looking forwards, as in fig. 754. It should begin precisely midway between the outer malleolus and Fig. 754. Fig. 755. Chopart's amputation. the head of the fifth metatarsal bone, which indicates the site of the calcaneo- cuboid articulation, and terminate on the inner margin of the foot, directly opposite, at the astragalo-navicular articulation. The integument being dissected up, the blade of the knife, which should be sharp-pointed, and at least six inches in length by half an inch in width, is thrust into the two joints just men- tioned, and, being brought out below, is next carried forwards, in close contact with the bones, . as far as the ball of the toes, in order to form the inferior and main flap. The only arteries which usually require to be tied are the dorsal and two plantar. The extremity of the plantar flap should be well rounded off before it is stitched to the dorsal, and during the cure spe- cial care should be taken to keep the gastroc- nemial muscles completely relaxed, by placing the leg upon its outer surface over a pillow. From neglect of this precaution the stump is liable to be retracted, so that the cicatrice, by constantly coming in contact with the ground, is apt to ulcerate and cause severe suffering. Should such a contingency arise, the proper remedy will be the subcutaneous division of the tendo Achillis ; an operation which need never be performed in anticipation of this occurrence, since it may always be effectually avoided if the requisite care be taken during the after-treat- ment. The adjoining drawing, fig. 755, taken from life, exhibits the ordinary appearances of the stump. Stump after Chopart's amputation. AMPUTATION AT THE ANKLE. 1081 AMPUTATION AT THE ANKLE. Although amputation at the ankle-joint has long been knowrn to the pro- fession, yet the credit of popularizing it is justly due to the teachings and influence of Professor Syme, who performed it for the first time in 1842. Since then he has repeated it upwards of thirty times, and his example has now been so frequently followed by others, in America as well as in Europe, that it may be regarded as one of the established operations in surgery. Less dangerous than amputation of the leg in its continuity, it is particularly adapted to those cases in which there is caries of the posterior tarsal bones, Fig. 757. Amputation at the ankle. especially the astragalus and calcaneum, without any involvement of the ends of the tibia and fibula. When such involvement exists, except in a very slight degree, the limb should be taken off higher up, other- wise it will be difficult, if not impossible, to prevent a recur- rence of the disease. Syme's amputation—for so this operation is now generally distinguished—is performed with two flaps, one of which is taken from the front and the other from the sole of the foot, the two meeting at the outer and inner ankle. The best instrument is a large scalpel; the foot is placed at a right angle with the leg, and the circulation is controlled by means of the tourniquet applied to the popliteal artery. The ope- ration is commenced by making a perpendicular incision from the centre of one malleolus to that of the other directly across the sole of the foot, and then carrying another, of a curvilinear shape, with the convexity looking forward, over the fore part of the limb, so as to join the two points of the former at an angle of 45°. The lines of these cuts are well seen in fig. 756. The anterior flap is now carefully raised, the astragalus disarticulated, and the posterior flap dissected off frora the calcaneum, by passing the knife closely over its surfaces, as in fig. 757, in order to avoid wounding the tibial artery. The tendo Achillis being severed from its connec- tions, the operation is finished by sawing away the two malleoli and a thin slice of the tibia, just enough to include its cartilaginous incrustation. The posterior flap thus formed consisting of the thick and hardened cushion of the heel, offers an Mode of removing the calcaneura iu Syme's amputation. 1082 SPECIAL AMPUTATIONS. Fig. 758. Stump after Syme's operation. admirable covering for the exposed bones, to which it usually unites by the first intention, and which afterwards enables them to bear pressure with great facility. The only objection to it is that, unless special care is taken in its adjustment, it raay form a sac for the accumulation of matter, thus greatly retarding the cure. This, however, is generally easily prevented by the proper application of the bandage in dressing the stump at and for some tirae after the operation. Should this contin- gency, however, arise, relief raust be afforded by a small puncture through the plantar surface of the flap. The appearance of the stump, after the parts are healed, is shown in fig. 758. In performing this operation there are three points which deserve special attention. The first is not to have a redundancy of flap, which will seldom happen if they are both shaped in the manner here described; the second is not to cut any holes into the posterior flap while severing its connections with the calcaneum; and the last is not to divide the posterior tibial artery prior to its separation into its plantar branches, otherwise sloughing of the soft parts might ensue from deficient nourishment. If these precautions be ob- served, it will be difficult to make a bad stump. When the cure is com- pleted the Jimb will be frora an inch to an inch and a half shorter than natural. When, in consequence of disease, the flaps cannot be formed according to the plan now laid down, they may be taken from the sides of the limb, includ- ing as much of the integument of the heel as possible. The operation is easy enough of execution, but the cicatrice after the healing of the stump will be much in the way of the patient's Fig. 759. comfort, and may lead to the necessity of amputating the limb higher up. The operation of Mr. Syme was modified a few years ago by M. Pirogoff, of Russia, by retaining a portion of the cal- caneum, and thus imparting greater length and rotundity to the sturap. It is performed as in the ordinary disarticula- tion of the ankle, by making a curvilinear incision round the foot in front, and a perpendi- cular one under the sole, ex- tending from the fore part of one malleolus to that of the other. The anterior flap being dissected up, the knife, a short, stout bistoury or scalpel, is in- troduced into the joint, so as to divide the different ligaments, and detach the astragalus. The saw is now applied just behind the astraga- lus, and moved obliquely downwards and forwards, in order to separate the anterior portion of the calcaneum, as seen in fig. 759. The operation is completed by removing the two malleolar projections, along with a thin layer Mode of sawing the calcaneum in Pirogoff's operation. AMPUTATION OF THE LEG. 1083 of the articulating extremity of the tibia, tying the vessels, and stitching the flaps accurately 'together. The advantages of this procedure are that we obtain not only a longer stump, but one that is better adapted to bear pres- sure, that there is no danger of wounding the posterior tibial artery, and that the posterior flap is not so liable to form a pouch for the lodgment of pus. Its disadvantages are the tardiness of the cure, and the fact that the disease necessitating a resort to the knife raay recur in the retained portion of the bone. The latter objection does not, of course, apply when the operation is performed on account of injury. When the dressing is completed, the upper surface of the calcaneura is in immediate contact with the lower surface of the tibia and fibula, and, in consequence of this arrangement, the parts will neces- sarily be some time in healing, the consolidation of the contiguous bones taking place slowly, though very perfectly. In operating upon the cadaver, I have ascertained that an excellent stump may be made by bringing the wedge- shaped portion of the heel-bone up between the malleolar processes of the tibia and fibula, their cartilaginous surfaces being previously well abraded. It is worthy of consideration whether the parts, when thus treated upon the living subject, would not afford a better support for useful progression. The results of Pirogoff's amputation are altogether favorable, the mortality having thus far been very trivial. When the cure is completed, the patient is generally able to walk without the aid of a cane, the limb being not more than about half an inch shorter than in the natural state. A very long, useful, and seemly stump may sometimes be formed by remov- ing the foot with all the tarsal bones, excepting the astragalus, although such a procedure cannot be often required, inasmuch as this piece is usually dis- eased along with its fellows. The operation, denominated the subastragular amputation, is performed upon the same principles as that of Syme. After the soft parts have been dissected up, the scaphoid and calcaneum are detached from their connections with the astragalus, the bistoury[being passed between their contiguous surfaces. Proper care is, of course, taken that the plantar arteries are cut long, to prevent sloughing of the heel flap. AMPUTATION OF THE LEG. The leg should always, if possible, be amputated at its inferior third, that is, about three inches or three inches and a half from the ankle; for here, as elsewhere, the rule is to afford the patient a long stump for the more ready adaptation of an artificial limb. Moreover, statistics serve to show that the mortality after the operation when performed here is remarkably small, the danger increasing as we approach the knee. Of 106 amputations of the leg in this situation, reported by the Parisian surgeons, only 13 proved fatal. The state of the parts, however, concerned in the injury or disease requiring the operation does not often leave us room for choice, and hence we are gene- rally obliged to cut off the extremity much higher up than would otherwise be desirable. The mode of performing the amputation must necessarily vary according to the portion of the leg which is the subject of it. When the operation is performed in the inferior third of the leg, two flaps are formed from the sides of the limb, by cutting from without inwards; or, instead of this, one may be made in front, and the other behind, as depicted in fio- 760 Composed entirely of integument in front, they receive a con- siderable quantity of muscular substance behind, and should each be from two inches to two inches and a half in length. The interosseous tissues are divided on a level with the retracted flaps, and the two bones are sawn in such a manner as to sever the fibula before the tibia. Three principal arteries usually require the ligature. The edges of the wound are approxi- 1084 SPECIAL AMPUTATIONS. mated vertically, to facilitate drainage. Fig. 761 exhibits the shape of the stump as obtained from a sketch from life. Fig. 7G0. Amputation of the leg at its inferior third. The circular operation makes an excellent stump when the leg requires removal in the lower third of its length ; I have practised it in several in- stances, and in every case, save one, with the Fig. 761. most gratifying results, the persons being able to walk with great facility, with the aid of an artificial limb. In the exceptional case, the wound gaped, and the bones became necrosed some days after the operation, owing, apparently, to some defect of the constitution, which ultimately caused the death of the patient. Amputation of the leg at its superior ex- tremity should never be performed above the tubercle of the fibula, or above the attach- ments of the hamstring muscles, which are so necessary to control the moveraents of the sturap. In general the sturap should be at least three inches in length, otherwise it will hardly be able to subserve any useful pur- pose, and it would be better, in such a case, to remove the limb at the knee. Two flaps are formed in this operation; one, which ia entirely cutaneous, in front, by cutting from without inwards, and the other behind, at the expense of the muscles of the calf, by cutting from within outwards, as seen in fig. 762. The latter should not be less than four inches in length, and, in very robust subjects, may even require to be longer. The anterior flap is formed by making a semilunar incision across the front of the limb, from the inner edge of the tibia to the outer edge of the fibula; it is detached by a few strokes of the knife, and held up by an assistant. The instrument is then inserted at the external angle of the preceding cut, and brought out at the corresponding point of the opposite side, care being taken, in performing this part of the operation, not to thrust the extreraity of the knife between the two bones; an occurrence which always betrays haste and embarrassment, if not actual want of anatomical knowledge. Transfixion being effected, the knife is drawn rapidly downwards, in close Stump after amputation of the lower part of the leg. AMPUTATION OF THE LEG. 1085 contact with the posterior surface of the bones, for the distance of several inches, when it is made to cut its way out, in order to give the flap its proper Fig. 762. Fig. 763*. Amputation of the leg above its middle. degree of convexity. As soon as this has been accomplished, the flap is retracted by the assistant, the interosseous structures are divided at the re- quisite height, and the two bones are sawn in such a manner as to sever the fibula before the tibia. The principal arteries will next claim attention, and it will generally be found that three—the anterior and posterior tibial, and interosseous—will require to be tied. When the amputation is performed uncommonly high up, the popliteal may be the only vessel demanding liga- tion, especially if it happen to extend unusually low down before it separates into its terminal branches. The interosseous artery is sometimes found with difficulty, owing to the fact that the tissues in which it is embraced are cut beyond the level of the flaps. The principal arteries having been secured, the next step of the operation is to retrench the posterior flap by shaving off its redundant muscular sub- stance, so as to adapt it more smoothly and accu- rately to the exposed bones. I consider this pro- cedure as one of paramount importance to the obtainment of a good stump, and it is one which I adopted many years ago before I was aware that it had been practised by any one else. I rarely allow the flap to be more than half an inch in thickness. Any considerable nervous trunk that may exist in the flap is now divided on a level with the bones, and the operation is completed by sawing off the anterior edge of the tibia, lest, if "permitted to remain, it should interfere with the healing of the wound, or, in time, cause so much pressure as to induce ulceration in the cica- trice. The appearances of the stump, made after the above fashion, are represented in fig. 763, from one of my patients. Amputation at the middle of the leg is per- formed in the same manner as at the superior ex- _ tremity, and does not, therefore, require any special notice. It is proper, however to add that a very good stump may be formed by taking the flaps Stump after amputation of the upper part of the leg. 1086 SPECIAL AMPUTATIONS. from the sides, as in the lower operation, although I have always preferred the other method. AMPUTATION AT THE KNEE. Amputation at the knee-joint was performed by Fabricius Hildanus in 1581. In modern times it is said to have been first executed by Iloin, and, although his example was soon after followed by several of his cotempo- raries, yet the operation gradually fell into neglect, chiefly, as it would appear, because of the timidity of surgeons to penetrate into the large articulations. An attempt to revive the procedure, accompanied by a report of a number of successful cases, was made by Mons. Velpeau in 1830, but with so little effect that the subject was again forgotten, and the operation proscribed from our systematic treatises, until a few years ago. Since then much has been urged in commendation of it, and, if we may judge from the cases that have occurred in the hands of American and European sur- geons, it is reasonable to infer that it will soon come into general favor. The reasons which may be alleged in favor of this operation are, first, that the stump being longer than in amputation of the thigh, in its continuity, is more under the control of the patient, and, consequently, better able to bear the weight of the body upon an artificial limb, thus permitting progression without the aid of crutches; secondly, that, as there is no retraction of the muscles, there is less risk of exposure and exfoliation of the bone; thirdly, that the liability to pyemia is generally diminished from the fact that there is no injury inflicted upon the medullary canal; fourthly, that the wound is less than in the removal of the limb in its continuity; and finally, that the statis- tics of the operation, as furnished by Markoe, Stephen Smith, and others, display a smaller degree of mortality than amputation of the thigh. It need hardly be stated that disarticulation of the knee should never, as a matter of choice, be performed in preference to amputation of the leg in its continuity; such a procedure, involving more risk to life than the other, would not be justifiable; for, as remarked elsewhere, the nearer we approach the lower part of the trunk with the knife the greater is the mortality from its effects. There are two principal methods of performing this amputation, the rela- tive merits of which have not yet been fairly determined by statistical facts. The one consists in making a long flap in front, the other in making it behind, at the expense chiefly of the gastrocnemius muscle. Both operations are sufficiently easy, but when the surgeon has his choice he will be able, I think, to effect a raore rapid cure, as well as make a better sturap, by adopting the former method ; in either case, the healing process will be facilitated by saw- ing off the ends of the condyles. In the anterior operation, as it may be called, the knife is carried across the forepart of the leg, at least two inches and a half below the head of the tibia, in a semilunar direction, from the anterior margin of one hamstring muscle to that of the other; the flap is then carefully raised, the ligament of the patella divided, the disarticulation effected from before backwards, and the posterior short flap formed from the superior extremity of the gastroc- nemius muscle, care being taken to preserve as much of the skin as possible. The patella being retained in this operation serves to fill up the gap between the two condyles, and thus add to the rotundity of the stump. Another ad- vantage is that the line of the wound, after the approximation of the flaps, is brought into a more dependent position, thus admitting of the more ready exit of the discharges. In the posterior process, the principal covering of the bone is obtained from the muscles of the calf of the leg. The operation is commenced by drawing the knife across the centre of the patella, from one side to the other, AMPUTATION OF THE THIGH. 1087 the articulation being fully opened at the first incision. The integument is then dissected off from the patella, as high up as the superior extremity of this bone, which is then liberated from its tendon, and left adherent to the tibia. Introducing now the knife into the joint, the connecting structures are rapidly severed, and the main flap formed by carrying the instrument downwards, to a suitable distance, behind the bones. The operation is com- pleted by removing the condyles of the femur, the saw being held in such a manner as to separate a larger portion of the inner than of the outer of these prominences, so as to give the stump a perfectly horizontal direction. Or, what is preferable, because less likely to be followed by suppuration and other mischief, while the stump is equally good after the cure, the condyles are left intact, the flaps being brought in direct contact with their articulating sur- faces. After each of these operations the popliteal artery will, of course, require to be tied, and, in general, also several of its branches. In that by the pos- terior method, the ends of the ligatures, which are usually placed close together, ought to be brought out through a small aperture in the centre of the long flap ; a circumstance which will greatly expedite the adhesive pro- cess. The flaps should be stitched with the utmost nicety, and be well sup- ported by plaster and bandage. The great fault apt to be committed in both these operations is that there is usually too little integument left for covering the bone, the consequence of which is that the wound is long in healing, and that the sturap can never be well adapted to an artificial limb. The most valuable statistics of this operation are those furnished by Dr. Thomas M. Markoe, in an article on amputation of the knee-joint in the New York Journal of Medicine and Surgery, for January, 1856. Of 46 cases therein given, 29 were successful and 17 fatal, thus showing a mortality of 37 per cent. Of these cases, 18 occurred in the practice of this country, chiefly in that of the New York surgeons, with only 5 deaths. The first amputation of this kind, in America, was performed in 1824, by the late Professor Nathan Smith, of New Haven, the patient recovering without an untoward symptom. If wre compare the results of these operations with those of amputation of the thigh, it will be found, contrary to what might have been anticipated, and what, at first sight, very few would believe, that they are in favor of the former by 7 per cent. Thus, in the 46 cases of amputation at the knee there were 17 deaths, or a percentage of 37, while in 1055 cases of amputation of the thigh, performed by European and American surgeons, there were 464 deaths, or a percentage of 44. AMPUTATION OF THE THIGH. The thigh may be removed in any portion of its length; at its inferior third, at its middle, at its superior third, or at the hip-joint, according to the particular exigencies demanding the operation. The great general rule, mentioned elsewhere, of leaving as long a lever, in all cases, as possible, is still more applicable here than in the leg and arm ; experience having shown that it is extremely difficult to adapt a short stump of the thigh to an artificial limb, especially when, as not unfrequently happens, it is at the same time very bulky. The operation which I have always performed, and which, in my judgment, is decidedly the best, is that by flaps, taken from the an- terior and posterior parts of the thigh. I have seen enough of the circular method to satisfy me that it is, as a general rule, even when well executed, seriously objectionable, on the ground that it seldom affords an adequate covering for the stump. Hence it is so often followed by exfoliation of the bone tedious suppuration, and ulceration of the integuments. From all 1088 SPECIAL AMPUTATIONS. these mishaps the flap amputation is almost entirely exerapt. I will not deny that I have occasionally witnessed adrairable results from the circular operation, but that it is more liable to be followed by accidents and by future inconvenience and suffering is unquestionable, and it is for these reasons, and not because it involves any particular difficulty or skill in its execution, that it should give place to the flap method. Although the operation by the antero-posterior flap usually furnishes the best result, from the circumstance that there is less liability to retraction, yet a very excellent stump may be made by taking the covering frora the sides of the limb, or even by dividing the parts obliquely. The fact is, the surgeon has often no choice in the matter, such being the nature of the disease or injury demanding the operation. In a case of horrible deformity and ulcera- tion of the leg, from the effects of a burn, followed by permanent anchylosis of the knee-joint, which came under my observation, many years ago, in a boy five years of age, I was obliged to depend entirely upon one flap taken from the posterior surface of the thigh, and the result could not possibly have been raore satisfactory. Whenever circumstances require a departure from the ordinary rules of procedure, the educated surgeon will have no difficulty in adapting his skill to the exigencies of each particular case. The lowest point at which amputation of the thigh can conveniently be performed is about four inches above the centre of the knee. The anterior Fig. 764. Amputation of the thigh. flap should always be made first, as the posterior includes the femoral artery. The soft parts being forcibly raised with the thumb and fingers, applied to the opposite side of the limb, the knife is entered about three inches above the superior extremity of the patella, and, transfixion being completed, is drawn downwards close along the anterior surface of the femur, cutting its way out at the point just mentioned. The flap being now carefully retracted, the instrument is re-introduced into the wound at its upper edge, behind the bone, so as to fashion the posterior flap, which should be somewhat longer than the anterior, otherwise there will be danger of insufficiency of covering. This flap is now also held back, when, the knife being passed rapidly round the bone, on a level with the retracted structures, so as to divide any muscular fibres that may have escaped it in the previous stages of the operation, the AMPUTATION OF THE THIGH. 1089 borite is sawn off in the usual manner. The femoral artery with several of its branches will require ligation, and the principal nervous trunks should be retrenched before approximating the flaps. The stump left by the flap operation, as here described, is a very pretty one, and could not possibly be more serviceable. The drawing fig. 765 is frora life. The operation now described raay Fig. 765. occasionally be advantageously exe- cuted, according to Yermale's me- thod, by lateral flaps, of which the outer one should always be formed first. The transfixion is effected at the same height of the limb as in the preceding case, that is; about four inches above the upper extremity of the patella, the knife being inserted at the centre of the thigh in front, and pushed out at a corresponding point in the ham, whence it is carried downwards and outwards nearly as far as the external condyle. The in- ner flap is formed in the same man- ner, except that the instrument is kept in closer contact with the bone, lest the femoral artery be split. In other respects, the operation is to be conducted in the same manner as in the antero-posterior flap procedure. In the middle and upper third of stump after amputation of the thigh. the thigh, the method by anterior and posterior flaps deserves a decided preference over that by lateral flaps. The great advantages which it possesses over the latter are that the muscles are more evenly divided, and that, consequently, there is greater probability of obtaining a smooth and useful stump for sustaining the weight of the body upon an artificial limb. The different steps of the operation are similar to those which characterize amputation in the lower third of the thigh, and hence there is no necessity whatever for any formal description of it, as they will be readily comprehended by what precedes. Amputation of the thigh by the rectangular method of Mr. Teale is de- scribed at page 545 of the first volume, and does not, therefore, require any special notice here. No statistics, on an extended scale, of amputation of the thigh in its conti- nuity, after gunshot injuries, have yet been published. The operation was performed, according to Mr. Macleod, by the English surgeons in the Cri- mea, in the upper third of the thigh 39 times, with a fatal result in 34. All the cases, excepting one, were primary, and that one perished. Amputation of the middle third of the limb was performed in 65 cases, of which 38 died. Of these cases, 56 were primary, with 31 deaths, or a mortality of 55.3 per cent.; 9 cases were operated upon at a later period, and of these 7, or 77.7 per cent, died. Removal of the limb in its lower third was effected in 60 cases, of which 46 were primary, with a mortality of 50 per cent., and 14 secondary, with a mortality of 71.4 per cent. The result of the experience of the surgeons in the Schleswig-Holstein campaigns, in these amputations, was equally unfavorable. Much of this frightful mortality is, doubtless, justly attributable to the excessive shock sustained by the crushing effects of the injury necessitating vol. n.—69 1090 SPECIAL AMPUTATIONS. the amputation, to the violence inflicted upon the patients during their trans- portation frora the field of battle, and to the influence of the vitiated air of military hospitals; all tending to produce a state of exhaustion incompatible with repair, and promotive of the occurrence of erysipelas, osteophlebitis, pyemia, and typhoid fever. AMPUTATION AT THE HIP. Amputation at the hip-joint may become necessary both on account of disease and accident; but the operation is so formidable a one, and so fraught with danger, that it should never be performed unless the patient has no other chance of escape. The great risk which attends it is due to the loss of blood, suppuration, erysipelas, and pyemia. The hemorrhage, however, will not, in any case, be likely to be profuse, if proper care be taken to compress the arteries during the formation of the flaps, and if the operation be performed, as it always should be, in twenty-five or thirty seconds, good and trustworthy assistants being at hand to anticipate the surgeon's wishes and facilitate his moveraents. Under highly favorable circumstances, much of the enormous wound may unite by. the first intention ; but, in general, more or less suppu- ration takes place, and in some instances the discharge is so copious as to lead to fatal exhaustion. The greatest danger of all, however, is the occur- rence of pyemia, or secondary abscess, especially in amputation at the hip- joint in consequence of injury, as a compound fracture, or a gunshot wound. The shock of the operation must formerly have been very violent, and been of itself often sufficient to cause death within a short time after its perform- ance ; now, however, that we can avail ourselves of the use of anaesthetic agents, no special risk is to be apprehended frora that source. This operation, for a long time regarded as impracticable, and until lately alternately praised and censured, was first practised by Lacroix, in the case of a child, fourteen years of age, laboring under gangrene from the use of ergot. It may be performed in a great variety of ways, with two of which the surgeon should be familiar, as the circumstances of the case may leave him no opportunity for choice. These are the lateral and the antero-poste- rior flap methods, of which the first deserves a decided preference, from the fact that it admits of more ready drainage during the healing of the stump. In the lateral amputation, the external incisions should always be made first, though this is not so important when there are skilful assistants, of whom there should be at least four; one for administering chloroform, two for retracting the flaps and compressing the arteries, and one for holding the limb. If these matters be properly attended to, the operation is a compara- tively easy one, and may often be executed in an almost incredibly short time, and with the loss of hardly a few ounces of blood. The buttock befhg brought well over the edge of the table, the thigh pretty widely separated and everted, and the femoral artery compressed over the brim of the pelvis, the knife, which should be upwards of a foot in length, is entered, supposing the ope- ration is performed on the left limb, immediately below the tuberosity of the ischium, and made to issue at a point midway between the anterior superior spinous process of the ilium and the great trochanter. The external flap is now formed by cutting downwards and outwards, in close contact with the bone, for at least four inches, especially if the subject be at all muscular. An assistant is ready to seize and retract the flap the moment it is fashioned, as well as to compress the orifices of the bleeding vessels. Reinserting the knife into the upper angle of the wound, it is rapidly pushed down, ahong the inner surface of the bone, so as to form a large flap in that direction, to compensate for the small one on the outside. The assistant having charge of the femoral artery in the groin now grasps the divided vessel, at the sarae AMPUTATION AT THE HIP. 1091 time lifting up the flap. The next step of the operation is the disarticula- tion, which *is readily effected by opening the upper and inner part of the joint, and then swiftly carrying the knife round the head of the bone, pre- viously rendered prominent by depressing the knee. The arteries are now secured, first the femoral, and successively any others that may require the ligature, the assistants maintaining the compression until each vessel is ready to be tied. The antero-posterior amputation at the hip-joint, delineated in fig. 766, is to be conducted upon the same general principles as the lateral, the only difference being the man- ner in which the flaps are Fig. 766. made. Great care must also be taken to hold the scrotum out of the way. It will be most convenient to make the anterior flap first; this, when the ope- ration is performed on the left side, is done by en- tering the knife on the outside of the hip, mid- way between the anterior superior spinous process of the ilium and the great trochanter, carrying it across the neck of the femur, and pushing it out at the Centre Of the thigh, Amputation at the hip-joint. immediately below the pelvis. The flap, which should be about four inches in length, is thep formed in the usual manner; the joint is opened at its upper and inner part, as in the preceding case; and, the disarticulation being effected, the posterior flap is fashioned by cutting along the back part of the bone. Great stress, is very properly laid by all surgeons upon the prevention of hemorrhage in this amputation. With this view not a few recommend, as a preliminary step, the ligation of the femoral artery, while the majority believe that compression of that vessel, as it passes over the pubic bone will, in general, be quite sufficient. In a case of amputation at the hip-joint, by Professor Pancoast, at the Pennsylvania Hospital, in June, 1860, this object was very effectually attained by compression of the abdominal aorta by means of a tourniquet, encircling the body at the umbilicus. The patient, a man, aged thirty-eight years, bore the operation well under ether, breathing with perfect ease, and losing hardly any blood, the application of the instrument being rendered the more satisfactory in consequence of the previous evacua- tion of the bowels. The operation, performed on account of a large enceph- aloid tumor of the upper part of the thigh, has been completely successful, there having been no return of the disease when the man was last heard from, in December, 1861. The appearances of the stump and the line of the cicatrice, in the antero- posterior operation, are well displayed in-the annexed sketch, fig. 7B7, from a daguerreotype kindly sent to me by Professor J. F. May, of Washington City. His patient, who was a man forty years of age, had been laboring under caries of the bead, neck, and shaft of the thigh-bone, attended with great enlargeraent of the limb. The operation was performed within thirty seconds, with a loss of blood hardly amounting to eight ounces. A rapid 1092 SPECIAL AMPUTATIONS. and complete recovery followed. The likeness here represented was taken nearly two years and a half after the operation. ' Fig. 767. Stump after amputation at the hip-joint. After both of these operations, during the first four or five hours, the flaps should be supported simply by a few adhesive strips, and kept constantly wet with cold water. At the end of this time, when all oozing will probably have ceased, they should be approximated by numerous points of the inter- rupted suture, plaster, and bandage, care being taken to interpose a small tent at the inferior angle of the wound, for the purposes of drainage, which raust always necessarily be considerable after such an extensive operation. When the patient is very robust, I should regard it as good practice to remove a large portion of the muscular mass composing the internal flap, under the conviction that the procedure, by insuring the more rapid healing of the huge wound, would greatly diminish the risk of pyemia and other accidents. From the various statistics of amputations at the hip-joint, it may be in- ferred that the results are, as a general rule, much more favorable when the operation is done for the reraoval of disease than for the relief of accident; depending, probably, upon the fact that, in the former case, the system is more inured to suffering, and, consequently, more tolerant of the effects of the operation, while, in the other, the change is too sudden and severe to enable it to bear up under its exhausting influence. Mr. Erichsen, availing himself of the labors of Dr. Stephen Smith, and also of those of other writers, has given the results of 126 cases of this operation, of which 76 proved fatal. Of 47 cases in which it was per- formed for injuries, 35 died. According to Mr. Macleod, of the ten cases that occurred in the Crimea, not one recovered. A successful case of ampu- tation of the hip-joint has recently been reported by Dr. J..M. Warren, as the first of the kind that has ever taken place in Boston. It was performed on account of osteo-sarcoma of the femur, the patient being a lad sixteen years of age. Mons. Lagouest, who served with the French army in the Crimea, has made an effort to collect all the cases in which this operation has been per- formed on account of gunshot injury. In 30 of these the operation was immediate, and all perished; in 11 it was mediate, 8 dying, and 3 recovering; and in 3 it was ulterior, 2 proving fatal, and 1 unsuccessful. "Of the first category, some died during the operation itself, others soon after they had been carried to their beds, and all within ten days, except two patients men- tioned by Larrey, one of whom lived twenty-one and the other thirty days." All experience seems to show that amputation of this joint, if performed AMPUTATION AT THE HIP. 1093 immediately after a severe injury, whether gunshot, compound fracture, or compound dislocation, or wound of any kind, proves alraost invariably fatal. Hence the practical conclusion is to postpone the operation always to the latest possible period; certainly, if practicable, until the establishment of suppurative action, and until the system has had time pretty thoroughly to react. In compound fractures of the thigh, involving the head or neck of that bone and the integrity of the femoral vessels, the case will, of course, not admit, of much delay, and the patient must, therefore, run his chance. If the vessels are intact, resection of the upper part of the femur should take the place of ablation of the limb at the joint. If the soft parts are extensively injured and the bone violently shattered, but its head sound, the most judi- cious practice is to amputate the limb at or near the trochanters, leaving the extremity of the bone in the acetabulum. The happy results of consecutive amputation at^the hip-joint in gunshot lesions are well exemplified in the practice of Dr. Roux, of Toulon, who performed the operation six times upon soldiers wounded during the war in Italy, with four recoveries and two deaths. * , INDEX. Abdomen, abscesses within the cavity of, ii. 710 dropsy of, ii. 716 gunshot injuries of, ii. 710 tapping of, ii. 716 • wounds of, ii. 709 walls of, abscess of, ii. 711 buffer accidents to, ii. 709 cystic tumor of, ii. 715 fatty tumor of, ii. 714 fibro-plastic tumor of, ii. 714 tumors of, ii. 714 Abdominal aorta, ligation of, i. 816 for iliac aneurism, i. 792 organs, wounds of, ii. 689 suture in, ii. 700 treatment of, ii. 700 Ablation of the tongue, ii. 553 Abscess, acute, of the tonsils, ii. 571 treatment of, ii. 571 chronic, i. 152 of the tonsils, ii. 576 cold, i. 152 congestive, i. 151 counter-opening in, i. 148 diffuse, i. 149 hepatic, ii. 711 iliac, ii. 713 lumbar, ii. 262 metastatic, i. 161 multiple, i. 1&6 of antrum of Highmore, ii. 500 of anus, ii. 652 of bladder, ii. 726 of bone, i. 860 treatment of, i. 862 of brain, ii. 211 of cornea, ii. 299 of frontal sinus, ii. 409 of groin, ii. 1035 of ham, ii. 1031 of hip-joint, ii. 67 of jaw, lower, ii. 510 upper, ii. 500 of lachrymal sac, ii. 358 of mammary gland, ii. 961, 981 of membrane of the tympanum, ii. 392 of nates, ii. 1032 of neck, ii. 479 of orbit, ii. 373 of palate, ii. 568 of parotid gland, ii. 556 of pharynx, ii. 578 of prostate gland, ii. 829 of spermatic cord, ii. 865 of strangulated hernia, ii. 618 of testicle, ii. 845 Abscess— of thyroid gland, ii. 472 of tonsils, ii. 571, 576 of vagina, ii. 935 of vertebrae, ii. 263. parietal, ii. 711 phlegmonous, i. 141 of anus, ii. 653 of pharynx, ii. 578 psoas, ii. 262 renal, ii. 713 scrofulous, i. 151 of anus, ii. 652 of bone, i. 860 of pharynx, ii. 578 spinal, ii. 263, 865 valve-like opening in, i. 155 splenic, ii. 713 syphilitic, i. 414 urethral, ii. 823 within the abdominal walls, ii. 711 cavity of the abdomen, ii. 711 Abscesses, i. 140. See Abscess. Accumulations of wax in the auditory tube, ii. 383 Acetabulum, fracture of, i. 986 Acid, chromic, as an escharotic, i. 501 nitrate of mercury, as an escharotic, i. 501 Acids, mineral, as escharotics, i. 501 Aconite, as an antiphlogistic, i. 99 Acromion process, fracture of, i. 974 Actual cautery, as an escharotic, i. 499 as a counter-irritant, i. 497 as a styptic, i. 707 Acupressure, i. 701 Acupuncturation as a counter-irritant, i. 498 for the cure of hernia, ii. 596 Adenitis, acute, i 659 treatment of, i. 660 cervical, i. 414 chronic, i. 660 treatment of, 661 suppurative, i. 660 treatment of, i. 660 syphilitic, of the neck, i. 414 treatment of, i. 415 Adenoid tumors of the mammary gland, ii. 970 Adhesion, primary, i. 309 secondary, i. 309 Adhesions, morbid, from burns, ii. 993 of lids, ii. 365 of tongue, ii. 553 Adhesive strips in fractures, i. 935 Adipose tumors, i. 234 JEtal changes of the teeth, ii. 523 Air, collections of, in the uterus, ii. 908 1096 INDEX. Air— escape of, into pleural cavity, ii. 482 introduction of, into veins, i. 837 cause of death in, i. 838 local phenomena of, i. 839 symptoms of, i. 837 treatment of, i. 840 Air-passages, cauterization of, ii. 441 diseases and injuries of, ii. 431 examination of, ii. 431 foreign bodies in the, ii. 444 Albugo, ii. 302 Allarton's operation of lithotomy, ii. 800 Alopecia, syphilitic, i. 413 Amaurosis, ii. 338 Ammoniaco-magnesian calculus, ii. 766 Amputating knives, i. 548 Amputations, i. 533 after-treatment of. i. 546 at the ankle, ii. 1081 Pirogoff's, ii. 1082 Syme's, ii. 1081 at the elbow, ii. 1073 at the hip, ii. 1090 at the knee, ii. 1086 at the shoulder, ii. 1075 at the wrist, ii. 1072 circular, i. 541 circumstances demanding, i. 534 congestion of lungs from, i. 559 considerations in regard to, i. 533 constitutional effects of, i. 557 dressings after, i. 550 flap, i. 543 for acute mortification, i. 176 for affections of the bones, i. 539 for affections of the joints, i. 539 for aneurism, i. 539 for articular wounds, ii. 23 for caries, i. 871 for chronic mortification, i. 182 for complicated dislocations, ii. 109 for complicated fractures, i. 944, 946 for dislocations, i. 537 for fractures, i. 537 for injuries, i. 535 for malformations, i. 540 for morbid growths, i. 538 for mortification, i. 534 for tetanus, i. 540 for traumatic mortification, i. 177 for traumatic tetanus, i. 672 for tumors, i. 538 for ulcers, i. 540 for wounds, i. 340, 536 hectic irritation from, i. 560 manner of dividing the bone in, i. 542 methods of, i. 540 mortality after, i. 563 natural, in acute mortification, i. 173 of the arm, ii. 1074 of the fingers, ii. 1069 of the foot, ii. 1077 Chopart's, ii. 1079 Hey's, ii. 1078 of the forearm, ii. 1072 of the hand, ii. 1069 of the index-finger, ii. 1070 of the inferior extremity, ii. 1077 of the leg, ii. 1083 of the little finger, ii. 1071 of the metatarsal bone of great toe, ii. 1 of the penis, ii. 873 of the thigh, ii. 1087 I Amputations— of the thumb, ii. 1070 of the toes, ii. 1077 oval, i. 544 primary, i. 538 affections of the stump after, i. 552 pyemia from, i. 559 I rectangular, i. 545 retention of urine from, i. 558 secondary, i. 538 affections of the stump after, i 555 shock from, i. 557 special, ii. 1069 statistics of, i. 566 synchronous, i. 551 tetanus from, i. 560 j time for, i. 537 traumatic fever from, i. 558 Amussat's operation for artificial anus, ii. 686 Amylene, i. 585 Anaesthesia, local, i. 585 freeiing mixtures, i. 585 Anesthetics, i. 575 age no bar to exhibition of, i. 581 amylene i. 585 chloroform, i. 579 ether, i. 584 inadmissibility of, in certain cases, i. 57P kerosoline, i. 585 mortality from, i. 578 I opium, i. 576 I Anal fistule, ii. 653 specula, ii. 647 tumors, ii. 674 j Anastomotic aneurism, i. 842 of bone, i. 903 Anchylosis, ii. 80 extra-articular or spurious, ii. 86 I from contraction of muscles, ii. 86 from inodular tissue, ii. 86 from formation of bone, ii. 86 from morbid growths, ii. 86 from paralysis, ii. 87 ' treatment of, ii. 87 intra-articular or true, ii. 81 apparatus for, ii. 83 Barton's operation for, ii. 85 causes of, ii. 81 pathology of, ii. 81 treatment of, ii. 82 of elbow, ii. 81 of knee, ii. 1027 of lower jaw, ii. 516 instruments for, ii. 517 Anel's probe, ii. 35r syringe, ii. 357 Aneurism, i. 723 amputation in, i. 539 anastomotic, i. 842 arterio-venous, i. 761 Brasdor's operation for, i. 747 by anastomosis, i. 842 causes of, i. 727 death from, by inflammation of sac, i. 742 by injurious compression, i. 741 by sudden rupture of sac, i. 741 from mortification, i. 742 from suppuration of sac, i. 74 diagnosis of, i. 736 dissecting, i. 722 effects and termination of, i. 738 3 false, i. 759 varieties of, i. 761 fibrinous concretions of, i. 731 INDEX. Aneurism— general medical treatment of, i. 759 Hunterian operation for, i. 744 after-treatment of, i. 746 statistics of, i. 747 internal, Valsalva's treatment of, i. 757 needle, i. 698 nomenclature of, i. 729 of bone, i. 903 of the arteries of the leg, i. 801 of the foot, i. 801 of the hand, i. 792 of the axillary artery, i. 785 diagnosis of, L 786 mortality of, i. 787 symptoms of, i. 785 treatment of, i. 786 of the brachial artery, i. 791 of the common carotid, i. 772 . diagnosis of, i. 774 effects of, i. 777 frequency of, i. 772 mortality of, i. 776 progress of, i. 775 symptoms of, i. 773 treatment of, i. 775 of the common iliac, i. 792 ligature of abdominal aorta for, i. 792 of the external carotid, i. 779 of the external iliac, i. 794 frequency of, i. 795 treatment of, i. 795 of the femoral artery, i. 796 diagnosis of, i. 796 frequency of, i. .796 mortality of, i. 798 progress of, i. 797 treatment of, i. 797 of the gluteal artery, i. 794 ; ii. 1032 of the innominate artery, i. 766 diagnosis of, i. 769 effects of, on neighboring structures, i. 767 frequency of, i. 766 prognosis of, i. 769 statistics of treatment of, i. 770 symptoms of, i. 766 treatment of, i. 770 of the internal carotid, i. 780 of the internal iliac, i. 794 of the ophthalmic artery, i. 779 of the popliteal artery, i. 798 diagnosis of, i. 799 frequency of, i. 798 mortality of, i. 800 progress of, i. 800 treatment of, i. 800 of the radial artery, i. 791 of the sciatic artery, i. 794 of the subclavian artery, i. 781 diagnosis of, i. 781 frequency of, i. 781 progress of, i. 782 statistics of treatment of, i. 783 treatment of, i. 782 of the thoracic aorta, i. 763 of the ulnar artery, i. 791 of the vertebral artery, i. 780 sacciform, i. 729 spontaneous cure of, i. 739 symptoms of, i. 734 treatment of, i. 743 by compression, i. 749 by deligation, i. 744 Aneurism, treatment of— by forcible flexion, i. 754 by galvano-puncture, i. 754 by injection, i. 755 by Valsalva's method, i. 751 true, causes of, i. 724 causes of greater frequency in certain arteries, i. 725 diagnosis of, i. 736 effects of, i. 738 influence of age in formation of, i. 728 of sex in formation of, i. 728 locality of, i. 726 terminations of, i. 738 varieties of, i. 729 tubular, i. 732 varicose, i. 761 treatment of, i. 761 varieties of, i. 729 Wardrop's operation for, i. 748 Aneurismal diathesis, i. 727 tumors of bone, i. 902 varix, i. 762 ; ii. 1026 treatment of, i. 763 ; ii. 1026 Angeioleucitis, i. 657 after venesection, i. 490 treatment of, i. 658 , Ankle,' amputation at the, ii. 1081 dislocation of, ii. 163 Ankle-joint, excision of the, ii. 1058 tuberculosis of the, ii. 61 Anodynes, as antiphlogistics, i. 102 in the treatment of strangulated hernia, ii. 609 Anterior tibial muscle, division of tendon of, ii. 1020 Anteversion of the uterus, ii. 900 Anthrax, i. 605- Antimonio-saline mixture, i. 103 Antiphlogistic, aconite as an, i. 99 anodynes as, i. 102 blisters as local, i. 114 cathartics as, i. 92' cold and warm applications as local, i. 107 compression as a local, i. 112 counter-irritants as local, i. 113 destructives as local, i. 113 diaphoretics as, i. 100 digitalis as an, i. 99 diuretics as, i. 101 emetics as, i. 98 general bleeding as an, i. 88 iodine as a local, i. Ill ipecacuanha as an, i. 99 local bleeding as an, i. 106 mercury as an, i. 94 nauseants as, i. 98 nitrate of silver as an, i. 110 poultices as local, i. 109 regimen, i. 104 rest and position as local, i. 105 suppurants as local, i. 115 tartar emetic as an, i. 99 veratrum viride as an, i. 100 vesicants as, i. 114 Antrum of Highmore, abscess of, ii. 500 affections of, ii. 499 dropsy of, ii. 501 encephaloid of, ii. 503 ■ inflammation of, ii. 499 perforation of, ii. 500 * polyp of, ii. 502 scirrhus of, ii. 505 vascular tumors of, ii. 502 1098 INDEX. Antrum of Highmore— wounds of, ii. 499 Anus, abscess of, ii. 652 artificial, ii. 643 Amussat's operation for, ii. 686 Dupuytren's enterotome for, ii. 645 formation of, ii. 685 Gross's enterotome for, ii. 645 Littre's operation for, ii. 686 radical cure of, ii. 644 results of operation for, ii. 687 treatment of, ii. 644 fissure of, ii. 658 fistule of, ii. 653 injuries of, ii. 647 treatment of, ii. 647 imperforate, ii. 683 prolapse of, ii. 661 sacs of the, ii. 660 ulceration of, ii. 658 wounds of, ii. 649 and nates, pruritus of, ii. 681 and rectum, cancer of, ii. 677 examination of, ii. 647 malformations of, ii. 682 neuralgia of, ii. 680 stricture of, ii. 676 Aorta, abdominal, ligation of, i. 816 for iliac aneurism, i. 792 thoracic, aneurism of, i. 763 Aphonia, a symptom of foreign bodies in the larynx, ii. 449 Aponeurosis, palmar, contraction of, ii. 993 plantar, section of, ii. 1020 Aponeuroses, affections of, i. 655 Aponeurositis, i. 655 Apoplexy of the mammary gland, ii. 967 ' Arm, amputation of, ii. 1T)74 artificial, i. 563 Armsby's operation for the radical cure of reducible hernia, ii. 599 Arrow wounds, i. 321 * Arterial hemorrhage, i. 689 secondary, i. 708 tumor, i. 843 hemorrhage of, i. 844 origin of, i. 843 structure of, i. 842 treatment of, i. 845 by amputation, i. 849 by compression, i. 849 by escharotics, i. 845 by excision, i. 845 by heated needles, i. 848 by injections into, i. 848 by ligation of main artery lead- ing to, i. 847 by seton, i. 849 by starvation, i. 847 by strangulation, i. 846 by vaccination, i. 849 varix, i. 723 wounds, i. 689 Arteries, acute inflammation of, i. 717 aneurism of, i. 723. See also Artery. atheromatous degeneration of, i. 720 changes in after division, i. 691 after ligation, i. 699 chronic affections of, i. 719 collateral ciwulation of, i. 692 common carotid, ligation of both, i. 805 compression of, i. 702 diseases of, i. 717 Arteries— earthy degeneration of, i. 719 fatty degeneration of. i. 720 fibrous transformation of, i. 719 gangrene of, i. 718 hemorrhage of, i. 689 inflammation of, i. 717 ^ injuries of, i. 689 intra-parietal separation of coats of, i. 722 ligation of, i. 695. See also Ligation. of foot, aneurism of, i. 801 injuries of, i. 801 of hand, wounds of, i. 792 treatment-of, i. 792 of leg, aneurism of, i. 801 of stump, varicose enlargement of, i. 557 operations on, i. 802 plantar, wounds of, i. 801 softening of, i. 718 subcutaneous hemorrhage of, i. 709 suppuration of, i. 718 thyroid, ligation of, for goitre, ii. 476 torsion of, i. 707 ulceration of, i. 721 varicose enlargement of, i. 723 wounds of, i. 689 Arteriotomy, i. 492 Arterio-venous aneurism, i. 761 Arteritis, acute, i. 717 symptoms of, i. 718 treatment of, i. 719 ulceration after, i. 721 Artery, abdominal aorta, ligation of, i. 816 anterior tibial, ligation of, i. 826 axillary, aneurism of, i. 785 ligation of, i. 813 brachial, aneurism of, i. 791 injury of, after venesection, i. 491 ligation of, i. 814 carotid, common, aneurism of, i. 772 ligation of, i. 803 statistics of ligation of, i. 805 carotid, external, aneurism of, i. 779 ligation of, i. 806 carotid, internal, aneurism of, i. 780 circumflex, ligation of, i. 822 epigastric, ligation of, i. 822 facial, ligation of, i. 808 femoral, aneurism of, i. 796 compression of, i. 824 ligation of, for elephantiasis, i 630 common, ligation of, i. 823 deep, ligation of, i. 825 forceps, spring, i. 694 gluteal, aneurism of, i. 794 ligation of, i. 820 iliac, common, aneurism of, i. 792 ligation of. i. 817 external, aneurism of, i. 794 ligation of, i. 821 internal, aneurism of, i. 794 ligation of, i. 819 innominate, aneurism of, i. 766 ligation of, i. 802 | internal maxillary, ligation of, i. 809 lingual, ligation of, i. 807 occipital, ligation of, i. 808 ophthalmic, aneurism of, i. 779 peroneal, ligation of, i. 829 popliteal, aneurism of, i. 798 ligation of, i. 826 posterior tibial, ligation of, i. 827 radial, aneurism of, i. 791 INDEX. 1099 Artery, radial— ligation of, i. 816 sciatic, aneurism of, i. 794 ligation of, i. 821 subclavian, aneurism of, i. 781 ligation of, i. 809 on its tracheal aspect, i. 789 superior thyroid, ligation of, i. 807 temporal, ligation of, i. 808 ulnar, aneurism of, i. 791 ligation of, i. 816 vertebral, aneurism of, i. 780 ligation of, i. 809 Arthritis, rheumatic, chronic, ii. 77 cause of, ii. 77 .4 symptoms of, ii. 77 treatment of, ii. 79 Articular concretions, ii. 35 wounds, ii. 19 Artificial anus, ii. 643 formation of an, ii. 685 Artificial arm, i. 563 limbs, i. 560 pupil, ii. 313 Ascarides in the rectum, ii. 651 Ascites, ii. 716 tapping for, ii. 716 Assistants in operations, i. 513 Astragalus, dislocations of, ii. 161 excision of, ii. 1056 Atheromatous degeneration of arteries, i. 720 Atrophy, i. 218 from cessation of function, i. 218 from deficiency of nutritive matter, i. 219 from deficient supply of blood, i. 219 from inflammation, i. 219 from loss of nervous influence, i. 218 of bone, i. 893 of muscles, i. 645 of the mammary gland, ii. 966 of the prostate gland, ii. 836 of the testicle, ii. 850 of thefuterus, ii. 905 treatment of, i. 220 Auditory tube, affections of, ii. 380 accumulations of wax in, ii. 383 erysipelas of the, ii. 388 foreign bodies in, ii. 381 fungous growths of, ii. 386 hemorrhage of, ii. 388 herpetic affections of, ii. 388 inflammation of, ii. 387 of ceruminous glands of, ii. 388 malformations of, ii. 380 malignant tumors of, ii. 387 occlusion of, ii. 380 polypous growths of, ii. 384 Avulsion, i. 480 Axilla, affections of, ii. 1002 Axillary artery, aneurism of, i. 785 ligation of, i. 813 dislocation of the humerus, ii. 147 Balanitis, ii. 884 treatment of, ii. 891 Baldness, syphilitic, i. 413 Bandage as a therapeutic agent, i._ 507 for the eyes after operations, ii. 282 for the knee, ii. 1038 perineal, ii. 960 plaster of Paris, in treatment of fractures, i. 939 . ... starch, in treatment of fractures, i. 9.i9 Bandages for the breast, ii. 979 Batldages— for the fingers, ii. 1004 for the inferior extremity, ii. 1038 for the superior extremity, ii. 1004 for the testicle, ii. 852 Bandaging, i. 503 gangrene from, i. 506 of the head, ii. 245 Barton's operation for anchylosis, ii. 85 Bed sores, i. 609 treatment of, i. 609 Beer's cornea knife, ii. 330 Bellocq's canula, ii. 414 Bending of the bones, i. 947 Bibron's antidote to poison of rattlesnake, i. 352 Biceps tendon, dislocations of, ii. 158 Bichloride of mercury as an escharotic, i. 500 in tertiary syphilis, i. 434 Bifid spine, ii. 265 Bilateral operation of lithotomy, ii. 797 statistics of, ii. 798 Bistouries, i. 473 Bladder, abscess of, ii. 726 symptoms of, ii. 726 treatment of, ii. 727 affections of, ii. 720 catarrh of, ii. 730 cause of, ii. 730 diagnosis of, ii. 730 morbid alterations produced by, ii. 731 prognosis of, ii. 731 symptoms of, ii. 730 treatment of, ii. 732 chronic inflammation of, ii. 730 encephaloid of, ii. 754 symptoms of, ii. 754 erectile tumor of, ii. 752, case of, ii. 752 extrophy of, ii. 720 autoplastic operations for, ii. 722 Simon's mode of operating for, ii. 721 fatty tumor of, ii. 752 female, inversion and prolapse of, ii. 942 foreign bodies in, ii. 804 instruments for removal of, ii. 804 fungous tumor of, ii. 752 gangrene of, ii. 727 symptoms of, ii. 727 treatment of, ii. 727 hemorrhage of, ii. 750 causes of, ii. 750 diagnosis of, ii. 751 symptoms of, ii. 751 treatment of, ii. 751 hernia of, ii. 755 diagnosis of, ii. 756 treatment of, ii. 756 heterologous formations of, ii. 753 hypertrophy of muscular walls of, ii. 731 inflammation of, ii. 724 symptoms of, ii. 725 treatment of, ii. 726 inversion and prolapse of, through female urethra, ii. 942 irritability of, ii. 734 causes of, ii. 734 pathology of, ii. 734 prognosis of, ii. 735 symptoms of, ii. 734 treatment of, ii. 735 laceration of, ii. 724 symptoms of, ii. 724 1100 INDEX. Bladder, laceration of— treatment of, ii. 724 malformations of, ii. 720 neuralgia of, ii. 736 treatment of, ii. 737 paralysis of, ii. 737 hysterical, ii. 739 senile, ii. 737 treatment of, ii. 738 polyps of, ii. 752 puncture of, ii. 745 inter-pubic method of, ii. 747 supra-pubic method of, ii. 746 through perineum, ii. 746 through rectum, ii. 746 sacculated, ii. 731 scirrhus of, ii. 754 stone in. See Stone in the bladder. suppuration of, ii. 726 prognosis of, ii. 727 symptoms of, ii. 727 treatment of, ii. 727 sympathies and irritations of, i. 44 tubercular disease of, ii. 755 ulceration of, ii. 728 causes of, ii. 728 diagnosis of, ii. 728 symptoms of, ii. 728 treatment of, ii. 729 wounds of, ii. 722 gunshot, ii. 723 symptoms of, ii. 722 treatment of, ii. 723 Blear eye, ii. 366 Blennorrhagia, ii. 878 Blisters as local antiphlogistics, i. 114 permanent, as counter-irritants,, i. 495 Blood, abstraction of, i. 483 changes of, in inflammation, i. 76 effusion of, in chambers of eye, ii. 317 in sub-conjunctival areolar tissue, ii. 296 extravasation of, a cause of compression of the brain, ii. 206 transfusion of, i. 492 Bloodletting, i. 483 from the jugular vein, ii. 480 general, in inflammation, i. 88 local, in inflammation, i. 106 Bloodvessels, gunshot wounds of, ii. 984 Bloody tumor of the neck, ii. 479 Bodies, foreign. See Foreign bodies. movable, within the joints, ii. 35 Boil, i. 603 Bone, abscess of, i. 860 absorption of, after fracture, i. 952 affections of, after amputation, i. 555 amputation in, i. 539 aneurismal tumors of, i. 902 atrophy of, i. 893 bending of, i. 947 cancer of, i. 912 caries of, i. 862 colloid tumors of, i. 911 cystic disease of, i. 905 diastasis of, i. 950 diseases of, i. 851 effects of aneurism upon, i. 738 encephaloid of, i. 910 excision of, i. 570 exfoliation of, i. 875 exostoses of, i. 896 fibro-cartilaginous tumors of, i. 901 fissure of, i. 950 Bone— fractures of, i. 917 fragility of, i. 890 granulation of, i. 870 gunshot wounds of, ii. 986 hematoid tumors of, i. 904 hydatic tumors of, i. 907 hypertrophy of, i. 894 inflammation of, i. 856 injuries of, i. 851 melanosis of, i. 912 mortification of, i. 871 myeloid tumors of, i. 909 necrosis of, i. 871 neuralgia of, i. 915 of stump, necrosis of, i. 555 osteomyelitis of, i. 854 rachitis of, i. 886 reparation of, i. 875 scirrhus of, i. 911 , separation of, at epiphyses, i. 950 sequester of, i. 875 sero-cystic tumors of, i. 904 softening of, i. 882 suppuration of, i. 860 syphilitic hypertrophy of, i. 427 caries of, i. 426 necrosis of, i. 426 tertiary syphilis of, i. 425 tubercular disease of, i. 913 tumors, benign, of, i^896 malignant, of, i.*10 ulceration of, i. 862 Bone instruments, i. 881 nippers, i. 549 Bones and their appendages, diseases, &c. of, i. 851 Bones, carpal, excision of, ii. 1044 cuboid, excision of, ii. 1057 metacarpal, excision of, ii. 1045 of the foot, excision of, ii. 1053 of the forearm, excision of, ii. 1046 of the hand, excision of, ii. 101* • of the leg, excision of, ii. 1064 pelvic, excision of, ii. 1044 tarsal, excision of, ii. 1054 Bonnet's operation for the radical cure of hernia, ii. 596 Bougie, i. 459 Bowels, internal strangulation of, ii. 643 sympathies and irritations of, i. 42 See also Intestines. Bozeman's suture, ii. 948 Brachial artery, aneurism of, i. 791 injury of, after venesection, i. 491 ligation of, i. 814 Brachio-cephalic artery, ligation of, i. 802 Brain, abscess of, ii. 211 and its membranes, wounds of, ii. 232 concussion of, ii. 197 compression of, ii. 204 from depressed bone, ii. 210 from effusion of pus, ii. 211 from extravasated blood, ii. 206 from foreign bodies, ii. 211 contusions of, ii. 231 fungus of, ii. 236 hernia of, ii. 236 inflammation of, ii. 202 recovery after bad injuries of, ii. 235 sympathies and irritations of, i. 39 traumatic inflammation of, ii. 202 Brain-bruise, ii. 231 Brasdor's operation for aneurism, i. 747 INDEX. 1101 Breast. See Mammary gland. Bridle stricture of the urethra, ii. 812 Brittleness of callus, i. 961 Bronchial tubes, foreign bodies in, ii. 453 Bronchocele.' See Goitre. Bronchotomy, ii. 463 Bubo, i. 401, ii. 882 diagnosis of, i. 404 from direct absorption, i. 402 gangrenous, i. 404 gonorrhoea!, ii.^882 indolent, i. 403 phagedenic, i. 404 scrofulous, i. 404 suppurative, i. 403 treatment of, i. 405 ulcerated, i. 403 varieties of, i. 403 Bubon d'embUe, i. 402 Buchanan's operation of lithotomy, ii. 799 Buck's knife for oedema of the glottis, ii. 435 Buffer accidents, ii. 709 Bunions, ii. 1009 treatment of, ii. 1009 Burns, i. 610 and scalds, treatment of, i. 613 carbonate of lead in, i. 615 cicatrices of, ii. 993 morbid adhesions of, ii. 993 subnitrate of bismuth in, i. 615 Burses, affections of, i. 651 dropsy of, i. 653 fibroid bodies of, i. 654 inflammation of, i. 652 of the ham, ii. 1031 of stump, i. 557 synovial, of neck, ii. 478 Bursitis, acute, i. 652 chronic, i. 653 Button-hole operation for stricture of urethra, ii. 821 Button suture, ii. 948 Butyroid tumors of the mammary gland, ii. 969 Cesarean section, ii. 920 Calcaneum, dislocation of, ii. 161 excision of, ii. 1055 fractures of, i. 1008 Calcaneus, ii. 1015 Calcareous concretions of the mammary gland, ii. 966 deposit in the urine, ii. 760 transformation, i. 214 tumor, i. 245 Calculous concretions of the prepuce, ii. 877 formations of sublingual gland, ii. 562 Calculi, nasal, ii. 417 of the scrotum, ii. 862 prostatic, ii. 841 treatment of, ii. 842 salivary, ii. 561 urinary. See Stone in bladder. Callus, i. 930 brittleness of, i. 961 diseases of, i- 959 exuberance of, i. 960 permanent, i. 931 softening of, i. 961 temporary, i. 930 Canals, lachrymal, affections of, ii. 356 inflammation of, ii. 356 obstruction of, ii. 356 stricture of, ii. 357 Cancer, i. 256 cells, i. 257, 261, 266, 270 chimney-sweeper's, ii. 864 colloid, i. 271 differential diagnosis of, i. 276 encephaloid, i. 264 epithelial, i. 268 juice, i. 260 melanotic, i. 273 of bone, i. 910 treatment of, i. 912 of the anus and rectum, ii. 677 bougie in treatment of, ii. 680 excision of, ii. 680 treatment of, ii. 679 of the gums, ii. 535 of the lip, ii. 538 of the lymphatic ganglions, i. 662 of the navel, ii. 719 of the oesophagus, ii. 582 of the penis, ii. 872 of the pharynx, ii. 582 of the scrotum, ii. 864 of the spermatic cord, ii. 870 of the sublingual gland, ii. 562 of the tongue, ii. 550 of the uterus, ii.*916 scirrhous, i. 258 Cancroid disease of the gums, ii. 535 Canula, Bellocq's, ii. 414 double, i. 481 for polyps of nose, ii. 423 Caoutchouc, i. 300 Capillaries, affections of, i. 842 arterial tumors of, i. 842 state of, in inflammation, i. 80 venous tumors of, i. 849 Carbonate of lead in treatment of burns, i. 615 Carbuncle, i. 605 Carbuncular inflammation of the lips, ii. 536 Carcinoma, i. 256. See Cancer. Caries, i. 862 amputation for, i. 871 causes of, i. 863 diagnosis of, i. 866 excision of bone for, i. 890 morbid anatomy of, i. 863 of the foot, ii. 1053 of the jaw, ii. 510 of the orbit, ii. 373 of the skull, ii. 226 of the teeth, ii. 524 of the vertebrae. See Tuberculosis of spine. operations for, i. 868 prognosis of, i. 867 scraping the bone for, i. 869 symptoms of, i. 864 syphilitic, i. 426 treatment of, i. 867 Carotid, common, aneurism of, i. 772 ligation of, i. 803 external, aneurism'of, i. 779 ligation of, i. 806 internal, aneurism of, i. 780 primitive, ligation of, for innominatal aneurism, i. 771 Carpal bones, dislocation of, ii. 134 excision of, ii. 1044 fractures of, i. 988 Carpo-metacarpal joints, dislocations of, ii. 133 Carte's compressor, i. 751 Cartilages, interarticular, tt. 35 semilunar, dislocations of, ii. 173 1102 INDEX. Cartilaginous degeneration of the testicle, ii. 847 tumors, i. 243 Castration, ii. 851 Cataract, ii. 317 after-treatment of, ii. 332 anterior division of lens through cornea in, ii. 325 catoptric test in diagnosis of, ii. 323 ■ causes of, ii. 318 diagnosis of, from glaucoma and amauro- sis, ii. 321 displacement of the lens in, ii. 327 division of, ii. 325 and couching the lens in, ii. 328 drilling the lens in, ii. 327 extraction of the lens in, ii. 329 by inferior section, ii. 330 by exterior and inferior section, ii. 330 by superior section, ii. 330 false, ii. 323 horizontal displacement of the lens in, ii. 328 lamellar, ii. 323 operations for, ii. 324 pathology of, ii. 320 posterior division of the lens in, ii. 325 reclination of the lens in, ii. 329 symptoms of, ii. 321 treatment of, ii. 323 varieties of, ii. 317 Catarrh of the bladder, ii. 730 treatment of, ii. 732 Cathartics as antiphlogistics, i. 92 Catheter, female, ii. 943 mode of retaining in the bladder, ii. 745 Sims's, ii. 955 Catheters, ii. 743 Catheterism, ii. 743 in the female, ii. 943 of the Eustachian tube, ii. 402 Catlin, i. 549 Catoptric test for cataract, ii. 322 Cauliflower excrescence of the uterus, ii. 918 Caustic potassa as an escharotic, i. 500 Cauterization of the air passages, ii. 441 in treatment of stricture of the urethra, . ii. 819 of the prostate gland, ii. 835 Cautery, actual, as an escharotic, i. 499 as a counter-irritant, i. 496 as a hemostatic, i. 707 galvanic, i. 499 in coxalgia, ii. 75 Cavity of the tympanum, inflammation of, ii. 394 Cellular cysticerce in the eye, ii. 297, 317 transformation, i. 213 Cellulo-adipose tissue, diseases of, i. 589 Ceruminous glands, inflammation of, ii. 389 Cervical adenitis, i. 414 Chalk-stones, ii. 39 Chambers of the eye, diseases of, ii. 316 dropsy of, ii. 316 effusion of blood into, ii. 317 hydatid of, ii. 317 Chancre, i. 383 complications of, i. 398 constitutional treatment of, i. 394 diagnosis of, i. 390 diphtheritic, i. 389 escharotics in, i. 392 gangrene as a consequence of, i. 388 Chancre— Hunterian, i. 384 indolent, i. 396 indurated, i. 386 in the female, i. 400 local treatment of, i. 392 mercurials in, i. 397 of the urethra, i 399 treatment of, i. 399 phagedenic, i. 388 treatment of, i. 395 serpiginous, i. 389 sloughing, i. 388 soft, i. 386 treatment of, i. 391 varieties of, i. 384 Changes, textural, i. 210 Charbon, i. 367 Cheiloplasty, ii. 546 Chemosis, ii. 285 Chest, accumulations in, ii. 485 fistulous wounds of, ii. 486 injuries and diseases of, ii. 481 tapping of, ii. 492 wounds of, ii. 481 hemorrhage from, ii. 487 Chigoe in the skin, i. 640 Chilblain, i. 621 Chimney-sweeper's cancer, ii. 864 Chlorate of potassa as an antimercurial, i. 97 Chloride of zinc as an escharotic, i. 500 Chloroform, i. 579 advantages of, over ether, i. 577 effects of, i. 582 fatality from, i. 577 mixture of, with ether, i. 584 mode of administration, i. 580 poisoning by, i. 583 precautions in administering, i. 580 quantity required, i. 581 treatment of poisoning of, i. 583 Chopart's amputation, ii. 1079 Chordee, ii. 881 treatment of, ii. 890 Choroid, diseases of, ii. 339 inflammation of, ii. 339 Choroiditis, acute, ii. 339 diagnosis of, from iritis, ii. 340 treatment of, ii. 341 Chromic acid as an escharotic, i. 501 Chronic rheumatic arthritis, ii. 77 Cicatrices, diseases of, i. 209 of burns and scalds, ii. 993 structure of, i. 208 Cicatrization in inflammation, i. 207 Circulation, collateral, i. 710 Circumcision, ii. 875 Circumflex iliac artery, ligation of, i. 822 Circular, amputation, i. 541 Clap. See Gonorrhoea. Clamp of Hoey, i. 751 Clavicle, dislocations of, ii. 119 excision of, ii. 1040 fractures of, i. 969 Cleft palate, ii. 563 instruments for, ii. 565 obturator for, ii. 564 operation for, ii. 565 Clitoris, hypertrophy of, ii. 942 Cloacae, i. 876 Clot, external, i. 691 internal, i. 691 Clove-hitch knot, ii. 130 Club-foot, ii. 1011 INDEX. 1103 Club-foot- apparatus for, ii. 1017 etiology of, ii. 1012 tenotomy in, ii. 1018 treatment of, ii. 1016 varieties of, ii. 1013 calcaneus, ii. 1015 equinus, ii. 1014 valgus, ii. 1014 varus, ii. 1013 Club-hand, ii. 994 treatment of, ii. 994 Coccyx, dislocation of, ii. 128 fractures of, i. 988 Cold as a hemostatic, i. 706 as a local antiphlogistic, i. 107 Collapse of the lungs, ii. 484 treatment of, ii. 485 nervous, i. 371 Collateral circulation, i. 710 Collodion, i. 300 Colloid cancer, i. 271 of bone, i. 911 of the breast, ii. 977 of the testicle, ii. 850 Coloboma iridis, ii. 308 Complicated dislocations, ii. 107 fractures, i. 942 Compress, graduated, plan of, i. 705 Compression as a hemostatic, i. 702 by graduated compress, i. 705 permanent, i. 704 temporary, i. 702 as a local antiphlogistic, i. 112 digital, in treatment of aneurism, i. 752 indirect, i. 705 instrumental, in treatment of aneurism, i. 749 in treatment of cancer, i. 279 lateral, i. 705 mechanical, a cause of contraction, i. 219 of the brain, ii. 204 from depression of bone, ii. 210 treatment of, ii. 210 from effusion of pus, ii. 211 treatment of, ii. 212 from extravasation of blood, ii. 206 treatment of, ii. 208 from foreign bodies, ii. 211 symptoms of, ii. 205 of the femoral artery, i. 824 of the nerves, i. 666 treatment of stricture of urethra by, ii. 818 Compressor, alternating, of Carte, i. 752 of Gibbons, i. 751 of Gross, i. 548 Concretions, calcareous, of the mammary gland, ii. 966 earthy, of duct of Steno, ii. 559 intestinal, ii. 651 osseous, ii. 35 Concussion and compression of the brain, dif- ferential diagnosis of, ii. 205 of the brain, ii. 197 consequences of, ii. 202 symptoms of, ii. 199 treatment of, ii. 200 of nerves, i. 666 of the spinal cord, ii. 247 Condylomata, i. 430 treatment of, i. 439 Congenital dislocations, ii. 113 of elbow, ii. 146 of hip, ii. 192 Congenital dislocations— of lower jaw, ii. 119 of shoulder, ii. 157 of wrist, ii. 136 hydrocele, ii. 857 irregularities of the testicle, ii. 843 malformations, i. 225 occlusion of the Eustachian tube, ii. 401 scrotal hernia, ii. 630 vices of the iris, ii. 308 Congestion, i. 50 active, i. 50 of lungs, after amputation, i. 559 passive, i. 52 Conjunctiva, cellular cysticerce of, ii. 297 diseases of, ii. 283 dryness of, ii. 295 * effusion of blood beneath the, ii. 296 encanthis, ii. 296 fatty tumor beneath the, ii. 297 iprceps, ii. 330 gonorrhoeal inflammation of, ii. 288 granular inflammation of, ii. 286 hypertrophy of, ii. 294 , oedema beneath, ii. 297 pterygium, ii. 294 purulent inflammation of, ii. 287 simple inflammation of, ii. 283 tumefaction of, ii. 285 xeroma, ii. 295 Conjunctival ophthalmia, ii. 283 Conjunctivitis, ii. 283 gonorrhoeal, ii. 288 granular, ii. 286 or infancy, ii. 287 purulent, ii. 287 treatment of various forms of, ii. 289 Continued suture, i. 303 in wounded intestine, ii. 699 • Contraction, i. 220 from effusive inflammation, i. 221 from mechanical compression, i. 221 of the fingers, ii. 992 of the muscles, i. 645 Contused wounds, i. 315 Contusions, i. 315 of the brain, ii. 231 of the face, ii. 270 of the nerves, i. 666 of the scalp, ii. 195 of the spermatic cord, ii. 865 secondary effects of, i. 343 Coracoid process, fracture of, i. 976 Cord, spermatic, affections of, ii. 865 hydrocele of, ii. 865 spinal. See Spinal cord. Cornea, abscess of, ii. 299 diseases and injuries of, ii. 297 exterior and inferior section of, ii. 330 fatty degeneration of, ii. 304 foreign bodies in, ii. 297 gangrene of, ii. 300 inferior section of, ii. 330 inflammation of, ii. 298 knife, ii. 330 curved, ii. 331 opacity of, ii. 302 staphyloma of, ii. 303 superior section of, ii. 330 ulceration of, ii. 300 wounds of, ii. 297 Corneitis, ii. 298 Corns, ii. 1007 treatment of, ii. 1008 1104 • INDEX. Coronoid process, fractures of, i. 992 reparation of, i. 993 Corrigan's button cautery, i. 495 Costal cartilages, fractures of, i. 981 Counter-irritation, i. 494 by actual cautery, i. 499 by acupuncturation, i. 498 by dry cupping, i. 495 by electro-puncturation, i. 498 by galvano-cauterization, i. 499 by issue, i. 496 by permanent blisters, i. 495 by rubefacients, i. 494 by the knife, i. 496 by the moxa, i. 497 by the seton, i. 495 £>j the Vienna paste, i. 496 Counter-irritants as local antiphlogistics, i. 113 Coxalgia, ii. 63 Cranial bones, diseases of the, ii. 225 Cranium. See Skull. Crepitation, i. 924 Cretaceous degeneration of the lymphatic gan- glions„i. 663 Croup, false membrane of, ii. 433 tracheotomy in, ii. 433 Crushing, i. 481 forceps, ii. 790 of the prostate gland, ii. 835 for stone in the bladder, ii. 777 in the female, ii. 803 Crypts, mucous, of the vulva, inflammation of, ii. 938 Crystalline lens, diseases and injuries^f, ii. 317 capsule of, diseases and injuries of, ii. 317 cataract, ii. 317 dislocation of, ii. 333 Cuboid bone, dislocation of, ii. 160 excision of, ii. 1057 Cuneiform bone of foot, dislocation of, ii. 160 excision of, ii. 1055 of wrist, dislocations of, ii. 134 Cupping, i. 485 dry, as a counter-irritant, i. 495 Curette, ii. 384 Curvature, lateral, of the spine, ii. 250 treatment of, ii. 254 myotomy in, ii. 256 of the septum of the nose, ii. 416 posterior, of the spine, ii. 259 Cutaneous transformation, i. 213 Cutting pliers, i. 549 Cystic calculus, ii. 767 disease of bone, i. 905 of the breast, ii. 967 of the jaw, ii. 513 of the prostate gland, ii. 840 of the testicle, ii. 848 of the tongue, ii. 552 sarcoma, ii. 848 tumors, i. 247 of the abdominal walls, ii. 715 of muscles, i. 647 of the navel, ii. 718 of the scrotum, ii. 861 of the submaxillary gland, ii. 561 of the thyroid gland, ii. 473 . of the vagina, ii. 937 Cysticerce, cellular, in the anterior chamber of eye, ii. 317 of the subconjunctival areolar tissue, ii. 297 Cystitis, ii. 724, 882 Cystitis— symptoms of, ii. 725 treatment of, ii. 726 Cystocele, ii. 755 Cystorrhoea, ii. 730 Cysts, serous, of the tonsils, ii. 575 Dacryadenitis, ii. 354 Dacryocystitis, acute, ii. 358 chronic, ii. 359 Dead bodies, poisoned wounds from, i. 362 Deafness, artificial drum for, ii. 400 from disease of the tympanum and other causes, ii. 399 from occlusion of the Eustachian tube, ii. 401 nervous, ii. 396 Decapitation of bone, i. 570 Deficiency of the fingers, ii. 990 Deformity of fingers, jaw, &c. See Fingers, Jaw, Ac. Degeneration, atheromatous, of arteries, i. 720 cartilaginous, of the testicle, ii. 847 earthy, of arteries, i. 719 fatty, of arteries, i. 720 fibrous, of the testicle, ii. 847 of the cornea, ii. 304 Delirium, traumatic, i. 376 treatment of, i. 378 Delitescence in inflammation, i. 121 Dental periostitis, ii. 527 Dentition, ii. 521 Deposits, urinary. See Urinary deposits. j Depression, apparent, of cranial bones, ii. 223 of bone, a cause of compression of brain, ii. 210 of cataract, ii. 327 of cranial bones, without fracture, ii. 222 Dermoplasty, i. 617 Destructives, as local antiphlogistics, i. 113 Diagnosis, general, i. 446 Diaphragm, wounds of, ii. 497 Diaphragmatic hernia, ii. 642 Diaphoretics, as antiphlogistics, i. 100 Diastasis, i. 950 Diathesis, aneurismal, i. 727 hemorrhagic, i. 714 strumous, i. 291 Diffused hydrocele of the cord, ii. 865 Digital compression in treatment of aneurism, i. 752 phalanges, excision of, ii. 1044 Diphtheritic chancre, i. 389 inflammation of the pharynx, ii. 578 Diphtheritis of the pharynx, ii. 578 of the tongue, ii. 549 Diploe, injuries of, ii. 226 Direct inguinal hernia, ii. 626 Discharges, examination of, in general diag- nosis, i. 463 Discoloration, inflammatory, i. 64 Dislocations, ii. 89 after-treatment of, ii. 106 amputation in, i. 537, ii. 109 barriers to reduction of, ii. 99 causes of, ii. 92 chronic or neglected, ii. 110 period of reduction of, ii. Ill reduction of, ii. 112 complicated, ii. 107 congenital, ii 113 causes of, ii. 114 morbid anatomy of. ii. 114 treatment of, ii. 115 INDEX. 1105 Dislocations— diagnosis of, ii. 96 divisions of, ii. 89 general considerations on, ii. 89 mode of reduction of, ii. 101 morbid anatomy of, ii. 98 of the ankle, ii. 163 backwards, ii. 164 compound, ii. 166 forwards, ii. 164 inwards, ii. 164 outwards, ii. 164 upwards, ii. 166 of the astragalus, ii. 161 backwards, ii. 161 ' forwards, ii. 162 of the calcaneum, ii. 161 of the carpal bones, ii. 134 of the carpo-metacarpal joints, ii. 133 of the clavicle, ii. 119 congenital, ii. 123 double, ii. 123 infra-acromial, ii. 122 infra-coracoid, ii. 123 sternal extremity, ii. 119 backwards, ii. 120 forwards, ii. 119 upwards, ii. 121 scapular extremity, ii. 121 downwards, ii. 122 forwards and downwards, ii. 123 upwards, ii. 121 of the crystalline lens, ii. 333 of the cuboid, ii. 160 of the cuneiform bone, ii. 134, 160 of the elbow, ii. 139 compound, ii. 146 of the fingers, ii. 132 of the foot, ii. 159 of the great toe, ii. 159 of the hand, ii. 129 of the hip-joint, ii. 174 anomalous, ii. 187 ■chronic, ii. 189 congenital, ii. 191 diagnosis of, ii. 177 general diagnosis of, ii. 183 iliac, ii. 176 pubic, ii. 182 reduction of, ii. 177—184 sciatic, ii. 180 thyroid, ii. 181 of the humerus. See Dislocations of the shoulder, and Dislocations of the elbow. of the hyoid bone, ii. 116 of the knee, ii. 170 backwards, ii. 172 compound, ii. 173 congenital, ii. 173 forwards, ii. 170 inwards, ii. 172 outwards,-ii. 172 of the lower jaw, ii. 116 congenita], ii- 119 reduction of, ii. 117 subluxation of, ii. 118 of the metacarpo-phalangeal joints, ii. 132 backwards, ii. 132 forwards, ii. 132 reduction of, ii. 132 of the metatarsal bones, ii. 159 of the os magnum, ii. 134 of the patella, ii. 167 * VOL. II.—70 Dislocations of the patella.— inwards, ii. 168 outwards, ii. 168 upwards, ii. 169 vertically, ii. 168 of the pelvis, ii. 127 at symphysis pubis, ii. 128 coccyx, ii. 128 sacro-iliac, ii. 127 of the pisiform bone, ii. 134 of the radio-ulnar joints, ii. 136 inferior radio-ulnar joint, ii. 136 backwards, ii. 137 forwards, ii. 137 superior radio-ulnar joint, ii. 137 backwards, ii. 138 forwards, ii. 137 outwards, ii. 138 subluxation of, ii. 139 of the radius and ulna, at the elbow, ii. 139 backwards, ii. 140 congenital, ii. 146 forwards, ii. 143 in opposite directions, ii. 146 inwards, ii. 144 lateral, ii. 144 outwards, ii. 145 of the ribs, ii. 126 of the scaphoid, ii. 160 of the semilunar cartilages, ii. 173 of the shoulder, ii. 146 accidents of, ii. 156 after-treatment of, ii. 156 anomalous, ii. 154 axillary, ii. 147 . chronic, ii. 157 complicated, ii. 154 congenital, ii. 157 doubles ii- 155 general diagnosis of, ii. 153 nomenclature of, ii. 147 reduction of, ii. 152 scapular, ii 151 subacromial, ii. 158 subcoracoid, ii. 158 thoracic, ii. 151 of the spine, ii. 124 atlo-axoid, ii. 126 occipito-atloid, ii. 126 reduction of, ii. 125 of the tarsal joints, ii. 160 of the teeth, ii. 523 of the tendon of the biceps, ii. 158 of the tendons, i. 649 of the thigh. See Dislocations of the hip- joint. of the thumb, ii. 129 reduction of, ii. 130 of the tibia. See Dislocations of the knee. of the tibio-fibular joints, ii. 167 of the trapezio-metacarpal joint, ii. 131 backwards, ii. 131 inwards, ii. 132 of the ulna, ii. 145 of the wrist, ii. 13$ backwards, ii. 135 congenital, ii. 136 forwards, ii. 135 prognosis of, ii. 99 resection in, ii. 109 seat of, ii. 91 simple, ii. 93 symptoms of, ii. 93 treatment of, ii. 99 1106 Displacement of the ball of the eye, ii. 28 of the crystalline lens, ii. 327 Dissecting aneurism, i. 722 Dissection wounds, i. 362 Diuretics, as antiphlogistics, i. 101 Dorsal artery, ligation of, i. 827 Double vagina, ii. 935 Drainage tubes, i. 502 Dressings, i. 501 appliances used in, i. 501 drainage tubes, i. 502 dressing-forceps, i. 501 lint, i. 502 perforated muslin, i. 502 poultices, i. 503 scissors, i. 501 sponges, i. 501 spongio-piline, i. 502 unguents, i. <603 of ulcers, i. 203 of wounds, i. 299 Erilling the lens for cataract, ii. 327 ropsy, abdominal, ii. 716 extra-peritoneal, ii. 717 of the antrum of Highmore, ii. 501 treatment of, ii. 502 of the eye, ii. 316 of the joints, ii. 32 injections in, ii. 35 subcutaneous puncture in, ii. 34 treatment of, ii. 33 of the kidneys, ii. 703 of the synovial burses, i. 653 of the upper jaw, ii. 501 of the uterus, ii. 909 Duct, nasal. See Dacryocystitis. of Steno, affections of, ii. 558 earthy concretions of, ii. 559 fistule of, ii. 559 . Dysmenorrhoea, ii. 906 treatment of, ii. 907 Ear, diseases of, ii. 375 external, affections of the, ii. 379 chalky concretions of the, ii. 380 fibrous tumor of the, ii. 375 malformations of the, ii. 379 wounds of the, ii. 374 internal, diseases of the, ii. 396 instruments for the, ii. 376 mode of examining the, ii. 376 specula for examining the, ii. 376 syringes for the, ii. 378 Earache, ii. 407 Earthy concretions of the duct of Steno, 559 of the scrotum, ii. 862 Earthy degeneration of arteries, i. 719 of lymphatic ganglions, i. 663 Ecchymosis, i. 317 Echinococci, i, 251 Ecraseur, i. 481 in the treatment of internal piles, ii. 672 Ectropion, ii. 364 operations for, ii^364 Eiloid tumor, i. 635 Elbow, affections of, ii. 1000 amputations at the, ii. 1073 anchylosis of, ii. 81 complicated fracture of the, ii. 1003 dislocations of the, ii. 139 excision of the, ii. 1048 miner's, i. 653 tuberculosis of, ii. 59 NDEX. Electro-puncturation, as a Oounter-irritant, i. 498 Electro-puncture in hydrocele, ii. 857 Elephantiasis, i. 627 amputation in, i. 631 ligation of the principal artery in, i. 630 morbid anatomy of, i. 726 of the scrotum, ii. 862 treatment of, ii. 863 symptoms of, i. 628 treatment of, i. 630 Elevator for extracting teeth, ii. 532 Elkoplasty, i. 204 Emetics, as antiphlogistics, i. 98 Emphysema of the trunk, ii. 489 Emprosthotonos, i. 667 Empyema, ii. 490 Encanthis, ii. 296 Encephaloid, i. 264 hematoid, i. 267 of bone, i. 910 of the antrum of Highmore, ii. 503 of the bladder, ii. 754 of the eye,ii. 351 of the frontal sinus, ji. 410 of the groin, ii. 10.37 of the lower jaw, ii. 515 of the lymphatic ganglions, i. 662 of the mammary gland, ii. 975 of the muscles, i. 647 of the nose, ii. 424 of the nymphae, ii. 941 of the ovary, ii. 925 of the prostate gland, ii. 840 of the scrotum, ii. 864 of the testicle, ii. 850 of the upper jaw, ii. 503 of the uterus, ii. 917 Enchondroma, i. 243, 901 Encysted calculi, ii. 771 hydrocele, ii. 858 of the cord, ii. 865 congenital, ii. 865 diffused, ii. 866 tumors, i. 247 of the lachrymal gland, ii. 355 of the lip, ii. 539 of the neck, ii. 478 .of the nymphae, ii. 941 of the spermatic cord, ii. 870 of the upper jaw, ii. 506 Endosteitis, i. &54 treatment of, i. 856 Enemata, administration of, ii.648 ii. i Enlargement, chronic, of the lachrymal gland, ii. 356 inflammatory, of the gums, ii. 534 of the prepuce, ii. 876 varicose, of arteries, i. 723 Enterocele, ii. 592 Entero-epiplocele, ii. 693 Enterotome, Dupuytren's, ii. 645 Gross's, ii. 645 Enterotomy, ii. 708 Entropion, ii. 363 operation for, ii. 363 Enucleation, i. 480 Epicanthus, ii. 368 Epigastric artery, ligation of, i. 822 Epilepsy, trephining in, ii 230 Epiplocele, ii. 592 Episiorraphy, ii. 901 Epispadias, ii. 805 Epistaxis, ii. 412^ INDEX. 1107 Epithelioma, i. 268 of the face, ii. 273 of the lip, ii. 540 Epulis, ii. 512 Equinia, i. 359 Equiflus, ii. 1015 Erectile tumors, i. 846 of the bladder, ii. 752 of the tongue, ii. 551 Erections, morbid, of the penis, ii. 871 Ergot, a cause of chronic gangrene, i. 179 Ergotism, i. 179 Erysipelas, i. 589 causes of, i. 591 constitutional treatment of, i. 596 contagiousness of, i. 591 diagnosis of, i. 595 epidemic, i. 590, 594 erratic, i. 593 local treatment of, i. 599 cedematous, i. 593 of the auditory tube,- ii. 388 of the vulva, ii. 938 pathology of, i. 595 phlegmonous, i. 593 prognosis of, i. 596 • simple, i. 593 symptoms of, i. 594 varieties of, i. 592 Erythema, syphilitic, i. 415 Escharotics, i. 499 acid nitrate of mercury, i. 501 actual cautery, i. 499 bichloride of mercury, i. 500 caustic potaslh, i. 500 chloride of zinc, i. 500 chromic acid, i. 501 Manec's paste, i. 500 mineral acids, i. 501 Vienna paste, i. 500 Ether, inhalation of, i. 584 mixture of, with chloroform, i. 584 Eustachian tube, catheterism of, ii. 402 congenital occlusion of, ii. 401 diseases of, ii. 400 inflammation of, ii. 401 mechanical obstruction of, ii. 401 stricture of, ii. 401 ulceration of, ii. 401 Eversion of the lids, ii. 364 of the mucous membrane of the lip, ii. 540 Examination of the anus and rectum, ii. 647 of different organs a means of general diagnosis, i. 448 of discharges a means of general diagnosis, i. 463 of the patient, i. 446 Excision in caries, i. 890 of the bones and joints, i. 570, ii. 1040 dressing in, i. 574 incisions in, i. 573 instruments for, i. 571 position of the patient in, i. 573 removal of bone in, i. 574 sources of danger after, i. 574 of the ankle-joint, ii. 1058 of the astragalus, ii- 1066 of the bones of the foot, ii. 1053 of the forearm, ii. 1046 ' of the hand, ii. 1044 of the inferior extremity, ii. 1053 of the leg, ii. 1064 of the superior extremity, ii. 1044 Excision of the bones— of the trunk, ii. 1040 of the breast, ii. 978 of the calcaneum, ii. 1055 of the carpal bones, ii. 1044 of the clavicle, ii. 1040 of the cuboid bone, ii. 1057 of the cuneiform bone of foot, ii. 1055 of the digital phalanges, ii. 1044 of the elbow-joint, ii. 1048 of the fibula, ii. 1064 of the great trochanter, ii. 10G8 of the hip-joint, ii. 1065 of the humerus, ii. 1051 of the knee-joint, ii. 1059 ' of the lower jaw, ii. 518 of the metacarpal bones, ii. 1045 of the navicular bones, ii. 1057 of the olecranon, ii. 1048 of the patella, ii. 1064 of the pelvic bones, ii. 1044 of the prostate gland, ii. 835 of the radius, ii. 1046 of the ribs, ii. 1042 of the scapula, ii. 1041 of the shoulder-joint, ii. 1051 of the sternum, ii. 1043 of the tarsal bones, ii. 1054 of the tonsils, ii. 574 of the ulna, ii. 1046 of the upper jaw, ii. 506 of the uvula, ii. 577 of the wrist-joint, ii. 1045 • Excrescences, vascular, of the female urethra, ii. 942 wart-like, of the tongue, ii. 552 warty, of the prepuee, ii. 874 within the vulva, ii. 938 Exfoliation, i. 875 Exostosis, i. 896 of the great toe, ii. 1011 of the lower jaw, ii. 512 of the skull, ii. 225 of the teeth, ii. 527 of the upper jaw, ii. 505 treatment of, i. 900 Exploring needle, i. 460 4 Expulsion, spontaneous, of foreign bodies from the windpipe, ii. 454 Exsection of bone, i. 570 Exstrophy of the bladder, ii. 720 autoplastic operations for, ii. 722 Simon's mode of operating for, ii. 722 External ear, affections of, ii. 379 characters, as means of diagnosis, i. 455 piles, ii. 665 Extirpation of the globe of the eye, ii. 354 of the lachrymal gland, ii. 356 of the parotid gland, ii. 557 of the submaxillary gland, ii. 560 of the thyroid gland, ii. 477 of the tongue, ii. 553 Extra-articular anchylosis, ii. 86 capsular fracture of neck of femur, i. 1053 Extraction of calculi through the urethra, ii. 775 of cataract, ii. 329 of the teeth, ii. 529 of urinary calculi, difficulties in, ii. 789 Extra-peritoneal dropsy, ii. 717 Extravasation of blood after venesection, i. 4S'J of fecal matter into the peritoneal cavity, ii. 694 * | Extremities, affections of, ii. 983 1108 INDEX. Extremities— gunshot wounds of, ii. 983 onyxitis, ii. 989 Exuberant callus, i. 960 Exudation, fibrinous, i. 125 Eye, ball of, displacement of, ii. 282 bandage for, after operations, ii. 282 chambers of, diseases of, ii. 316 diseases and injuries of, ii. 275 encephaloid of, ii. 351 extirpation of globe of, ii. 354 foreign bodies in the, ii. 280 lachrymal apparatus, diseases and injuries of, ii. 35.4 malignant diseases of, ii. 350 melanosis of, ii. 353 m mode of examining the, ii. 275 neuralgia of, ii. 348 ocular inspection of, ii. 278 ophthalmoscope in examinations of, ii. 275 strumous diseases of, ii. 341 sympathies and irritations of, i. 45 syphilis of, i. 422 Eyebrows, wounds of, ii. 362 Eyelashes, inversion of, ii. 365 Face, injuries and diseases of, ii. 269 Facial artery, ligation of, i. 808 False cataract, ii. 323 membrane of croup, ii. 433 passages of the urethra, ii. 826 Farcy, i. 359 FaTty degeneration of arteries, i. 720 of the cornea, ii. 304 transformation, i. 214 of muscles, i. 644 tumors, i. 234 of the abdominal walls, ii. 714 of the bladder, ii. 752 of the lids, ii. 363 of the scrotum, ii. 862 of the spermatic cord, ii. 869 of the subconjunctival areolar tissue, ii. 297 of the testicle, ii. 848 Fauces, wounds of, ii. 563 Fecal matter, extravasation of, into the peri- toneal cavity, ii. 694 Feces, hardened, obstructing the rectum, ii. 651 Felon, ii. 995 Female genital organs, diseases and injuries of, ii. 896 Femoral artery, aneurism of, i. 796 compression of, i. 824 ligation of, i. 823 deep, ligation of, i. 825 hernia, ii. 631 Femur, dislocations of, at hip, ii. 174 fractures of, i. 1025 Fenestrated speculum, ii. 648 Fever, hectic, in inflammation, i. 163 inflammatory, i. 75 irritative, in inflammation, i. 76 syphilitic, i. 409 traumatic, after operation, i. 518 from amputation, i. 558 typhoid, in inflammation, i. 75 Fibrin, i. 126 Fibrinous calculus, ii. 768 exudation, i. 125 Fibroid bodies of synovial burses, ii. 41 recurring tumor, i. 242 Fibro-cartilaginous tumors of bone, i. 901 Fibro-cystic tumor of the nates, ii. 1034 plastic tumor, i. 241 of lymphatio ganglions, i. 664 of the abdominal walls, ii. 714 Fibrous degeneration of the testicle, ii. 847 polyp, i. 252 of the nose, ii. 418 transformation, i. 213 of arteries, i. 719 of the septum of the penis, ii. 872 tumors, i. 240 of the external ear, ii. 375 of the joints, ii. 40 of the neck, ii. 478 of the ovary, ii. 923 of the prostate gland, ii. 840 of the scalp, ii. 197 of the synovial membrane, ii. 40 of the uterus, ii. 914 of the vaginal tunic, ii. 859 Fibula, excision of, ii. 1064 fractures of, i. 1011 Field tourniquet, i. 703 Filaria medinensis in skin, i. 641 Fimbriated synovial membrane, ii. 40 Finger, amputation of, ii. 1069 dislocations of, ii. 132 fractures of, i. 988 index, amputation of, ii. 1070 little, amputation of, ii. 1071 Fingers, affections of, ii. 990. See also Hand, affections of. bandages for, ii. 1005 congenital irregularities of, ii. 990 contraction of, ii. 992 deficiency of, ii. 990 fractures of, i. 988 hypertrophy of, ii. 991 malformations of, ii. 990 shortening of tendons of, ii. 993 supernumerary, ii. 991 tenotomy of, ii. 993 webbed, ii. 991 whitlow of, ii. 995 Fissure of the anus, ii. 658 treatment of, ii. 659 of the bones, i. 950 of the iris, ii. 308 of the palate, ii. 563 of the tongue, syphilitic, i. 420 Fistule, i. 221 treatment of, i. 223 of the anus, ii. 653 Gross's operation for, ii. 656 operation by the seton for, ii. 657 ordinary operation for, ii. 656 question of operation for, ii. 656 of the chest, ii. 486 of the duct of Steno, ii. 559 of the lachrymal sac, ii. 361 of the mammary gland, ii. 966 of the trachea, ii. 440 perineal, after lateral operation of lithoto- my, ii. 794 umbilical, ii. 719 urethral, ii. 824 vesico-rectal, ii. 957. See Vesico-rectal. vesico-vaginal, ii. 946. See Vesico-vagi- nal. vesico-vagino-rectal, ii. 957 Flap amputation, i. 543 Flat-foot, ii. 1022 Flexion, forcible, in treatment of aneurism, i. 754 INDEX. 1109 Foetal remains in the scrotum, ii. 864 Foot and toes, affections of, ii. 1006 amputation of the, ii. 1077 bunions, ii. 1009 caries of, ii. 1053 club, ii. 1011 congenital and other deformities, ii. 1006 corns, ii. 1007 dislocations of, ii. 159 excision of bones of, ii. 1053 exostosis of great toe, ii. 1011 flat, ii. 1022 fractures of, i. 1008 inversion of nail of great toe, ii. 1009 podelkoma, ii. 1023 pododynia, ii. 1023 Forceps, artery, Gross's, ii. 791 Physick's, i. 697, ii. 791 sliding, i. 695 spring, i. 694 crushing, ii. 790 dressing, i. 501 for conjunctiva, ii. 330 for extracting teeth, ii. 530 for removing urinary calculi, ii. 787 Gross's, for windpipe, ii. 458 in gunshot wounds, i. 335 polypus, ii. 421 torsion, i. 707 Trousseau's, for windpipe, ii. 459 urethral, ii. 808 Forcible flexion in treatment of aneurism, i. 754 Forearm, amputation of, ii. 1072 excision of bones of, ii. 1046 Foreign bodies a cause of compression of the brain, ii. 211 in the air-passages, ii. 444 contra-indications to removal of, ii. 461 diagnosis of, ii. 450 from aneurism of aorta, ii. 452 from foreign bodies in pharynx and oesophagus, ii. 452 from hooping-cough, ii. 452 from irritation produced by worms, ii. 452 from spasmodic croup, ii. 451 from spasm of glottis, ii. 452 expansion of, ii. 446 instruments for removal of, ii. 458 inversion of body in treatment of, ii. 456 mortality of, ii. 461 operations for, ii. 456 difficulties of, ii. 460 operative interference in, ii. 456 pathological effects of, ii. 446 situation of, ii. 445 spontaneous expulsion of, ii. 454 symptoms of, ii. 447 treatment of, ii. 455 in the auditory tube, ii. 381 _ ' instruments for removal of, ii. 381 in the bladder, ii. 804 in the bronchial tubes, ii. 453 in the cornea, ii. 297 in the eye, ii. 280 in the frontal sinus, ii. 410 in the larynx, ii. 444 in the nasal cavities, ii. 417 in the oesophagus, ii. 584 extraction of, ii. 585 instruments for extraction of, ii. 585 Foreign bodies— in the pharynx, ii. 584 in the rectum, ii. 650 extraction of, ii. 652 in the stomach and bowels, ii. 707 operations for, ii. 707 symptoms of, ii. 707 in the urethra, ii. 807 calculi descending from bladder, ii. 807 crushing of, ii. 808 developed there, ii. 807 excision of, ii. 808 introduced from without, ii. 809 removal of. ii. 807 symptoms of, ii. 807 Fractures, i. 917 adhesive strips in, i. 935 after-treatment of, i. 937 amputation in, i. 537 apparatus for, i. 933 coaptation of fragments in, i. 936 comminuted, i. 944 complicated, i. 942 accidents after, i. 943 hemorrhage in, i. 945 of leg, i. 1009 primary amputation in, i. 946 repair of, i. 943 secondary amputation in, i. 946 symptoms of, i. 942 compound, i. 942 statistics of, i. 947 dextrine bandage in, i. 939 diagnosis of, i. 926 displacement of fragments in, i. 926 dressing of, i. 936 general considerations on, i. 917 immovable apparatus in, i. 938 incomplete, i. 947 treatment of, i. 949 interperiosteal, i. 949 mode of repair of, i. 929 and time of examination of, i. 928 moulding tablet for, i. 939 of both tibia and fibula, i. 1014 of the calcaneum, i. 1008 of the carpal bones, i. 988 of the clavicle, i. 969 of the coccyx, i. 988 of the costal cartilages, i. 981 of the femur, i. 1025 at inferior fourth of shaft, i. 1028 at middle of shaft, i. 1027 at upper fourth of shaft, i. 1025 of condyles, i. 1039 _ of great trochanter, i. 1061 of neck, intracapsular, i. 1043 of superior extremity, i. 1041 extra-capsular, i. 1053 genera] diagnosis of, i. 1058 impacted, i. 1056 of the fibula, i. 1011 of the fingers, i. 988 of the foot, i. 1008 of the frontal sinus, ii. 409 of the hand, i. 988 of the humerus, i. 1000 complicated with dislocation, i. 1006 inferior extremity, i. 1000 complicated, i. 1003 condyles, i. 1001 shaft, i. 1000 superior extremity, i. 1004 1110 INDEX. « Fractures of the humerus, superior-— anatomical neck, i. 1005 great tuberosity, i. 1007 head, i. 1004 surgical neck, i. 1005 of the hyoid bone, i. 967 of the inferior extremity, i. 1039 of the larynx, i. 968 of the leg, i. 1009 complicated, i. 1019 of the lower jaw, i. 964 at neck, i. 964 at ramus, i. 964 of the malar bone, i. 963 of the metacarpal bones, i. 988 of the nasal bones, i. 961 cartilages, i. 963 of the patella, i. 1021 of the pelvic bones, i. 986 of the radius, i. 994 inferior extremity, i. 995 shaft, i. 994 superior extremity, i. 994 of the radius and ulna, shafts of, i. 989 of the ribs, i. 977 of the scapula, i. 974 , at its neck, i. 975 at the acromion, i. 975 at the coracoid process, i. 976 of the body, i. 976 of the skull, ii. 213 arrow, ii. 242 at its base, ii. 218 compound, ii. 216 gunshot, ii. 238 of external table alone, ii. 221 of internal table alone, ii. 222 punctured, ii. 220 simple, without depression, ii. 214 with depression and symptoms of compression, ii. 216 with depression of bone, ii. 215 of the sternum, i. 981 of the teeth, ii. 523 of the tibia, i. 1009 of the ulna, i. 990 coronoid process, i. 992 olecranon process, i. 991 shaft, i. 990 of the upper jaw, i. 963 of the vertebrae, i. 983 cervical, i. 983 dorsal, i. 983 luiribar, i. 983 odontoid process, i. 986 plaster of Paris bandage for, i. 939 simple, i. 924 splints for, i. 934 starch bandage for, i. 939 symptoms of, i. 924 treatment of, i. 932 ununited, i. 951 causes of, i, 952 local remedies in, i. 953 operations for, i. 954 statistics of, i. 956 treatment of, i. 953 vicious union of, i. 957 treatment of, i. 957 Fragilitas ossium, i. 890 Fragility of bones, i. 890 causes of, i. 891 symptoms of, i. 892 treatment of, i. 892 | Frenum of the prepuce, diseases of, ii. 877 of the tongue, malformations of, ii. 553 Frog-face, ii. 419 Frontal bone, gunshot injuries of, ii. 241 sinus, abscess of, ii. 409 diseases and injuries of the, ii. 409 foreign bodies in, ii. 410 Frost-bite, i. 618 treatment of, i. 620 Fungoid tumor of the navel, ii. 718 Fungous growths of the auditory tube, ii. 386 tumor of bladder, ii. 752 of the teeth, ii. 526 Fungus hematodes. See Encephaloid. of the brain, ii. 236 of the testicle, ii. 846 Furuncle, i. 603 treatment of, i. 604 Fusible calculus, ii. 767 Gall-bladder, wounds of, ii. 706 Galvano-cauterization, i. 499 puncture, in treatment of aneurism, i. 754 Ganglion, i. 650 of Meckel, excision of, i. 681 Ganglions, carcinomatous disease of, i. 662 earthy degeneration of, i. 663 ' encephaloid of, i. 662 fibro-plastic tumor of, i. 664 hypertrophy of, i. 661 inflammation of, i. 659 lymphatic, affections of, i. 659 melanosis of, i. 663 scirrhus of, i. 663 tubercle of, i. 663 Gangrene, i. 168 a consequence of chancre, i. 388 chronic, from ergot, i. 179 from bandaging, i. 506 hospital, i. 182 causes of, i. 184 constitutional treatment of,«i. 187 local treatment of, i. 188 of arteries, i. 718 of skin, i. 608 white, i. 608 of the bladder, ii. 727 of the cornea, ii. 300 of the mammary gland, ii. 963 of the membrane of the tympanum, ii. 392 of the parotid gland, ii. 556 of the teeth, ii. 524 of the tonsils, ii. 571 senile, i. 177 Gangrenous bubo, i. 404 Gastrotomy, ii. 707 Gelatinoid polyp, i. 252 of auditory tube, ii. 385 of nose, ii. 418 Geiy's suture, ii. 700 General diagnosis, i. 446 Genital organs, female, diseases and injuries of, ii. 896 male, diseases and injuries of, ii. 843 Gerdy's operation for the radical cure of re- ducible hernia, ii. 596 Gibbons's alternating compressor, i. 751 Gland, lachrymal. See Lachrymal gland. mammary. See Mammary gland. parotid. See Parotid gland. . sublingual. See Sublingual gland. submaxillary. See Submaxillary gland. thyroid. See Thyroid gland. INDEX. 1111 Glanders, i. 359 Glands, ceruminous, inflammation of, ii. 389 lymphatic, affections of, i. 659 salivary, affections of, ii..555 Gleet, ii. 880 treatment of, ii. 880 Globe of the eye, extirpation of, ii. 354 Glossitis, ii. 547 treatment of, ii. 548 Glottis, oedema of, ii. 434 Glover's suture, i. 303 Gluteal artery, aneurism of, i. 794 ligation of, i. 820 Goitre, ii. 473 operations for, ii. 476 treatment of, ii. 475 Gonorrhoea, ii. 878 chronic, ii. 880 complications of, ii. 881 constitutional effects of, ii. 883 copaiba in, ii. 886 cubebs in, ii. 887 dry, ii. 880 injections in, ii. 887 in the female, ii. 944 iodine in, ii. 889 pathology of, ii. 880 symptoms of, ii. 879 treatment of, ii. 885 virus of, ii. 878 Gonorrhoeal ophthalmia, ii. 288 Gorget, in the operation of lithotomy, ii. 797 Gouty concretions of joints, ii. 39 Granular condition of neck of uterus, ii. 903 conjunctivitis, ii. 286 polyp, i. 252 Granulating process, union by,i. 309 Granulations, diseases of, i. 206 in inflammation, i. 205 of bone, i. 930 structure of, i. 205 Great toe, exostosis of, ii. 1011 inversion of nail of, ii. 1009 Groin, affections of, ii. 1035 diagnosis of, ii. 1037 Grooved director, i. 475 Growths, condylomatous, i. 430 fungous, of the auditory tube, ii. 384 morbid, i. 228 amputations in, i. 538 of the skin, i. 622 Guerin's operation for the radical cure of re- ducible hernia, ii. 596 Gum lancet, ii. 530 Gums, affections of, ii. 533 cancroid disease of, ii. 535 inflammation of, ii. 533 inflammatory enlargement of, ii. 534 hypertrophy of, ii. 534 mortification of, ii. 533 ulceration of, ii. 533 wounds of, ii. 533 Gunshot wounds, i. 323 of the abdomen, head, &c. See Abdomen, Head, &c. Hachenberg's operation for the radical cure ' of hernia, ii. 599 Ham, abscess of, ii. 1031 affections of, ii. 1031 burse of, ii. 1031 tumors of, ii. 1031 Hand and fingers, affections of, ii. 990 amputation of, ii. 1069 Hand and fingers— bones of, excision of, ii. 1044 club, ii. 994 congenital irregularities, ii. 990 contraction of, ii. 992 dislocations of, ii. 129 fractures of, i. 988 hypertrophy of, ii. 991 phlegmonous inflammation and abscess of, ii. 998 removal of rings from, ii. 995 tenotomy of, ii. 992 tumors of, ii. 998 varicose aneurism of, ii. 997 whitlow, ii. 995 wounds of arteries of, i. 792 Hare-lip, ii. 540 operations for, ii. 542 pin, i. 302 suture, ii. 543 Hays's knife-needle, ii. 326 Head, bandaging of the, ii. 245 injuries aud diseases of, ii. 193 chronic hydrocephalus, ii. 242 compression of brain, ii. 204 concussion of brain, ii. 197 contusions* of scalp, ii. 195 fractures of skull, ii. 213 fungus of brain, ii. 236 gunshot wounds of, ii. 237 tapping of skull, ii. 244 tumors of scalp, ii. 196 wounds of brain and its membranes, ii. 233 of scalp, ii. 193 Healing of wounds, i. 306 Heart, sympathies and irritations of, i. 41 wounds of, ii. 494 treatment of, ii. 496 Heat of inflammation, i. 69 Hectic fever, in inflammation, i. 163 treatment of, i. 166 irritation, from amputation, i. 560 Hematocele, ii. 858 of the scrotum, ii. 860 of the spermatic cord, ii. 867 ' retro-uterine, ii. 910 Hematoid form of encephaloid, i. 267 of the breast, ii. 976 tumor of bone, i. 904 of jaw, ii. 515 Hematuria, ii. 750 Hemorrhage after extraction of teeth, ii. 533 after lateral operation of lithotomy, ii. 791 arterial, i. 689 death fronj, i. 690 general means for arresting, i. 707 means of suppressing, i. 693 secondary, i. 708 spontaneous arrest of, i. 691 as an effect of inflammation, i. 167 intra-thoracic, ii. 487 in wounds of the chest, ii. 487 of the intestine, ii. 694 of leech bites, i. 485 of stump; i. 552 of the auditory tube. ii. 388 of the bladder, ii. 750 of the nose, ii. 412 plugging for, ii. 414 of the prostate gland, ii. 841 of the rectum, ii. 650 of the urethra, ii. 806 1112 INDEX. Hemorrhage— of the uterus, ii. 909 subcutaneous, i. 709 venous, i. 830 Hemorrhagic diathesis, i. 714 constitutional treatment of, i. 716 local treatment of, i. 717 infiltration into the labia, ii. 937 Hemorrhoidal veins, varicose, ii. 673 Hemorrhoids, ii. 665 Hemostatics, natural, i. 691 surgical, i. 693 acupressure as, i. 701 compression as, i. 702 ligature as, i. 693 styptics as, i. 706 torsion as, i. 707 Hemothorax, ii. 487 Hemp-seed calculus, ii. 766 Hepatic abscess, ii. 711 treatment of, ii. 712 Hernia, ii. 589 anatomy of, ii. 590 causes of, ii. 590 diaphragmatic, ii. 642 femoral, ii. 631 anatomy of, ii. 631 anomalous forms of, ii. 637 coverings of, ii. 632 diagnosis of, ii. 633 irreducible, ii. 635 reducible, ii. 634 strangulated, ii. 635 operation for, ii. 636 taxis in, ii. 635 treatment of, ii. 634 infantile, ii. 631 inguinal, direct, ii. 626 coverings of, ii. 626 treatment of, ii. 626 incomplete oblique, ii. 625 coverings of, ft. 626 operation for, ii. 625 oblique, ii. 621 coverings of, ii. 623 diagnosis of, ii. 622 strangulated, ii. 624 treatment of, ii. 624 division of stricture in, ii. 624 taxis in, ii. 624 operation for, ii. 624 treatment of, ii. 624 irreducible, ii. 601 apparatus for, ii. 603 inflamed, ii. 604 % obstructed, ii. 604 treatment of, ii. §02 ischiatic, ii. 641 labial, ii. 641 of the bladder, ii. 755 of the brain, ii. 236 of the lungs, ii. 482 of the trachea, ii. 441 obturator, ii. 641 pelvic, ii. 641 perineal, ii. 641 reducible, ii. 592 treatment of, ii. 593 by acupuncturation, ii. 596 by Armsby's operation, ii. 599 by Hachenberg's operation, ii. 599 by injection of the tincture of iodine, ii. 596 Hernia, reducible, treatment of— by invagination of the integu- ments, ii. 596 by plastic operation, ii. 597 by Riggs's operation, ii. 599 by scarifying the neok of the sac, ii. 596 by trusses, ii. 593 by Wood's operation, ii. 600 by Wutzer's operation, ii. 597 radical cure of by trusses, ii. 593 sac of, ii. 591 scrotal, ii. 627 causes of irreducibility of, ii. 627 congenital, ii. 630 coverings of, ii. 628 diagnosis of, ii. 628 infantile, ii. 631 treatment of, ii. 629 strangulated, ii. 605 abscesses complicating, ii. 618 accidents in, ii. 618 causes of death in, ii. 620 division of the stricture in, ii. 613 external to the sac, ii. 618 intestine protruded, examination of, ii. 614 treatment of, ii. 615 mortality in, ii. 619 omentum protruded, examination of, ii. 617 treatment of, ii. 617 operation for, ii. 612 taxis in, ii. 608 treatment of, ii. 607 umbilical, in children, ii. 638 in the adult, ii. 639 in the foetus, ii. 638 irreducible, ii. 640 operation for, ii. 640 strangulated, ii. 640 treatment of, ii. 639 " vaginal, ii. 642 ventral, ii. 641 Hernial hydrocele, ii. 858 Herpetic affections of the auditory tube, ii. 388 ulcer of the prepuce, ii. 873 Heterologous formations of the bladder, ii. 753 of the prqstate, ii. 840 of the urethra, ii. 827 Hey's amputation of the foot, ii. 1079 Highmore, antrum of, affections of, ii. 499 Hip-joint, abscess of, ii. 67 amputation at the, ii. 1090 dislocations of, ii. 174 excision of, i. 1065; ii. 76 rheumatism of, ii. 70 sprain of, ii. 69 tuberculosis of, ii. 63 Hoey's clamp, i. 751 Hook for extracting teeth, ii. 532 Horns, i. 238 Horny tumors, i. 238 Hospital gangrene, i. 182 Housemaid's knee, ii. 1030 Humerus, dislocations of, at shoulder, ii. 146 excision of, ii. 1051 • fractures of, i. 1000 « Hunterian chancre, i. 384 operation for aneurism, i. 744 Hydatic tumors or hydatids, i. 250 in anterior chamber of eye, ii. 317 of bone, i. 907 treatment of, i. 909 INDEX. 1113 Hydatic tumors, or hydatids— of muscles, i. 646 of the frontal sinus, ii. 410 of the mammary gland, ii. 968 of the testicle, ii. 850 Hydrarthrosis, ii. 32 Hydrocele, ii. 852 congenital, ii. 857 diffuse, of the spermatic cord, ii. 866 encysted, ii. 858 hernial, ii. 858 in children, ii. 858 of the spermatic cord, ii. 865 treatment of, ii. 854 Hydrocephalus, chronic, ii. 242 puncture of cranium for, ii. 244 treatment of, ii. 244 Hydrometra, ii. 909 Hydrophobia, in dog, i. 358 in man, i. 352 Hydrophthalmia, anterior, ii. 316 posterior, ii. 316 Hydrorachitis, ii. 264 treatment of, ii. 266 Hydrosarcocele, ii. 853 Hydrothorax, ii. 4^9 Hyoid bone, dislocations of, ii. 116 fractures of, i. 967 Hypertrophic tumors, i. 232 # Hypertrophy, i. 216 from chronic irritation, i. 216 from increase of functional activity, i. 216 from mechanical obstruction, i» 216 » of bone, i. 427, 894 of the clitoris, ii. 942 of the gums, ii. 534 of the inguinal lymphatic ganglions, ii. 1036 of the lips, ii. 536 of the lymphatic ganglions, i. 661 of the mammary gland, ii. 965, 981 of the mucous membrane of nose, ii. 416 of the muscular fibres of. the bladder, ii. 731 of the nymphae, ii. 941 of the prepuce, ii. 877 of the prostate gland, ii. 830 senile form of, ii. 832 symptoms of, ii. 832 treatment of, ii. 833 of the scrotum, ii. 861 of the skin, i. 627 of the tendons, i. 649 of the tongue, ii. 550 of the tonsils, ii. 572 of the upper jaw, ii. 506 of the uterus, ii. 905 of the veins, i. 833 syphilitic, of bone, i. 427 treatment of, i. 217 Hypospadias, ii. 805 Hysterotomy, ii. 920 ICHORHEMIA, i. 156 Idiosyncrasy, i. 37 Iliac abscess, ii. 713 artery, common, aneurism of, i. 792 ligation of, i. 817 external, aneurism of, i. 794 ligation of, i. 821 internal, aneurism of, i. 794 ligation of, i. 819 crest, fracture of, i. 987 dislocation of femur, ii. 176 Immediate union, i. 307 Immobility of the lower jaw, ii. 516 of the tongue, ii. 553 Imperforate anus, ii. 683 operation for, ii. 683 treatment of, ii. 683 Incised wounds, i. 310 Incision of the prostate gland, ii. 835 Incisions, i. 476 forms of, i. 479 making of, i. 478 positions of knife in making of, i. 477 Incomplete inguinal hernia, ii. 625 Incontinence of urine, ii. 747 after lateral operation of lithotomy, ii. 793 apparatus for irremediable, ii. 750 • from external injury, ii. 747 from inflammation, ii. 747 from morbid sensibility of the neck of the bladder, ii. 748 from paralysis of the bladder, ii. 747 nocturnal, ii. 748 of retention of urine, ii. 742 treatment of, ii. 748 in boys, ii. 748 Incurvation of the penis, ii. 873 operation for, ii. 873 Index finger, amputation of, ii. 1070 Indolent bubo, i. 403 Indurated chancre, i. 38*5 Induration, effect of on tissues, i. 212 in inflammation, i. 211 treatment of, i. 212 Infancy, purulent ophthalmia of, ii. 287 Infantile hernia, ii. 631 palsy, i. 686 syphilis, i. 440 Inferior extremity, affections of, ii. 1006 bandages for, ii. 1038 maxilla, affections of, ii. 510 Infiltration of urine, ii. 823 treatment of, ii. 823 urethral form of, ii 823 vesical form of, ii. 823 purulent, i. 149 urinary, after lateral operation of litho- tomy, ii. 793 Inflammation, i. 54 abscesses, in, i. 140 aconite in, i. 99 acute, i. 63 constitutional symptoms of, i. 72 treatment of, i. 88 local symptoms of, i. -63 adhesive, healing by, i. 309 after venesection, i. 489 anodynes in, i. 102 antiphlogistic regimen in, i. 104 atrophy in, i. 219 bleeding in, i. 88 blisters in, i. 114 cathartics in, i. 92 causes of, i. 55 changes of blood in, i. 76 chronic, i. 116 hypertrophy in, i. 216 mercurials in, i. 118 symptoms of, i. 117 treatment of, i. 118 cicatrization in, i. 207 cold and warm applications in, i. 107 compression in, i. 112 contraction in, i. 221 counter-irritants in, i. 113 1114 INDEX. Inflammation— delitescence in, i. 121 deposition of serum in, i. 122 destructives in, i. 113 diaphoretics in, i. 100 digitalis in, i. 99 discoloration in, i. 64 diuretics in, i. 101 emetics in, i. 98 extension of, i. 59 from metastasis, i. 58 from sympathy, i. 58 functional disorder in, i. 70 general bloodletting in, 1. 88 granulation in, i. 205 heat in, i. 69 hectic fever in, i. 163 hemorrhage as an effect of, i. 167 hospital gangrene as a result of, i. 182 indications for general bleeding in, i. 88 induration in, i. 211 intimate nature of, i. 79 iodine in, i. Ill ipecacuanha in, i. 99 irritative fever in, i. 76 local bleeding in, i 106 treatment of, i. 105 lymphization in, i. 125 mercurials in, i. 94 metastasis in, i. 121 mortification in, i. 168 nauseants in, i. 98 nitrate of silver in, i. 110 pain in, i. 65 plastic matter in, i. 131 poultices in, i. 109 resolution in, i. 121 softening in, i. 210 state of bloodvessels in, i. 79 of nerves in, i. 84 suppurants in, i. 115 • suppuration in, i. 134 swelling in, i. 68 symptoms of, i. 63, 72 tartar emetic in, i. 99 terminations of, i. 63, 121 treatment of, i. 87 typhoid fever in, i. 75 ulceration in, i. 189 varieties of, i. 61 veratrum viride in, i. 100 vesicants in, i. 114 Inflammatory fever, i. 75 Inguinal hernia, ii. 621 direct, ii. 626 incomplete, ii. 625 oblique, ii. 621 Injection in the treatment of aneurism, i. 755 Injections, administration of, ii. 648 in hydrocele, ii. 856 Injuries, amputation in, i. 535 effects of, on nervous system, i. 371 Innominatal aneurism, ligation of carotid for, i. 770 Innominate artery, aneurism of, i. 766 ligation of, i. 802 for subclavian aneurism, i. 783 bone, fracture of, i. 986 Insect wounds, i. 346 Insects in skin and cellular tissue, i. 640 Instrumental compression in treatment of aneurism, i. 749 results of, i. 752 Instrumental— exploration, a means of general diagnosis, i. 458 Instruments, in minor surgery, i. 472 bistouries, i. 473 forceps, i. 474 Museux's, i. 475 for removal of bone, i. 881 grooved director, i. 475 needles, i. 476 scalpels, i. 472 scissors, i. 474 suture needle, i. 476 trocar, i. 476 Interarticular cartilages, ii. 35 Internal ear, diseases of, ii. 396 piles, ii. 666 strangulation of the bowel, ii. 643 Inter-periosteal fractures, i. 949 Inter-pubic puncture of the bladder, ii. 747 Interrupted suture, i. 301 in wounded intestine, ii. 699 Intestines, foreign bodies in, ii. 707 protruded, in strangulated hernia, ii. 605 wounds of, ii. 691 constitutional sywptoms of, ii. 693 continued suture in, ii. 699 diagnosis of, ii. 693 effects of, ii. 694 Geiy's suture in, ii. 700 Gross's experiments in, 695 hemorrhage in, ii. 694 internal strangulation of, ii. 643 interrupted suture in, ii. 700 Lembert's suture in, ii. 700 . mode of reparation of, ii. 697 prognosis of, ii. 696 symptoms of, ii. 691 treatment of, ii. 699 without protrusion, ii. 701 Intestinal concretions, ii. 707 Intra-articular anchylosis, ii. 81 parietal separation of arterial tunics, i. 722 thoracic hemorrhage, ii. 487 Introduction of tubes into windpipe, ii. 443 Inversion and prolapse of the female bladder, ii. 942 complete, ii. 943 incomplete, ii. 943 treatment of, ii. 943 of body, for foreign bodies in windpipe, ii. 456 of eyelashes, ii. 365 of lids, ii. 363 of nail of big toe, ii. 1009 of the uterus, ii. 901 Invagination of the integuments for the cure of hernia, ii. 596 Iodide of potassium in tertiary syphilis, i. 432 Iodine, as a local antiphlogistic, i. Ill injections of, in scrofulous abscess, i. 156 in the cure of hernia, ii. 596 in serpent wounds, i. 351 in treatment of erysipelas, i. 600 Irideremia, ii. 308 Iris, diseases and injuries of, ii. 308 artificial pupil,-ii. 313 congenital vices of, ii. 308 fissure of, ii. 308 inflammation of, ii. 308 obliteration of pupil, ii. 313 prolapse of, ii. 312 wounds of, ii. 308 ■INDEX. 1115 Iritis, ii. 308 . differential diagnosis of, ii. 310 rheumatic, ii. 310 syphilitic, i. 422 ; ii. 310 treatment of, ii. 311 Iron, perchloride of, as a hemostatic, i. 706 persulphate of, as a hemostatic, i. 706 Irreducible hernia, ii. 601 Irritability of the bladder, ii. 734 treatment of, ii. 735 Irritation, i. 37 effects of, i. 47 * hecti^, from amputation, i. 560 of the bladder, i. 44 of the bowels, i. 42 » of the brain, i. 39 of the ears, i. 46 of the eyes, i. 45 of the heart, i. 41 of the kidneys, i. 43 of the liver, i. 43 of the lungs, 4. 41 of the nerves, i. 40 of the rectum, i. 42 of the skin, i. 45 of the spinal cord, i. 40 of the stomach, i. 42 of the teeth, i. 42 of the testicle, i. 44 of the uterus, i. 44 treatment of, i. 49 Irritative fever in inflammation, i. 76 " Ischium, fracture of, i. 987 Ischiatic hernia, ii. 641 Issue, as a counter-irritant, i. 496 Joints, affections of, amputations in, i. 539 anchylosis of, ii. 80 chronic rheumatic inflammation of,' ii. 77 diseases of, ii. 19 dislocations of, ii. 89 dropsy of, ii. 32 excision of, i. 570 gunshot wounds of, ii. 985 inflammation of, ii. 26 injuries of, ii. 19 movable bodies within,' ii. 35 neuralgia of, ii. 87 sprains of, ii. 23 tuberculosis of. ii. 41 wounds of, ii. 19 Jiirg's apparatus for torticollis, ii. 472 Jugular vein, bleeding from, ii. 480 Keloid tumors, i. 631 treatment of, i. 634 Keratonyxis, ii. 326 Kerosoline, i. 585 Key for extracting the teeth, ii. 531 Kidneys, abscess of, ii. 713 dropsy of, ii. 713 , sympathies and irritations of, i. 43 Knee, affections of, ii. 1027 amputation at the, ii. 1086 anchylosis of. ii. 1027 operation for, ii. 1027 bandage for the, ii. 1038 dislocations of, ii. 170 excision of, ii. 1059 housemaid's, ii. 1030 knock, ii. 1028 treatment of, ii. 1029 tuberculosis of the, ii. 62 Knife, Beer's, ii. 330 the four positions of, i. 477 Knife-needle, Hays', ii. 326 Knives, amputating, i. 548 Knock knee, ii. 1028 Knot, clove-hitch, ii. 130 reef, i. 696 surgeon's, i. 696 Labia, affections of the, ii. 937 Labial hernia, ii. 641 Lacerated wounds, i. 313 Laceration of muscles, i. 642 of the bladder, ii. 724 treatment of, ii. 724 of the penis, ii. 871 treatment of, ii. 871 of the perineum, ii. 958 operation for, ii. 958 of the tendo Achillis. ii. 1027 of the trachea, ii. 468 of the urethra, ii. 806 treatment of, ii. 806 Lachrymal apparatus, affections of, ii. 354 canals, affections of. ii. 356 inflammation of. ii. 356 laceration of, ii. 356 obstruction of, ii. 356 stricture of, ii 357 gland, affections of, ii. 354 chronic enlargement of, ii. 356 encysted tumor of, ii. 355 extirpation of, ii. 356 inflammation of, ii. 354 sac, abscess of, ii. 358 acute inflammation of, ii. 358 affections of, ii. 358 Jacobson's lithotrite, ii. 777 Jameson's operation for the radical cure of re- ducible hernia, ii. 597 Jaw, lower, affections of, ii. 510 anchylosis of, ii. 516 caries of, ii. 510 chronic abscess of, ii. 510 cystic disease of, ii. 513 deformity of, ii. 516 dislocations of, ii. 116 encephaloid of, ii. 515 epulis of, ii. 512 excision of, ii. 518 exostosis of, ii. 512 fractures of, i. 964 hematoid tumors of, ii. 515 necrosis of, ii. 511 upper, abscess of, ii. 500 diseases and injuries of, ii. 499 dropsy of, ii. 501 encephaloid of, ii. 503 encysted tumors of, ii. 506 excision «f, ii. 506 exostosis of, ii. 505 fractures of, i. 963 hypertrophy of, ii. 506 inflammation of, ii. 499 perforation of. ii. 500 polyps of, ii. 502 scirrhus of, ii. 505 vascular tumors of, ii. 502 wounds of, ii. 499 Joint, ankle. See Ankle. elbow. See Elbow. hip. See Hip. knee. See Knee. shoulder. See Shoulder. wrist. See Wrist. 1116 INDEX. Lachrymal sac— chronic inflammation of, ii. 359 fistule of, ii. 361 laceration of. ii. 358 Lacteal tumors, ii. 969 . Lamellar cataract, ii. 323 Lancet, gum, ii. 530 Lancets, varieties of, i. 487 Laryngitis, ii. 433 tracheotomy in, ii. 433 Laryngoscope, i. 462, ii. 431 Laryngotomy, ii. 463 Laryngo-tracheotomy, ii. 465 Larynx, cauterization of, ii. 441 fistule of, ii. 440 foreign bodies in, ii. 444 fracture of. i. 968 gangrene of, ii. 434 inflammation of, ii. 433 introduction of tubes into, ii. 443 oedema of, ii. 434 Buck's knife for, ii. 435 treatment of, ii. 435 paralysis of, ii. 440 perforation of by foreign body, ii. 462 polyps of, ii. 438 scalds, ii. 436 spasm of, ii. 439 sponge-probang for, ii. 442 syphilis of, i. 421 ulceration of, ii. 436 warts of, ii. 439 Larynx and trachea, paralysis of, ii. 400 spasm of, ii. 399 Lashes, eye, inversion of, ii. 365 Lateral operation for stone, ii. 783 curvature of the septum of the nose, ii. 416 of the spine, ii. 250 Lead, carbonate of, in treatment of burns, i. 615 Leeches, application of to the uterus, ii. 897 Leeching, i. 483 Leg. affections of, ii. 1024 amputation of, ii. 1083 artificial, i. 560 excision of bones of, ii. 1064 fractures of, i. 1009 ulceration of, i. 198 Lembert's suture, ii. 700 Lens, crystalline, cataract of, ii. 317 diseases and injuries of, ii. 317 dislocation if, ii. 333 displacement of, ii. 327 division or solution of, ii. 325 through cornea, ii. 326 drilling the, ii. 327 extraction of, ii. 329 horizontal displacement of, ii. 328 mixed operation for cataract, ii. 328 operations on for cataract, ii. 324 reclination of for cataract, ii. 329 Lepoid tumor, i. 635 treatment of, i. 635 Lids, diseases of, ii. 361 eczema of, ii. 366 eversion of, ii. 364 fatty degeneration of, ii. 363 inversion of, ii. 363 of eyelashes, ii. 365 morbid adhesions of, ii. 365 ptosis, iL 367 stye, ii. 362 tumors of) ii. 362 wounds of, ii. 361 Ligation, i. 481 of the abdominal aorta, i. 816 for iliac aneurism, i. 792 of the anterior tibial artery, i. S26 of the axillary, i. 813 of the brachial, i. 814 of the brachio-cephalic, i. 802 of the circumflex iliac, i. 822 of the common carotid, i. 803 iliac, i. 817 of the dorsal, i. 827 of the epigastric, i. 822 of the external carotid, i. 806 iliac, i. 821 of the facial, i. 808 of the femoral, i. 823, 825, 820 . of the gluteal, i. 820 of the innominate, i. 802 of the internal iliac, i. 819 maxillary, i. 809 of the lingua], i. 807 of the occipital, i. 808 of the peroneal, i. 829 of the plantar, i. 829 of the popliteal, i. 826 of the posterior tibial, i. 827 of the radial, i. 816 of the sciatic, i. 821 of the subclavian, i. 809 on its tracheal aspect, i. 789 of the superior thyroid, i. 807 o"f the temporal, i. 808 of the ulnar, i. 816 of the vertebral, i. 809 of varicose veins, ii. 1025 LigatuVe, animal, i. 694 as a hemostatic, i. 693 changes in arteries from application of, i. 699 detachment of, from artery, i. 700 in treatment of aneurism, i. 744 in treatment of internal piles, ii. 672 mode of applying, to wounded vessel, i. 695 process of separation of, i. 700 reserve, i. 698 varieties of, i. 693 Limbs, artificial, i. 560 Lingual artery, ligation of, i. 807 Lint, i. 502 Lip, affections of, ii. 536, 546 cancer of, ii. 538 carbuncular inflammation of, ii. 536 encysted tumor of, ii. 537 eversion of mucous membrane of, ii. 540 hare, ii. 540 hypertsophy of, ii. 537 plastic operations on, ii. 546 ulcers of, ii. 536 » vascular tumors of, ii. 538 wounds of, ii. 536 Lipoma of the nose, ii. 425 Lithectasy, ii. 800 Lithotomy, ii. 783 after-treatment of, ii. 794 Allarton's operation of, ii. 800 bilateral operation of, ii. 797 statistics of, ii. 798 Buchanan's operation for, ii. 799 difficulties of extracting stone in, ii. 789 explosion of pre-existing disease after, ii. 794 general results of different methods of, ii. 802 INDEX. 1117 Lithotomy— hemorrhage after, ii. 791 impotence after, ii. 794 incontinence of urine after, ii. 793 in the female, ii. 803 lateral operation of, ii. 783 accidents in, ii. 790 extent of incision in prostate in, ii. 788 extraction of calculus in, ii. 787 instruments for, ii. 784 incisions in, ii. 785 position of patient in, ii. 785 relapse after, ii. 796 statistics of, ii. 795 varieties of, ii. 796 lesion of prostate gland in, ii. 792 median operation of, ii. 799 medio-lateral operation of, ii. 799 operation of lithectasy in, ii. 866 with the gorget in, ii. 797 with the lithotome in, ii. 797 orchitis after, ii. 794 perineal fistule after, ii. 794 peritonitis after, ii. 793 phlebitis after, ii. 792 recto-vesical operation of, ii. 800 retention of urine after, ii. 792 sinking after, ii. 792 sloughing of the rectum after, ii. 793 supra-pubic operation of, ii. 800 tetanus after, ii. 793 undue inflammation of the wound after, ii. 792 urinary infiltration after, ii. 793 use of scoop in, ii. 788 vaginal, ii. 803 wounds of the rectum in, ii. 793 Lithotripsy, ii. 777 comparative value of, ii. 782 ill effects of, ii. 781 instruments for, ii. 777 mode of performing, ii. 780 relapse after, ii. 782 selection of cases for, ii. 779 statistics of, ii. 782 Lithotriptor?, ii. 777, 778 Lithotrite, ii. 777, 778 Little finger, amputation of, ii. 1071 Littr6's operation for artificial anus, ii. 685 Liver, sympathies and irritations of, i. 43 wounds of, ii. 704 cases of, ii. 705 symptoms of, ii. 704 treatment of, ii. 705 Lobulated polyp of the auditory tube, ii. 385 Lumbar abscess, ii. 262 Lungs, collapse of, ii. 484 congestion of, from amputation, i. 559 hernia of, ii. 482 sympathies and irritations of, i. 41 wounds of, ii. 481 Lupus, i. 636 causes of, i. 636 exedent, i. 638 treatment of, i. 638 non-exedent, i. 637 treatment of, i. 637 of the face, ii. 273 Luxations. See Dislocations. Lymph, i. 125 organization of, i. 126 Lymphatic ganglions, diseases of, i. 659 of the groin, hypertrophy of, n. 1036 Lymphatic— vessels, diseases of, i. 657 inflammation of, i. 658 varicose enlargement of, i. 659 Lymphatitis, i. 657 Lymphization in inflam'mation, i. 125 treatment of, i. 133 Maggots in wounds, i. 345 Malar bone, fractures of, i. 963 Male genital organs, diseases and injuries of, ii. 843 Malformations, amputation in, i. 540 congenital, i. 225 of the anus and rectum, ii. 682 of the auditory tube, ii. 380 of the bladder, ii. 720 of the external ear, ii. 379 of the fingers, ii. 990 of the frenum of the iongue, ii. 553 of the nose, ii. 416 of the superior extremity, ii. 990 of the urethra, ii. 804 Malignant disease of the eye, ii. 350 of the mammary gland, ii. 971, 981 of the thyroid gland, ii. 477 of the tonsils, ii. 576 pimple, i. 367 pustule, i. 367 tumors, i. 256 contra-indications to removal of, i. 283 of auditory tube, ii. 387 of bone, i. 910 of mammary gland, ii. 971, 981 of muscles, i. 647 of ovary, ii. 925 of scalp, ii. 197 of skin, i. 635 reproductive tendency after removal of, i. 284 rules for excision of, i. 280 treatment after excision of, i. 282 Malpositions of the uterus, ii. 899 Mammary gland, abscess of, ii. 961 adenoid tumors of, ii. 970 affections of, ii. 960 apoplexy of, ii. 967 atrophy of, ii. 966 bandages for, ii. 979 benign tumors of, ii. 969 butyroid tumors of, ii. 969 calcareous concretions of, ii. 966 colloid of, ii. 977 disease of, in the female, ii. 960 • in the infant, ii. 981 in the male, ii. 980 encephaloid of, ii. 975 excision of, ii. 978 fistule of, ii. 966 gangrene of, ii. 963 hydatic tumors of, ii. 968 hypertrophy of, ii. 965, 981 inflammation of, ii. 960 lacteal tumors of, ii. 969 malignant tumors of, ii. 971, 981 melanosis of, ii. 977 neuralgia of, ii. 964' scirrhus of, ii. 971 sero-cystic tumors of, ii. 967 sore nipples of, ii. 963 tumors of, ii. 967, 981 region, affections of, ii. 982 Mammitis, ii 960 1118 INDEX. Mammitis— in infants, ii. 981 Manec's paste as an escharotic, i. 500 Manipulation in treatment of aneurism, i. 757 Mastoid cells, affections of the, ii. 406 Maxilla, inferior. See Jaw, lower. superior. See Jaw, upper. Maxillary artery, interna], ligation of, i. 809 sinus, affections of, ii. 499 Meckel, ganglion of, excision of, i. 681 Median operation of lithotomy, ii. 799 Medio-Iateral operation of lithotomy, ii. 799 Melanosis, i. 273 of bone, i. 912 of the eye, ii. 353 of the groin, ii. 1037 of the lymphatic ganglions, i. 663 of the mammary gland, ii. 977 of the muscles, i. 647 of the prostate gland, ii. 840 of the scrotum, ii. 864 of the skin, i. 639 of the testicle, ii. 850 Membrane, mucous, of lip, evfrrsion of, ii. 540 of nose, hypertrophy of, ii. 416 of the tympanum,- diseases of, ii. 390 pyogenic, i. 152 synovial, fibrous tumor of, ii. 40 fimbriated, ii. 40 Membranous cf oup, ii. 433 Mensuration, a means of general diagnosis, i. 453 Mercurial fumigations in tertiary syphilis, ii. 434 vapor bath in tertiary syphilis, i. 435 Mercury as an antiphlogistic, i. 94, 118 acid nitrate of, as an escharotic, i. 501 bichloride of, as an escharotic, i. 500 . in tertiary syphilis, i. 434 in inflammation, i. 94, 118 in syphilis, i. 397, 434, 435 ptyalism from, i. 96 Metastasis, a cause of inflammation, i. 58 in inflammation, i. 121 Metastatic abscess, i. 161 Metacarpal bones, excision of, ii. 1045 fractures of, i. 988 Metacarpo-phalangeal joints, dislocations of, ii. 132 Metatarsal bone of the great toe, amputation of, ii. 1078 bones, dislocations of, ii. 159 Metritis, ii. 902 Microscope, use 6f, in general diagnosis, i. 465 Mineral acids as escharotics, i. 501 • Miner's elbow, i. 653 Minor surgery, i. 472 abstraction of blood, i. 483 avulsion, i. 480 bandaging, i. 503 counter-irritation, i. 494 crushing, i. 481 dressing, i. 501 enucleation, i. 480 escharotics, i. 499 incisions, i. 476 instruments, i. 472 ligation, i. 481 transfusion of blood, i. 492 vaccination, i. 493 Mixed urinary deposit, ii. 760 Mode of reparation of wounds of the intestines. ii. 697 Moles, i. 626 treatment of, i. 627 Mollities ossium, i. 882 Molluscous tumors, i. 625 contents of, i. 626 treatment of, i. 626 Monro's apparatus for flexion of leg in rup- tured tendo Achillis, ii. 1027 Monsel's salt as a styptic, i. 706 Morbid erections of the penis, ii. 871 growths, i. 228 amputation in, i. 538 sensibility of the urethra, ii. 809 causes of, ii. 809 pathology of, ii. 810 symptoms of, ii. 809 treatment of, ii. 810 Mortality after amputations, i. 563 circumstances influencing, i. 563 statistics of, i. 567 after surgical operations, i. 522 Mortification, acute, i. 169 , amputation in, i. 534 constitutional symptoms of, i. 173 treatment of, i. 174 line of demarcation in, i. 173 local symptoms of, i. 172 treatment of, i. 175 natural amputation in, i. 172 question of amputation in, i. 176 chronic, i 177 amputation in, i. 182, 535 anomalous cases of, i. 180 constitutional treatment of, i. 181 local treatment of, i. 182 from action of phosphorous, i. 171 in inflammation, i. 168 of bone, i. 871 of the gums, ii. 533 , of the vulva, ii. 938 traumatic,question of amputation in, i. 177 varieties of, i. 169 Mother-mark, i. 844 • Moulding tablet in the treatment of fracture, i. 939 Mouth, diseases and injuries of, ii. 536 Movable bodies within the joints, ii. 35 development of, ii. 36 diagnosis of, ii. 38 structure of, ii. 36 subcutaneous removal of, ii. 39 symptoms of, ii. 37 treatment of, ii. 38 Moxa as a counter-irritant, i. 497 Mucocele, ii. 359 Mucous crypts of the vulva, inflammation of, ii. 938 membrane of the lip, eversion of, ii. 540 of the nose, hypertrophy of, ii. 416 membranes, syphilitic affections of, i. 415 transformation, i. 213 . tubercle, i. 416 Mulberry calculus, ii. 766 Multilocular ovarian cyst, ii. 924 Multiple abscess, i. 156 Mumps, ii. 555 Muscles, affections of, i. 642 atrophy of, i. 645 contraction of, i. 645 cysts of, i. 647 encephaloid of, i. 647 fatty transformation of, i. 014 gunshot wounds of, ii. 983 hydatids of, i. 646 INDEX. 1H9 Muscles— inflammation of, i. 644 laceration of, i. 642 malignant diseases of, i. 647 melanosis of, i. 647 of stump, inordinate retraction of, i. 554 rupture of, i. 642 tumors of, i. 646 ulceration of, i. 645 wounds of, i. 642 Muscular walls .of the abdomen, wounds of, ii. 709 Myelitis, ii. 250 Myeloid tumors, i. 254 of bone, i. 909 Myositis, i. 644 Myotomy in lateral curvature of the spine, ii. 256 * Nail of big toe, inversion pf, ii. 1009 Nasal bones, fractures of, i. 961 cartilages, fractures of, i. 963 cavities, diseases and injuries of, ii. 412 duct, affections of, ii. 1032. See also Da- cryocystitis. Nates, affections of, ii. 1032 pruritus of, ii. 681 Nauseants as antiphlogistics, i. 98 Navel. See Umbilicus. Nebula, ii. 302 Neck, abscess of, ii. 479 bloody tumors of, ii. 479 encysted tumors of, ii. 478 fibrous tumors of, ii. 478 injuries and diseases of, ii. 466 malignant tumors of, ii. 479 sebaceous tumors of, ii 478 serous tumors of, ii. 479 synovial burse of, ii. 478 tumors of, ii. 478 wounds of, ii. 466 wry, ii. 469 Necrosis, i. 871 causes of, i. 871 cloacae in, i. 876 exfoliation in, i. 875 extent of, i. 873 of bone of stump, i. 555 of the jaw, ii. 511 of the nose, ii. 425 of the orbit, ii. 373 of the skull, ii. 226 of the teeth, ii. 524 operations for, i. 880 prognosis of, i. 878 reparation in, i. 875 sequester of, i., 875 symptoms of, i. 877 syphilitic, i. 426 treatment of, i. 878 Needles, aneurism, i. 698 exploring, i. 461 for dressings, i. 476 Scarpa's, ii. 325 suture, i. 476 tenaculum, i. 698 Nerve, inferior maxillary, excision of for neu- ralgia, i. 681 superior maxillary, excision of for neu- ralgia, i. 682 Nerves, compression of, i. 666 concussion of, i. 666 contusions of, i. 666 diseases of, i. 667 Nerves— disordered functions of, i. 665 gunshot wounds of, ii. 985 injuries of, i. 665 • after venesection, i. 491 neuralgia, i. 6J5 of stump, bulbous enlargement of, i. 556 state of, in inflammation, i. 84 sympathies and irritations of, i. 40 wounds of, i. 665 , Nervous deafness, ii. 396 system, effects of injuries upon, i. 371 collapse, i. 371 prostration, i. 371 shock, i. 371 traumatic delirium, i. 376 Neuralgia, i. 675 causes of, i. 675 facial, excision of branches of fifth pair for, i. 681 of bone, i. 915 of the anus and rectum, ii. 680 of the bladder, ii. 736 of the ear, ii. 407 of the eye, ii. 348 , of the joints, ii. 87 , ■ of the mammary gland, ii. 964 of the stump, i. 556 of the testicle, ii. 851 of the urethra, ii. 810 of the uterus, ii. 908 patholdgy of, i. 677 prognosis of, i. 677 section and excision of nerves for, "i. 681 symptoms of, i. 676 treatment of, i. 677 Neuromata of stump, i. 556 Neuromatous tumors, i. 245 Nevus, i. 844 Nipples, sore, ii. 963 Nitrate of silver as a local antiphlogistic, i. no Nitric acid in treatment of internal piles, ii. 672 Nocturnal incontinence of urine, ii. 748 Node, i. 426 treatment of, i. 438 Noli me tangere, i. 636 Nose, calculi of, ii. 417 diseases and injuries of, ii. 412 encephaloid of, ii. 424 foreign bodies in, ii. 417 hemorrhage of, ii. 412 hypertrophy of mucous membrane of, ii. 416 lipoma of, ii. 425 malformations of, ii. 416 necrosis of, ii. 425 plugging of the, ii. 414 polyps of, ii. 418 reconstruction of, ii. 426 ^ septum of, curvature of, ii. 416 syphilis of, i. 421 ulceration of, ii. 414 wounds of, ii 425 Nucleus of urinary calculi, ii. 763 Nymphae, affections of, ii. 941 Obliteration of the pupil, ii. 313 of veins, ii. 1025 Oblique inguinal hernia, ii. 621 Obstruction of the lachrymal canals, n. dob Obturator for cleft palate, ii. 564 hernia, ii. 641 1120 INDEX. Occipital artery, ligation of, i. 808 Occlusion, congenital, of Eustachian tube, ii. 401 mechanical, of Eustachian tube, ii. 401 of the auditory tube, ii. 380 of the rectum, ii. 683 « of the uterus, ii. 906 of the vagina, ii. 935 of the vulva, ii. 940 Ocular inspection of eye, ii. 278 Odontalgia, ii. 528 Odontoid process, fracture of, i. 986 GSdema of the larynx, ii. 434 of the sub-conjunctival areolar tissue, ii. 297 of the vulva, ii. 938 (Esophagotomy, ii. 587 (Esophagus, affections of, ii. 577 carcinoma of, ii. 582 forceps, ii. 588 foreign bodies in, ii. 584 organic stricture of, ii. 580 opening of, ii. 587 paralysis of, ii. 584 passage of tubes along, ii. 588 .polyps of, ii. 583 spasmodic stricture of, ii. 579 wounds of, ii. 579 Olecranonj excision of, ii. 1048 process, fractures of, i. 991 union of, i. 991 Omentum, protruded, in strangulated hernia, ii. 606 treatment of, ii. 617 Onychia maligna, ii. 989 syphilitic, i. 424 treatment of, i. 437 Onyxitis, ii. 989 Opacity of the cornea, ii. 302 Operations, i. 515 accidents during, i. 515 dangers after, i. 518 dressings and after-treatment of, i. 516 plastic, i. 524 Operative surgery, i. 508 Ophthalmia, purulent, ii. 287 of infancy, ii. 287 gonorrhoeal, ii. 288 strumous, ii. 341 Ophthalmic artery, aneurism of, i. 779 Ophthalmoscope, i. 462, ii. 275 Opisthotonos, i. 667 Orbitar plate of frontal bone, gunshot injuries of, ii. 241 Orbit, abscess of, ii. 373 • affections of, ii. 373 caries of, ii. 373 necrosis of, ii. 373 tumors of, ii. 373 Orchitis, acute, ii. 844 treatment of, ii. 845 chronic, ii. 845 treatment of, ii. 847 syphilitic, i. 428 Organs, abdominal, wounds of, ii. 689 female genital, oiseases and injuries of, ii. 896 male genital, diseases and injuries of, ii. 843 urinary, diseases and injuries of, ii. 720 Organic stricture of the oesophagus, ii. 580 of the rectum and anus, ii. 676 Oscheo-hydrocele, ii. 858 Os magnum, dislocations of, ii. 134 Osseous concretions, ii. 35. system. See Bone. tumors, i. 244 Ossification of the testicle, ii. 848 . of the thyroid gland, ii. 474 Osteitis, i. 856 treatment of, i. 859 Osteomalacia, i. 882 Osteomyelitis, i. 854 of stump, i. 554 Otalgia, ii. 407 Otitis, ii. 387 Otorrhoea, ii. 387 Otoscope, i. 462, ii. 403 Oval amputation, i. 544 Ovarian dropsy, ii. 923 tumors, ii. 922 diagnosis of, ii. 925 excision of a portion of sac of, ii. 929 extirpation of, ii. 930 fibrous, ii. 923 injections in, ii. 930 malignant, ii. 925 mortality of, ii. 933 multilocular, ii. 92t ovariotomy for, ii. 930 progress of, ii. 927 tapping for, ii. 928 treatment of, ii. 928 unilocular, ii. 923 Ovariotomy, ii. .930 circumstances rendering it proper, ii. 931 mortality of, ii. 923 Ovaritis, ii. 921 treatment of, ii. 922 Ovary, affections of, ii. 921 inflammation of, ii. 921 malignant growths of, ii. 925 tumors of, ii. 922 Oxalic calculus, ii. 766 .deposit, ii. 759 treatment of, ii. 759 Ozaena, ii. 415 treatment of, ii. 415 syphilitic, i. 421 treatment of, i. 438 Pain of inflammation, i. 65 of spasm, i. 66 Palate, abscess of, ii. 568 affections of, ii. 563 cleft, ii. 563 fissure of, ii. 563 inflammation of, ii. 563 tumors of, ii. 568 ulceration of, ii. 563 wounds of, ii. 563 Palmar aponeurosis, contraction of, ii. 993 Palmer's artificial limbs, i. 561 Palsy, infantile, i. 686 treatment of, i. 687 partial, i. 687 ' treatment of, i. 688 wasting, i. 682 pathology of, i. 685 prognosis of, i. 685 progress of, i. 684 symptoms of, i. 683 treatment of, i. 685 Pancoast's operation for cataract, ii. 328 for incurvation of the penis, ii. 873 for the radical cure of reducible hernia, ii. 596 suture, ii. 428 INDEX. 1121 Papule, syphilitic, i. 411 Paracentesis of the chest, ii. 492 Paralysis of the bladder, ii. 737 causing incontinence of urine, ii. 747 hysterical, ii. 739 senile, ii. 737 treatment of, 737 of the larynx and trachea, ii. 440 of the oesophagus,'ii. 584 of the pharynx, ii. 584 Paralytic affections, i. 682 Paraphymosis, ii. 875 treatment of, ii. 876 Parietal abscess, ii. 711 Paronychia, ii. 995 Parotid gland, abscess of, ii. 556 affections of, ii. 555 extirpation of, ii. 557 gangrene of, ii. 556 inflammation of, ii. 555 morbid growths of, ii. 557 tumors over the, ii. 558 duct of, affections of, ii. 558 earthy concretions of, ii. 559 fistule of, ii, 559 Parotitis, ii.,555 treatment of, ii. 556 Partial palsy, i. 687 Passages, false, of the urethra, ii. 826 Patella, dislocations of, ii. 167 excision of, ii. 1064 fractures of, i. 1021 Patient, attitude of, a means of general diag- nosis, i. 454 examination cf, a means of general diag- nosis, i. 446 position of in operations, i. 515 preparation of, for operations, i. 510 . Pelvic bones, dislocations of, ii. 127 excision of, ii. 1044 fractures of, i. 986 Penis, affections of, ii. 870 amputation of, ii. 873 carcinoma of, ii. 872 fibrous transformation of septum of, ii. 872 incurvation of, ii. 873 laceration of, ii. 871 morbid erections of, ii. 871 phlebitis of, ii. 871 strangulation of, ii. 871 ulcers of, ii. 872 wounds of, ii. 870 Perforation of the bladder during lithotripsy, ii. 781 of the larynx, ii. 462 Pericardium, wounds of, ii. 494 Perineal bandage, ii. 960 fistule after lateral operation of lithotomy, ii. 794 hernia, ii. 641 puncture of the bladder, ii. 746 section for stricture of the urethra, ii. 820 Perineum, laceration of, ii. 958 operation for, ii. 958 Periostitis, i. 851 acute, i. 852 chronic, i. 853 dental, ii. 527 Pernio, i. 621 Peroneal artery, ligation of, i. 829 muscles, division of, ii. 1020 Persian fire, i. 367 Phagedena, i. 388 » VOL. II.—71 Phagedenic bubo, i. 404 chancre, i. 388 , Phalanges, digital, excision of, ii. 1040 Pharyngitis, ii. 577 treatment of, ii. 577 Pharynx, abscess of, ii. 578 affections of, ii. 577 carcinoma of, ii. 582 diphtheritis of, ii. 578 foreign bodies of, ii. 584 inflammation of, ii. 577 paralysis of, ii. 584 phlegmonous abscess of, ii. 578 polyps of, ii. 583 stricture of, ii. 579 strumous abscess of, ii. 578 wounds of, ii. 579 Phymosis, ii. 874 treatment of, ii. 875 Phlebitic ophthalmitis, ii. 350 Phlebitis, acute, i. 831 treatment of, i. 832 after venesection, i. 490 chronic, i. 833 of the penis, ii. 871 uterine, ii. 904 Phlebolites, i. 833 Phlebotomy, i. 486 Phlegmonous abscess. See Abscess, phlegmo- nous. Phosphatic calculus, ii. 766 deposit, ii. 760 triple, ii. 760 treatment of, ii. 760 Phosphorus, a cause of mortification, i. 171. ii. 510 Photophobia, ii. 341 Physick's artery forceps, i. 697, ii. 791 Physometra, ii. 908 Piles, external, ii. 665 treatment of, ii. 666 internal, ii. 666 ecraseur in treatment of, ii. 672 ligation of, ii. 672 nitric acid in treatment of, ii. C72 radical cure of, ii. 071 structure of, ii. 667 treatment of, ii. 670 Pimple, malignant, i. 367 Pin, hare-lip, i. 302 pliers, i. 303 Pirogoff's amputation at the ankle, ii. 1082 Pisiform bone, dislocations of, ii. 134 Plantar aponeurosis, section of, ii. 1020 arteries, wounds of, i. 829 artery, ligation of, i. 829 Plaster, adhesive, i. 299 isinglass, i. 300 of Paris bandage, ii. 939 Plastic matter, injurious effects of, i. 132 uses of, i. 130 operation for ectropion, ii. 364 surgery, i. 524 suture, i. 301 Pleurosthotonos, i. 667 Plugging of the nose, ii. 414 Pneumonocele, ii. 482 Pneumothorax, ii. 488 treatment of, ii. 489 Podelkoma, ii. 1023 Pododynia, ii. 1023 Poisoned wounds, i. 346 Polyps, fibrous, i. 252 gelatinoid, i. 252 1122 i\] Polyps— granular, i. 258 of the antrum of Highmore, ii. 502 treatment of, ii. 503 of the auditory tube, ii. 384 gelatinoid, ii. 385 instruments for removal of, ii. 386 lobulated, ii. 385 recurring fibroid, ii. 385 of the bladder, ii. 752 of the frontal sinus, ii. 410 of the larynx, ii. 438 of the nose, ii. 418 canula and wire for removal of, ii. 422 fibrous, ii. 418 forceps for removal of, ii. 421 gelatinoid, ii. 418 naso-pharyngeal, ii. 419 removal of, ii. 421 treatment of, ii. 421 « of the oesophagus, ii. 583 of the pharynx, ii. 583 of the rectum, ii. 675 of the tonsils, ii. 575 of the urethra, ii. 811 of the urethra, female, ii. 942 of the uterus, ii. 911 fibrous, ii. 911 gelatinoid, ii. 912 granular, ii. 912 termination of, ii. 913 treatment of, ii. 913 vascular, ii. 912 vesicular, ii. 912 of the vagina, ii. 936 of the vulva, ii. 939 transformations of, i. 253 vascular, i. 253. Polypoid tumors, i. 251 Polypus forceps, ii. 421 Popliteal artery, aneurism of, i. 79S ligation of, i. 826 Porte-caustique, ii. 819 Potassa, caustic, as an escharotic, i. 500 chlorate of, in salivation, i. 97 Potassium, iodide of, in tertiary syphilis, i. 432 Pott's disease of the spine, ii. 256 Pouches of the rectum, ii. 660 Poultices, i. 109 as local antiphlogistics, i. 109 varieties of, i. 109 Prepuce, affections of, ii. 873 calculous concretions in, ii. 877 diseases of the frenum of, ii. S77 enlargement of, ii. 876 herpetic ulcer of, ii. 873 hypertrophy of, ii. 877 paraphymosis of, ii. 875 phymosis of, ii. 874 psoriasic ulcer of, ii. 874 warty excrescences of, ii. 874 Priapism, ii. 871 treatment of, ii. 871 Primary syphilis, i. 383 Probe, 'i. 458 Anel's, ii. 357 Prolapse of the iris, ii. 312 of the rectum, ii. 661 complete variety of, ii. 662 incomplete variety of, ii. 662 operation for, .ii. 664 treatment of, ii. 663 Prolapse— of the uterus, ii. 900 treatment of, ii. 901 of the vagina, ii. 936 treatment of, ii. 336 Prostatitis, apute, ii. 828 treatment of, ii. 828 Prostate gland, abscess of the, ii. 829 acute inflammation of the, ii. 828 atrophy of the, ii. 836 calculi of the, ii. 841 cauterization of the, ii. 835 crushing the middle lobe of the, ii. 835 ' cystic disease of the, ii. 840 discharge from, ii. 836 diseases and injuries of the, ii. S2.S encephaloid of the ii. S40 excision of the, ii. 835 fibrous tumors of the, ii. 840 hemorrhage of the, ii. 841 heterologous formations of the, ii. 810 hypertrophy of the, ii. 830 incision of the, ii. 835 melanosis of the, ii. 840 scarification of the, ii. 835 scirrhus of the, ii. 840 tubercles of the, ii. 840 ulceration of the, ii. 829 Prostatorrhcea, ii. 830 causes of, ii. 836 diagnosis of, ii. 837 pathology of, ii. 838 prognosis of, ii. 839 treatment of, ii. 839 Prostration, nervous, i. 371 Pruritus of the anus and nates, ii. 681 of the vulva, ii. 939 Psoas abscess, ii. 2Q2 structure of, ii. 263 symptoms'of, ii. 268 treatment of, ii. 264 Psoriasic ulcer of the prepuce, ii. 87-1 Psoriasis of the scrotum, ii. 860 Psorophthalmia, ii. 366 Pterygium, ii. 294 operation for, ii. 295 Ptosis, ii. 367 Ptyalism, i. 96 treatment of, i. 97 Pubes, fracture of, i. 987 Pubic dislocation of femur, ii. 182 symphyses, dislocation of, ii. 128 Pulleys, ii. 102 Puncture of the bladder, ii. 745 inter-pubic method, ii. 747 supra-pubic method, ii. 746 through the perineum, ii. 746 rectum, ii. 746 of the cranium, ii. 220 of.nerves, i. 665 Punctured wounds, i. 318 Puncturing, i. 483 Pupil, artificial, ii. 313 instruments for operation of, ii. 314 operation by incision for, ii. 314 by detachment for, ii. 315 by excision for, ii. 315 obliteration of, ii. 313 Purgatives in the treatment of strangulated [ hernia, ii. 610 Purulent infection from lithotripsy, ii. 781 infiltration, i. 149 ophthalmia, ii. 287 of infants, ii. 287 • INDEX. 1123 Pus, i. 135 characters of, i. 136 effusion of, compressing the brain, ii. 211 into the pleural cavity, ii. 485 formation of, i. 135 in joints, ii. 28 treatment of, ii. 30 production of, i. 139 varieties of, i. 138 Pustule, malignant, i. 367 syphilitic, i. 410 Pyemia, i. 156 from amputation, i. 559 Pyogenic membrane, i. 152 Pyophthalmitis, ii. 350 Pyothorax, ii. 489 Quilled suture, i. 303 Rabid animals, wounds by, i. 352 Rabies, i. 352 Rachitis, i. 886 causes of, i. 886 pathology of, i. 887 symptoms of, i. 888 treatment of, i. 889 Radial artery, aneurism of, i. 791 ligation of, i. 816 Radical cure of hernia, ii. 595 Radio-ulnar dislocations, ii. 136 Radius, dislocations of, at elbow, ii. 139 backwards, ii. 140 forwards, ii. 143 outwards, ii. 145 excision of, ii. 1046 fractures of, i. 994 and ulna, dislocations of, at the elbow, ii. 139 fractures of shafts of, i. 989 Ramollissement, i. 210 Ranula, ii. 561 treatment of, ii. 562 Reclination of the lens in cataract, ii. 329 Rectal puncture of the bladder, ii. 746 Rectangular amputation, i. 545 Recto-vesical operation of lithotomy, ii. 800 Rectum, ascarides in, ii. 651 cancer, ii. 677 foreign bodies in, ii. 650 extraction of, ii. 652 hardened feces in, ii. 651 hemorrhage of, ii. 650 injuries of, ii. 649 treatment of, ii. 649 .malformations of, ii. 682 neuralgia of, ii. 680 occlusion of, ii. 683 opening into the urinary organs, ii. 684 into the vagina, ii. 685 organic stricture of, ii. 676 polyps of, ii. 675 pouches of, ii. 660 prolapse of, ii. 661 scirrhus of, ii. 678 • sloughing of, after lateral operation of lithotomy, ii. 793 stricture of, ii. 676 sympathies and irritations of, i. 42 ulceration of, ii. 658 wound of in lateral operation of li ii. 793 Reducible hernia, ii. 592 Reef-knot, i. 696 Regimen, antiphlogistic, i. 104 Renal abscess, ii. 713 dropsy, ii. 713 Reparation, mode of, in necrosis, i. 875 in wounded intestine, ii. 697 Reproduction of malignant tumors, i. 284 Resection in complicated dislocations, ii. 109 of ends of bone in ununited fracture, i. 955. See also Excision. Resolution, in inflammation, i. 121 Rest and position, as local antiphlogistics, i. 105 Retained testicle, ii. 843 Retention of urine, ii. 739 from affections of the bladder, ii. 741 from amputation, i. 558 from coagulated blood, ii. 741 from hypertrophy of the prostate, ii. 741 from imperforate prepuce, ii. 742 from inflammation of urethra and neck of bladder, ii. 742 from inspissated mucus, ii. 742 , from mechanical obstruction of the ure- thra, ii. 740 * from paralysis, ii. 742 in hysterical females, ii. 742 from pelvic tumor, ii. 743 from priapism, ii. 742 from spasm of the neck of the bladder, ii. 742 incontinence of, ii. 742 periodical, ii. 743 symptoms of, ii. 740 treatment of, ii. 740 Retina, acute inflammation of, ii. 335 amaurosis, ii. 338 chronic inflammation of, ii. 336 diseases of, ii. 334 Retinitis, acute, ii. 335 chronic, ii. 336 Retro-uterine hematocele, ii. 910 treatment of, ii. 911 Retroversion of the uterus, ii. 899 treatment of, ii. 899 Rheumatic arthritis, chronic, ii. 77 iritis, ii. 310 sclerotitis, ii. 307 synovitis, ii. 27 Rheumatism of the hip-joint, ii. 78 Rhinolites, ii. 417 Rhinoplasty, ii. 426 Indian method of, ii. 427 Italian method of, ii. 429 tongue and groove suture in, ii. 428 Rhinoscope, ii. 412 Ribs, dislocations of, ii. 126 excision of, ii. 1042 fractures of, i. 977 Rickets, i. 886 Riggs's operation for the radical cure of re- ducible hernia, ii. 599 Roseola, syphilitic, i. 409 Rubefacients, as counter-irritants, i. 494 Rupia, syphilitic, i. 423 Rupture of membrane'of the tympanum, n. 390 of muscles, i. 642 of spleen, ii. 707 of tendons, i. 648 Sabre cuts of the head, ii. 242 Sac, hernial, ii. 590 '■ ■ p lachrymal, abscess of, ii. 358 acute inflammation of, ii- 358 affections of, ii. 358 chronic inflammation of, ii. 359 1124 IND EX. Sac, lachrymal— fistule of, ii. 361 of the anus, ii. 660 treatment of, ii. 661 Sacciform aneurism, i. 729 fibrinous concretions of, i. 731 formation of, i. 730 Sacculated bladder, ii. 731 Sacro-iliac dislocation, ii. 127 Sacrum, fracture of, i. 987 Salivary calculus, ii. 561 glands, affections of, ii. 555 Sarcocele, syphilitic, i. 428 Sarcoma, cystic, ii. 848 of the scrotum, ii. 862 Saws, amputating, i. 549 Scabbing process, i. 308 Scalds, i. 610 , of the larynx,.ii. 436 "Scalp, contusions of, ii. 195 secondary effects of, ii. 195 tumors of, ii. 196 fibrous, if. 197 malignant, ii. 197 sanguineous, ii. 196 sebaceous, ii. 197 vascular, ii. 197 wounds of, ii. 193 contused, ii. 194 gunshot, ii. 194, 238 incised, ii. 193 lacerated, ii. 194 punctured, ii. 194 Scalpels, i. 473 Scaphoid bone, dislocation of, ii. 160 Scapula, excision of, ii. 1041 fractures of, i. 974 Scapular dislocation of humerus, i. 151 Scarification, i. 483 of the neck of the sac for the cure of her- nia, ii. 596 of the prostate gland, ii. 835 of the tonsils, ii. 569 Schwerdt's needle-forceps, for cleft palate, ii. 566 Sciatic artery, aneurism of, i. 794 ligation of. i. 821 dislocation of femur, ii. 180 Scirrhus, i. 258 of bone, i. 911 of the anus and rectum, if. 677 of the bladder, ii. 754 of the groin, ii. 1037 of the lymphatic ganglions, i. 663 of the mammary gland, ii. 971 of the oesophagus, ii. 582 of the ovary, ii. 925 of the pharynx, ii. 582 of the prostate gland, ii. 840 of the skin, i. 639 of the sublingual gland, ii. 562 of the submaxillary gland, ii. 560 of the testicle, ii. 850 of the tongue, ii. 551 of the upper jaw, ii. 505 of the uterus, ii. 916 Scissors, i. 501 dressing, i. 501 Sclerotica, diseases and injuries of, ii. 305 inflammation of, ii. 306 staphyloma of, ii. 305 wounds of, ii. 305 Sclerotitis, ii. 306 rheumatic, ii. 307 Sclerotitis— syphilitic, ii. 307 Scoop for removing calculi, ii. 788 Scrofula, i. 287 treatment of, i. 292 Scrofulous abscess, i. 151 bubo, i. 404 ulcer, i. 292 Scrotal hernia, ii. 627 Scrotum, affections of, ii. 860 calculi of, ii. 862 carcinoma of, ii. 864 cysts of, ii. 861 earthy concretions of, ii. 862 elephantiasis of, ii. 862 encephaloid of, ii. 864 fatty tumor of, ii. 862 foetal remains in, ii. 864 hematocele of, ii. 860 hypertrophy of, ii. 861 inflammation of, ii. 860 melanosis of, ii. 864 psoriasis of, ii. 860 sebaceous tumor of, ii. 861 sloughing of, ii. 860 varix of, ii. 864 wounds of, ii. 860 Sebaceous tumors, i. 623 of the neck, ii. 478 of the scrotum, ii. 861 treatment of, i. 625 Secondary hemorrhage, i. 331, 708 syphilis, i. 406 Section, Caesarean, ii. 920 Semilunar cartilages, dislocations of, ii. 173 Senile gangrene, i. 177 paralysis of the bladder, ii. 737 Sensibility, morbid, of the urethra, ii. 809 Separation, intra-parietal, of arterial tunics, i. 722 of bones at their epiphyses, i. 950 Septum of the nose, lateral curvature of, ii- 416 of the penis,'fibrous transformation of, ii. 872 Sequester, i. 875 Sero-cystic tumors of bone, i. 904 of the mammary gland, ii. 967 Serous cysts of the tonsils, ii. 575 tumor of neck, ii. 479 of kidney, ii. 713 Serpents, venomous wounds of, i. 348 Serpiginous chancre, i. 389 Serum, deposition of in inflammation, i. 122 effusion of into pleural cavity, ii. 185. Seton, as a counter-irritant, i. 495 in the treatment of anal fistule, ii. 657 of goitre, ii. 476 of hydrocele, ii. 856 , in ununited fractures, i. 955 Shock, i. 371 ^ from amputation, i. 557 "Skreaction after, i. 374 3§&iptoms of, i. 374 treatment of, i. 375 Shortening of the tendons of the fingers, ii. 993 Shortness of the vagina, ii. 934 Shoulder joint, nffeltiq'ns of, ii. 1000 amputation at, lL'3-075 dislocations of, ii. 146 excision of, ii. 1051 tuberculosis of, ii. 60 Silver suture, i. 304 INDEX. 1125 Simpson's uterine sound, ii. 897 Sims's catheter, ii. 955 Sinus, frontal, affections of, ii. 409 maxillary, affections of, ii. 499 Skin, condylomata of the, i. 430 hypertrophy of the, i. 627 secondary syphilitic affections of the, i. 409 sympathies and irritations of the, i. 45' tertiary syphilis of the, i. 423 treatment of the, i. 437 and cellular tissue, morbid growths of the, i. 589 eiloid tumor of the, i. 635 elephantiasis of the, i. 627 hypertrophy of the, i. 627 keloid tumor of the, i. 631 lepoid tumor of the, i. 635 lupus of the, i. 636 melanosis of the, i. 639 moles of the, i. 626 molluscous tumor of the, i. 625 sebaceous tumors of the, i. 623 scirrhus of the, i. 639 warts of the, i. 622 and cellulo-adipose tissue, diseases and injuries of the, i. 589 bed-sores, i. 608 burns, i. 610 carbuncle, i. 605 chilblain, i. 621 • erysipelas, i. 589 frost-bite, i. 618 furuncle, i. 603 gangrene, i. 608 insects, i. 640 morbid growths, i. 622 scalds, i. 610 Skull, apparent depression of bones of, ii. 223 caries of, ii. 226 depression of, compressing the brain, ii. 210 of bones of, without fracture, ii. 222 exostosis of, ii. 225 fractures of, ii. 213 arrow, ii. 242 at base, ii. 218 compound, ii. 216 gunshot, ii. 238 of external table alone, ii. 221 of internal table alone, ii. 222 punctured, ii. 220 simple, without depression, ii. 214 with depression and symptoms of compression, ii. 216 with depression of bone, ii. 215 hypertrophy of bones of, ii. 226 necrosis of, ii. 226 recovery after bad injuries of, ii. 235 tapping of, ii. 244 Sloughing of the rectum, after lateral opera- tion of lithotomy, ii. 793 of the scrotum, ii. 860 chancre, i. 388 Snake-bites, i. 348 Soft chancre, i. 386 Softening, from defective nutrition, i. 211 in inflammation, i. 210 of arteries, i. 718 . of bone, i. 882 causes of, i. 8S3 diagnosis of, i. 885 extent of, i. 882 Softening of bone— morbid anatomy of, i. 883 symptoms of, i. 884 treatment of, i. 885 of callus, i. 961 treatment of, i. 211 Solution of cataract, operations of, ii. 324 Sore nipples, ii. 963 treatment of, ii. 964 Sound, metallic, i. 460 uterine, Simpson's, ii. 897 Sounding for stone, ii. 769 errors of, ii. 770 Sounds, ii. 769 Spasm of stump, i. 553 of the larynx and trachea, ii. 439 Spasmodic stricture of the oesophagus, ii. 579 Specula, anal, ii. 647 for the ear, ii. 376 uterine, ii. 896 Speculum, i. 460 Spermatic cord, abscess of, ii. 865 affections of, ii. 865 carcinomatous disease of, ii. 870 contusions of, ii. 865 encysted tumors of, ii. 870 fatty tumors of, ii. 869 hematocele of, ii. 867 hydrocele of, ii. 865 inflammation of, ii. 865 syphilitic disease of, ii. 870 varicocele of, ii. 867 wounds of, ii. 865 Spermatorrhoea, ii. 893 cauterization in, ii. 894 treatment of, ii. 893 Sphacelus, i. 168 Spine, bifid, ii. 265 dislocations of, ii. 124 Spinal cord and column, concussion of, ii. 247 diseases and injuries of, ii. 247 hydrorachitis of, ii. 264 inflammation of, ii. 250 lateral curvature of, ii. 250 psoas abscess, ii. 262 sprains of, ii. 247 posterior curvature of, ii. 259 strumous abscess of, ii. 257 sympathies and irritations of, i. 40 tuberculosis of, ii. 256 wounds of, ii. 248 Spleen, rupture of, ii. 707 wounds of, ii. 706 Splenic abscess, ii. 713 Sponge probang for the larynx, ii. 442 Sponges, i. 501 Spongio-piline, i. 502 _ Spontaneous expulsion of foreign bodies from windpipe, ii. 454 Sprains, ii. 23 treatment of. ii. 25 of the hip-joint, ii- 69 of the spinal cord, ii. 247 Squint, ii. 3(is Staff, female, ii. 803 male, ii. 821 grooved, ii. 785 Staphyloma of the cornea, ii. 303 of the sclerotica, ii. 305 Staphylorraphy, ii. 564 Starch bandage, i. 939 Steno's duct. See Duct of Steno. Sternum, excision of, ii. 1043 fractures of, i. 981 1126 # INDEX. Stethoscope, i. 462 Stomach and bowels, foreign bodies in, ii. 707 sympathies and irritations of, i. 40 wounds of, ii. 689 Stone in the bladder, ii. 761 acids in treatment of, ii. 775 age most liable to, ii. 761 after-treatment of, ii. 794 alkalies in treatment of, ii. 775 Allarton's operation for, ii. 800 bilateral operation for, ii. 797 Buchanan's operation for, ii. 799 • causes of, ii. 762 chemical properties of, ii. 765 color of, ii. 764 consistence of, ii. 764 diagnosis of, ii. 769 dietetic regulations in, ii. 795 difficulties of extraction of, ii. 789 dilatation of urethra for, ii. 776 encysted, ii. 771 extraction of through the urethra, ii. 775 instruments for, ii. 776 forms of, ii. 764 ammoniaco-magnesian, ii. 766 cystic, ii. 767 fibrinous, ii. 768 fusible, ii. 767 hemp-seed, ii. 766 oxalic acid, ii. 766 phosphatic, ii. 766 uric acid, ii. 765 uro-ammoniac, ii. 766 xanthic, ii. 768 hemorrhage after removal of, ii. 791 impotence after, ii. 794 incontinence of urine after removal of, ii. 793 inflammation of wound in, ii. 792 in females, ii. 802 in the negro, ii. 762 lesion of prostate gland in removal of, ii. 792 lithectasy for, ii. 800 lithotomy for, ii. 783. See Lithotomy. lithotripsy for, ii. 777. See Lithotripsy. median operation for, ii. 799 medical treatment of, ii. 774 nucleus of, ii. 763 number of, ii. 763 orchitis after, i. 794 pathological effects of, ii. 773 perineal fistule after removal of, ii. 794 peritonitis after removal of, ii. 793 phlebitis after removal of, ii. 792 physical properties of, ii. 763 signaof, ii. 769 recto-vesfcal operation for, ii. 796 relapse after removal of, ii. 785 removal of, ii. 785, 797 results of different operations of lithotomy for, ii. 802 retention of urine after removal of, ii. 792 secondary hemorrhage after removal of, ii. 792 sinking from shock after removal of, ii. 792 situation of, ii. 768 sloughing of the rectum after removal of, ii. 793 sounding for, ii. 769 statistics of lateral operation for, ii. 795 supra-pubic operation for, ii. 800 symptoms of, ii. 769 Stone— tetanus after removal of, ii. 793 topography of, ii. 762 treatment of, ii. 774 urinary infiltration after removal of, ii. 793 varieties in lateral operation for, ii. 796 volume of, ii. 764 weight of, ii. 764 wound of the rectum in remoVal of, ii. 793 Strabismus, ii. 368 instruments in operation for, ii. 370 operation for, ii. 371 subconjunctival operation for, ii. 373 Strangulated hernia, ii. 605 Strangulation, internal, of the bowel, ii. 643 of the penis, ii. 871 Strapping the indolent ulcer, i. 203 the testicle, ii. 852 Stricture, i. 220 in strangulated hernia, division of, ii. 613 external to sac, ii. 618 of the Eustachian tube, ii. 401 of the lachrymal canals, ii. 357 of the oesophagus, organic, ii. 580 spasmodic, ii. 579 of the pharynx, ii. 579 of the rectum and anus, organic, ii. 676 of the trachea, ii. 437 of the urethra. See Urethra, stricture of. in the female, ii. 942 of the uterus, ii. 906 Struma, i. 287 Strumous abscess. ' See Abscess, scrofulous. diathesis, i. 291 disease of the hip-joint, ii. 63 of the eye, ii. 341 ophthalmia, ii. 341 synovitis, ii. 28 Stump, affections of, i. 552, 555 appearances of after amputation, i. 542- 545 burse over, i. 557 enlargement of arteries of, i. 557 hemorrhage of, i. 552 inflammation of, i. 553 inordinate retraction of, i. 554 necrosis of bone of, i. 555 neuralgia of, i. 556 neuromata of, i. 556 osteomyelitis of, i. 554 pain in the, i. 553 shortening of the tendons of, i. 557 spasm of muscles of, i. 553 formation of, for artificial limjbs, i. 560 Stye, ii. 362 Style, introduction of, ii. 360 Styptics, i. 706 Subacromial dislocation of humerus, ii. 158 Subclavian aneurism, ligation of innominate for, i. 783 artery, aneurism of, i. 781 ligation of, i. 809 on its tracheal aspect, i. 789 Subconjunctival cellular tissue, diseases of, ii. 296 operation for strabismus, ii. 373 Subcoracoid dislocation of the humerus, ii. 158 Subcutaneous hemorrhage, i. 709 surgery, i. 529 indications for, i. 531 tubercle, painful, i. 246 wound, healing of, i. 310 INDEX. 1127 Sublingual gland, affections of, ii. 561 calculous formations of, ii. 562 carcinoma of, ii. 562 ranula of, ii. 561 Submaxillary gland, affections of, ii. 560 cystic tumor of, ii. 561 excretory duct of, calculus of, ii. 561 extirpation of. ii. 560 scirrhus of, ii. 560 tumors of, ii. 560 Superior extremity, affections of, ii. 990 paralysis of, from wounds of the neck, ii. 468 maxilla, affections of, ii. 499 Supernumerary fingers, ii. 991 Suppositories, ii. 649 Supra-pubic operation of lithotomy, ii. 800 puncture of the bladder, ii. 746 Suppurants, as local antiphlogistics, i. 115 Suppuration, in inflammation, i. 134 of arteries, i. 718 of bladder, ii. 726 treatment of, ii. 727 of bone, i. 860 of joints, ii. 45 of hip joint, ii. 67 treatment of, ii. 76 of testicle, ii. 845 treatment of, ii. 846 Suppurative bubo, i. 403 Surgeon, duty of, i. 514 position of in operations, i. 515 qualifications of, i. 508 Surgery, minor, i. 472. See Minor Surgery. operative, i. 508 plastic, i. 524 preliminary observations on, i. 35 subcutaneous, i. 529 Suture, i. 301 Bozeman's, ii. 948 button, i. 301, ii. 948 clamp, i. 301 * continued, i. 303 in wounded intestine, ii. 699 Geiy's, in wounded intestine, ii. 700 glover's i. 303 interrupted, i. 301 in wounded intestine, ii. 699 Lembert's, in wounded intestine, ii. 700 needle, i. 476 plastic, i. 301 quilled, i. 303 silver, i. 304 tongue and groove, ii. 428 twisted, i. 302 Swelling of inflammation, i. 68 white, ii. 32 Sword cuts of the head, ii. 242 Syme's amputation at the ankle, ii. 1081 operation for stricture of the urethra, ii. 821 staff, ii. 821 ( Sympathetic affections of bladder, i. 44 of bowels, i. 42 of brain, i. 39 of ears, i. 46 of eyes, i. 45 of heart, i. 41 of kidneys, l. 43 of liver, i. 43 of lungs, i. 41 of nerves, i. 40 of rectum, i. 42 of skin, i. 45 Sympathetic affections— of spinal cord, i. 40 of stomach, i. 42 of teeth, i. 42, ii. 521 of testicle, i. 44 of uterus, i. 44 relations of teeth, ii. 521 Sympathy, i. 37 a cause of inflammation, i. 58 Syncope, from bleeding, i. 90 treatment of, i. 90 Synchronous amputation, i. 551 Synechia, anterior, ii. 313 posterior, ii. 313 Synovial burse, affections *>f, i. 651 of neck, ii. 478 . membrane, fibrous tumor of, ii. 40 fimbriated, ii. 40 Synovitis, acute, ii. 26 treatment of, ii. 29 chronic, ii. 30 rheumatic, ii. 27 strumous, ii. 28 syphilitic, ii. 28 Syphilides, i. 409 Syphilis, i. 381 infantile, i. 440 treatment of, i. 443 primary, i. 383 bubo, i. 401 chancre, i. 383 inoculation of virus of, in skin, i. 383 mercury in, i. 397 non-mercurial treatment of, i. 397 secondary, i. 406 alopecia, i. 413 cervical adenitis, i. 414 constitutional phenomena of, i. 408 non-contagiousness of, i. 408 of mucous membranes, i. 415 of skin, i. 409 transmissibility of, i. 408 treatment of, i. 412, 413, 417 tertiary, i. 418 condylomata, i. 430 iodide of potassium in, i. 432 mercurial fumigations in, i. 434 inunction in, i. 434 vapor-bath in, i. 435 mercury, bichloride of in, i. 434 of ear, i. 423 of eye, i. 422 of larynx, i. 421 of nose, i. 421 of osseous system, i. 425 of skin, i. 423 of testicle, i. 428 of throat, mouth, and tongue, i. 420 treatment of, i. 432 Syphilitic abscesses, i. 414 affections of mucous membranes, i. 415 of skin, diagnosis of, i. 409 exanthematous form of, i. 409 papular form of, i. 411 pustular form of, i. 410 scaly form of, i. 410 treatment of, i. 412 tubercular form of, i. 411 varieties of, i. 409 vesicular form of, i. 410 caries of skull, ii. 226 disease of the spermatic cord, ii. 870 erythema, i. 415 exostosis of skull, ii. 225 1128 INDEX. Syphilitic fever, i. 409 iritis, ii. 310 mucous tubercles, i. 416 necrosis, i. 426 orchitis, i. 428 sclerotitis, ii. 307 synovitis, ii. 28 ulcers of throat, i. 416 varieties of, i. 416 Syphil;zation, i. 444 Syringe, Anel's, ii. 421 for the ear, ii. 378 uterine, ii. 898 Taliacotian operation, ii. 429 Tapping of abdomen, ii. 716 of chest, ii. 492 * statistics of, ii. 493 of ovarian cyst, ii. 928 of skull, ii. 244 Tarsal bones, dislocation of, ii. 160 excision of, ii. 1053 Tartar on the teeth, ii. 527 Tartar-emetic, as an antiphlogistic, i. 99 Taxis in the treatment of strangulated hernia, ii. 608 Teale's method of amputation, i. 545 Teeth, accumulation of tartar on, ii. 527 aetal changes of, ii. 523 affections of, ii. 521 caries of, ii. 524 dentition, ii. 521 dislocation of, ii. 523 exostosis of, ii. 527 extraction of, ii. 529 fracture of, ii. 523 fungous tumors of membrane of, ii. 526 gangrene of, ii. 524 hemorrhage after extraction of, ii. 532 inflammation of lining membrane of, ii. 526 odontalgia, ii. 528 periostitis of, ii. 527 position of, ii. 522 sympathies and irritations of, i. 42, ii. 521 vicious position of, i. 522 Temporal artery, ligation of, i. 808 Tenaculum, i. 804 needle, i. 698 Tendo Achillis, division of, ii. 1019 laceration of, ii. 1026 Tendon of anterior tibial muscle, division of, ii. 1020 of biceps, dislocations of, ii. 158 of peroneal muscles, division of, ii. 1020 of posterior tibial muscle, division of, ii. 1020 Tendons, diseases and injuries of, i. 647 dislocations of, i. 649 ganglion of, i. 650 hypertrophy of, i. 649 inflammation of, i. 649 injuries of, i. 647 of stump, permanent shortening of, i. 557 rupture of, i. 648 wounds of, i. 647 Tenotome, i. 531 Tenotomy, i. 647 in club-foot, ii. 1019 Tertiary syphilis, i. 418 Testicle, abscess of, ii. 845 atrophy of, ii. 850 bandages for, ii. 852 Testicle- cartilaginous degeneration of, ii. S47 chronic inflammation of, ii. S46 colloid of, ii. 850 congenital irregularities of, ii. 843 cystic disease of, ii. 848 diseases of vaginal tunic of, ii. 852 encephaloid of, ii. 850 fatty tumor of, ii. 848 fibrous degeneration of, ii. 817 fungus of, ii. 846 hydatids of, ii. 850 inflammation of, ii. 844 melanosis of, ii. 850 neuralgia of, ii. 851 ossification of, ii. 848 removal of, ii. 851 retained, ii. 843 scirrhus of, ii. 850 ito ^ ' 1-K strapping of, ii. 852 * If $ - -+{C{\ 0^ suppuration of, ii. 845 sympathies and irritations of, i. 4 1 syphilis of, i. 428 tuberculosis of, ii. 849 wounds of, ii. 844 Tetanus, i. 667 amputation for, i. 540 causes of, i. 667 diagnosis of, i. 670 from amputation, i. 560 pathology of, i. 670 prognosis of, i. 670 symptoms of, i. 668 traumatic, i. 667 treatment of, i. 671 Textural changes, i. 210 Thecitis, i. 649 • treatment of, i. 650 Thigh, affections of, ii. 1031 amputation of, ii. 1087 deformity of, ii. 1031, Thoracic aorta, aneurism of, i. 763 dislocation of humerus, ii. 151 Thorax. See Chest. Throat, diseases and injuries of, ii. 536 syphilis of, i. 420 Thrombus, i. 317 Thumb, amputation of, ii. 1070 dislocations of, ii. 129 Thyroid artery, ligation of, for goitre, ii. 476 arteries, superior, ligation of, i. £07 dislocation of femur, ii. 181 gland, abscess of, ii. 472 cystic tumors of, ii. 473 diseases of, ii. 472 enlargement of, ii. 473 extirpation of, ii. 477 malignant disease of, ii. 477 ossification of, ii. 474 Tibia, dislocation of, at knee, ii. 170 fractures of, i. 1009 and fibula, dislocations of, at ankle, ii. 167 fractures of, i. 1014 Tibial artery, anterior, ligation of, i. 826 posterior, ligation of, i. 827 muscle, anterior, tendon of, division of, ii. 1020 posterior, tendon of, division of, ii. 1020 Tibio-fibular joints, dislocations of, ii. 167 , Tic douleureux. See Neuralgia. Toe, great, dislocation of, ii. 159 exostosis of, ii. 1011 INDEX. 112H Toe- nail of, inversion of, ii. 1009 Toes, amputation of, ii. 1077 deformities of, ii. 1006 Tongue, ablation of, ii. 553 affections of, ii. 547 cancer of, ii. 550 cystic disease of. ii. 552 diagnostic information from, i. 448 diphtheritis of, ii. 549 erectile tumors of, ii. 551 hypertrophy of, ii. 550 inflammation of. ii. 547 malformation of frenum of, ii. 553 morbid adhesions of, ii. 553 partial immobility of, ii. 553 scirrhus of, ii. 551 syphilitic fissure of, i. 420 ulcers of, ii. 549 wart-like excrescences of, ii. 552 wounds of, ii. 547 Tongue and groove suture, ii. 428 Tonsillitis, ii. 570 treatment of, ii. 570 Tonsillotome, ii. 575 Tonsils, abscess of, ii. 571 chronic, ii. 576 affections of, ii. 568 excision of, ii. 574 gangrene of, ii. 571 hypertrophy of, ii. 572 inflammation of, ii.. 570 malignant disease of, ii. 576 polyps of, ii. 575 scarification of, ii. 569 serous cysts of, ii. 575 ulceration of, ii. 571 Toothache, ii. 528 Tooth forceps, ii. 530 wounds, i. 322 Torsion, as a hemostatic, i. 707- forceps, i. 707 Torticollis, ii. 469 Jorg's apparatus for, ii. 472 subcutaneous operation for, ii. 471 treatment of, ii. 470 Tourniquet, i. 547, 702 for field-practice, i. 703 Trachea, fistule of, ii. 440 .hernia of, ii. 441 introduction of tubes into, ii. 443 laceration of, ii. 468 stricture of, ii. 437 Tracheotomy, ii. 463 in membranous croup, ii. 433 Transformations, i. 213 calcareous, i. 214 cellular, i. 213 cutaneous, i. 213 fatty, i. 214 of muscles, i. 644 fibrous, i. 213 of arteries, i. 719 of the septum of the penis, ii. 872 mucous, i. 213 Transfusion of blood, i. 492 Traumatic delirium, i. 376 fever, after amputation, i. 558 after operations, i. 518 tetanus, i. 667 Trephine, ii. 228 Trephining, ii. 227 in epilepsy, ii. 230 instruments for, ii. 228 Trichiasis, ii. 365 operation for, ii. 365 Trismus, i. 667 nascentium, i. 667 Trocar, i. 461, ii. 855 Trochanter of femur, fracture of, i. 1061 excision of, ii. 1068 Trousseau's forceps for windpipe, ii. 459 Truss, for the radical cure of reducible hernia, ii. 593 Tube, auditory, affections of, ij. 380 Eustachian, diseases of, ii. 400 Tubercle, i. 287. ■ See also Tuberculosis. mucous, i. 416 of bone, i. 913 of the prostate gland, ii. 840 | of the testicle, ii. 849 painful subcutaneous, i. 240 syphilitic, i. 411 Tuberculosis, i. 287 of ankle-joint, ii. 61 of atlo-axoid joints, ii. 54 of bone, i. 913 of bladder, ii. 755 of clavicular joints, ii. 54 of elbow-joint, ii. 59 of hip-joint, ii. 63 actual cautery in, ii. 75 causes of, ii. 63 diagnosis of, ii. 69 excision of bone in, ii. ?6 pathology of, ii. 72 prognosis of, ii. 72 suppuration in, ii. 67 symptomatology of, ii. 63 treatment of, ii. 73 . of joints, ii. 41 general observations on, ii. 14 of knee-joint, ii. 62 of lymphatic ganglions, i. 663 of occipito-atloid joints, ii. 54 of sacro-iliac joints, ii. 56 of shoulder-joint, ii. 60 of spine, ii 256 deformity in, ii. 259 pathology of, ii. 257 symptoms of, ii. 258 treatment of, ii. 260 of temporo-maxillary joint, ii. 53 of testicle, ii. 849 of wrist-joint, ii. 58 Tubercular abscess of bone, i. 914 Tubes, trachea, introduction of, ii. 443 passage of along the oesophagus, ii. 588 Tubular aneurism, i. 732 Tumors, i. 228 adenoid, of the mammary gland, ii. 97Q amputation in, i. 538 anal, ii. 674 aneurismal, of bone, i. 902 arterial, i. 842 benign, i. 231 excision of, i. 255 bloody, of the neck, ii. 479 bony, i. 244, 896 butyroid, of the mammary gland, ii. 969 calcareous, i. 245 cartilaginous, i. 243 colloid. See Colloid. cystic, of the abdominal walls, ii. 715 of the muscles, i. 647 of the navel, ii 718 of the scrotum, ii. 861 i of the submaxillary gland, ii. 561 1130 INDEX. Tumors— eiloid, i. 635 encephaloid. See Encephaloid. hematoid variety of, i. 267 encysted, i. 247 of the lachrymal gland, ii. 355 of the lip, ii. 537 of the nates, ii. 1033 of the neck, ii. 478 of the nymphae, ii. 941 of the upper jaw, ii. 573 erectile, i. "842 of the bladder, ii. 752 of the tongue, ii. 551 exostosic, i. 896 fatty, i. 234 of the abdominal walls, ii. 714 of the bladder, ii. 752 of the lids, ii. 362 of the subconjunctival areolar tissue, ii. 297 fibro-cartilaginous, of bone, i. 901 of the thyroid gland, ii. 473 of the vagina, ii. 937 cystic, of nates, ii. 1034 plastic, i. 241 of the abdominal walls, ii. 714 of the lymphatic ganglions, i. 664 fibrous, i. 240 of external ear, ii. 375 of joints, ii. 40 of neck, ii. 478 of ovary, ii. 923 of prostate gland, ii. 840 of scalp, ii. 197 of synovial membrane, ii. 40 of uterus, ii. 914 of vaginal tunic, ii. 859 fungous, of the bladder, ii. 752 of the teeth, ii. 526 general observations on, i. 228 horny, i. 238 hydatic, i. 250 of bone, i. 907 of the mammary gland, ii. 968 of the muscles, i. 646 hypertrophic, i. 232 in the walls of the abdomen, ii. 714 keloid, i. 631 lacteal, ii. 969 lepoid, of the skin, i. 635 lupoid, of the skin, i. 636 malignant, i. 256 colloid, i. 271 encephaloid, i. 264 epithelioma, i. 268 excision of, i. 280 melanosis, i. 273 of auditory tube, ii. 387 of bone, i. 910 of mammary gland, ii. 971, 981 of muscles, i. 647 of ovary, ii. 925 of scalp, ii. 197 of skin, i. 635 scirrhus, i. 258 treatment of. i. 279 melanotic. See Melanosis. moles, of the skin, i. 626 molluscous, of the skin, i. 625 myeloid, i. 254 of bone, i. 909 neuromatous, i. 245 non-malignant, i. 231 Tumors— of abdomen, ii. 714 of bone, i. S96 of the face, ii. 272 of the groin, ii. 1036 of the ham. ii. 1031 of the lids, ii. 362 of the mamma, ii, 967 of the nates, ii. 1033 of the neck, ii. 478 of the orbit, ii. 373 of the ovary, ii. 922 of the palate, ii. 563 of the parotid gland, ii. 558 of the scalp, ii. 196 of the skin, i. 622 of the submaxillary gland, ii. 560 osseous, i. 244, 896 over the parotid gland, ii. 558 polypoid, i. 251. See Polyp. recurring fibroid, i. 242 sanguineous, of the scalp, ii. 196 scirrhous. See Scirrhus. sebaceous, i. 623 of the neck, ii. 478 of the scrotum, ii. 861 of the skin, i. 623 sero-cystic. See Sero-cystic. serous, of the kidney, ii. 712 of the neck, ii. 479 spontaneous disappearance of, i. 231 vascular, i. 233 of the antrum of Highmore, ii. 502 of the scalp, ii. 196 venous, of the face, ii. 272 • warty, i. 622 Tunic, vaginal, affections of, ii. 852 Tympanites, a symptom of wounded bowel, ii. 692 Tympanitis, ii. 390 treatment of, ii. 391 Tympanum, cavity of, inflammation of, ii. 394 membrane of, abscess of, ii. 392 diseases of, ii. 390 gangrene of, ii. 392 inflammation of, ii. 390 perforation of, for deafness, ii. 390 rupture of, ii. 390 ulceration of, ii. 392 wounds of, ii. .390 Tyrrell's operation for cataract, ii. 327 Twisted suture, i. 302 Ulcerated bubo, i 403 Ulceration, i. 189. »SV* also Ulcers. elkoplasty in, i. 204 herpetic, of the prepuce, ii. 873 in inflammation, i. 189 of the anus, ii. 658 of the arteries, j 721 of the bladder, ii. 728 of the bones, ii. 728 of the cornea, ii. 300 of the Eustachian tube, ii. 401 of the foot, ii. 1023 of the gums, ii. 533 of the larynx, ii. 436 of the leg, i. 198 of the lips, ii. 536 of the membrane of the tympanum, ii. 392 of the muscles, i. 645 of the navel, ii. 718 of the nose, ii. 414 of the palate, ii. 563 INDEX. 1131 Ulceration— of the penis, ii. 872 of the prostate gland, ii. 829 of the rectum, ii. 658 of the throat, ii. 571 of the tongue, ii. 549 of the tonsils, ii. 571 of the uterus, ii. 902 of the veins, i. 833 of the vulva, ii. 939 psoriasic of the prepuce, ii. 674 scrofulous, i. 292 syphilitic, of the larynx, i. 421 of the throat, i. 420 tertiary, of the skin, i. 423 Ulcers, i. 192 acute, i. 194 constitutional treatment of, i. 195 local treatment of, i. 196 amputation in, i. 540 • chronic, i. 197 constitutional treatment of, i. 202 local treatment of, i. 203 classification of, i. 194 dressing of, i. 203 indolent, strapping of, i. 203 old, question of healing of, i. 204 Ulna, dislocation of, at elbow backwards, ii. 145 at wrist. See Dislocations of the wrist. excision of, ii. 1045 fractures of, i. 990 Ulnar artery, aneurism of, i. 791 ligation «f, i. 816 Umbilical hernia, ii. 638 Umbilicus, affections of, ii. 718 carcinoma of, ii. 719 cystic tumor of, ii. 718 fistule of, ii. 719 fungoid tumor of. ii. 718 ulceration of, ii. 718 Unilocular ovarian cyst, ii. 923 Union by adhesive inflammation, i. 309 by first intention, i. 309 by granulating process, i. 309 by scabbing process, i. 308 by secondary adhesion, i. 310 by second intention, i. 309 immediate, i. 307 of wounds, i. 306 Ununited fractures, i. 951 Urethra, chancre of, i. 399 diseases and injuries of, ii. 804 extraction of calculi through, ii. 775 instruments for, ii. 776 false passages of, ii. 826 symptoms of, ii. 827 treatment of, ii. 827 female, affections of the, ii. 942 catheterism of, ii. 943 inversion and prolapse of the bladder through, ii. 942 polyp of, ii. 942 stricture of, ii. 942 vascular excrescence of, ii. 942 foreign bodies in, ii. 807 removal of, ii. 807 hemorrhage of, ii. 806 treatment of, ii. 806 heterologous formations of, ii. 827 laceration of, ii. 806 treatment of, ii. 806 Urethra— malformations of, ii. 804 mbrbid sensibility of, ii. 809 treatment of, ii. 810 neuralgia of, ii. 810 treatment of, ii. 810 polypoid tumors of, ii. 811 ftricture of, ii. 811 bridle, ii. 812 causes of, ii. 815 diagnosis of, ii. 812 forms of, ii. 811 impermeability of, ii. 812 indurated, ii. 812 injurious effects of operation for, ft. 822 organic, ii. 811 pathological effects of, ii. 814 prognosis of, ii. 815 seat of, ii. 811 symptoms of, ii. 812 treatment of, ii. 815 by button'-hole incision, ii. 821 by cauterization, ii. 819 by compression, ii. 818 by dilatation, ii. 815 by incision, ii. 820 by perineal section, ii. 820 instruments for, ii. 815 varieties of, ii. 811 Urethral abscess, ii. 823 treatment of, ii. 823 fistule, ii. 824 operation for, ii. 825 treatment of, ii. 825 forceps, ii. 808 Urethritis, non-specific, ii. 892 symptoms of, ii. 892 treatment of, ii. 892 Urethroplasty, ii. 826 Uric calculus, ii. 765 deposit, ii. 757 treatment of, ii. 758 Urinals, ii. 750 Urinary calculi. See Stone in bladder. deposits, ii. 756 calcareous, ii. 760 mixed, ii. 760 oxalic, ii. 759 phosphatic, ii. 760 triple phosphateT, ii. 760 uric, ii. 757 fistules, ii.-757 infiltration after lateral operation of litho- tomy, ii. 793 organs, diseases and injuries of, ii. 720 Urine, incontinence of. See Incontinence of urine. infiltration of, ii. 823 treatment of, ii. 823 urethral form of, ii. 823 vesical form of, ii. 823 retention of. See Retention of urine. Uro-ammoniac calculus, ii. 766 Uterus, affections of, ii. 896 anteversion of, ii. 900 application of leeches to, ii. 897 of sedatives to, ii. 898 atrophy of, ii. 945 Caesarean section of, ii. 920 carcinoma of, ii. 916 cauliflower excrescence of, ii. 918 collections of gas in, ii. 908 1132 INDEX Uterus— development of mucous follicles of, ii. 904 dropsy of, ii. 909 encephaloid of, ii. 917 examination of, ii. 896 instruments for, ii. 896 fibrous tumors of, ii. 914 granular condition of neck of, ii. 90J hemorrhage of, ii. 909 hypertrophy of, ii. 905 inflammation of, ii. 902 inversion of, ii. 901 malpositions of, ii. 899 neuralgia of, ii. 908 occlusion of, ii. 906 polyps of, ii. 911 treatment of, ii. 913 varieties of, ii. 911 prolapse of, ii. 900 retroversion of, ii. 899 scirrhus of, ii. 906 stricture of, ii. 906, sympathies and irritations of, i. 44 ulceration of, ii. 902 Uterine sound, Simpson's, ii. 897 phlebitis, ii. 904 treatment of, ii. 905 specula, ii. 896 syringe, ii. 898 Uvula, acute inflammation of, ii. 576 affections of, ii. 576 elongation of, ii. 576 excision of, ii. 577 Vaccination, i. 493 Vaccinia, i. 494 Vagina, absence of. ii. 934 affections of, ii. 934 cystic tumor of, ii. 937 double, ii. 935 inflammation of, ii. 935 occlusion of, ii. 935 polyps of, ii. 936 prolapse of, ii. 936 shortness of, ii. 934 varicose veins of, ii. 940 Vaginal hernia, ii. 642 tunic, affections of, ii. 852 fibrous tumors of, ii. 859 hematocle of, ii. 858 hydrocele of, ii. 852 Vaginitis, ii. 935 treatment of, ii. 935 Valgus, ii. 1014 Valsalva's treatment for internal aneurism, i. 757 Varicocele, ii. 867 radical cure of. ii. 858 symptoms of, ii. 867 treatment of, ii. 868 Varicose aneurism, i. 761 enlargement of arteries, i. 723 of arteries of stump, i. 557 of lymphatics, i. 659 hemorrhoidal veins, ii. 673 treatment of, ii. 673 veins, i. 834 of the vagina, ii. 950 of the vulva, ii. 940 Varix, i. 834 anatomical characters of, i. 834 aneurismal, i. 762, ii. 1026 arterial, i. 723 Varix— effects of, i. 835 ligature in, i. 836 of the leg, ii. 1024 of the scrotum, ii. 864 radical cure of, i. 836 treatment of, i. 835 Vionna paste in, i. 837 Varus, ii. 1013 Vascular excrescence of the female urethra, ii. 942 polyp, i. 253 tumors, i. 233 of the antrum of Highmore, ii. 502 of the lips, ii. 538 Vein-stones, i. 833 Veins, air in, i. 837 chronic affections of, i. 833 diseases of, i. 831 hemorrhage of, i. 830 hemorrhoidal, varicose, ii. 673 hypertrophy of, i. 833 inflammation of, i. 831 injuries of, i. 830 obliteration of, i. 833 phlebolites in, i. 833 ulceration of, i. 833 varix of, i. 834 wounds of, i. 830 Venesection, i. 486 accidents of, i. 489 Venous hemorrhage, i. 830 tumors, i. 849 excision of, i. 850 of the face, ii. 272 • persulphate of iron in, i. 850 treatment of, i. 850 Ventral hernia, ii. 641 Veratrum viride as an antiphlogistic, i. 100 Verrucous growths, i. 622 Vertebrae, abscess of, ii. 262 caries of. See Tuberculosis of Spine. erosion of, from pressure of aneurism, i. 739 fractures of, i. 983 Vertebral artery, aneurism of, i. 780 ligation of, i. 809 Vesicants, as local antiphlogistics, i. 114 Vesicle, syphilitic, i. 410 Vesico rectal fistule, ii. 957 vaginal fistule, ii. 046 after-treatment of, ii. 9,56 causes of, ii. 946 diagnosis of, ii. 947 effects of operation for, ii. 956 position of patient in operation for, ii. 949 . prognosis of, ii. 948 treatment of, ii. 948 button-suture of Dr. Bozeman for, ii. 948 by Dr. Sims's method, ii. 948 by sutures, ii. 950 instruments for, ii. 950 palliative, ii. 948 preliminary, ii. 949 radical, ii. 948 wire-splint of Dr. Simpson for, ii. 953 vagino-rectal fistule, ii. 957 Vicious position of the teeth, ii. 522 union of fractures, i. 957 Vienna paste, as a counter-irritant, i. 496 INDEX. 1133 Vienna paste— in varicose veins, i. 837 Vulva, affections of the, ii. 937 erysipelas of the, ii. 938 hemorrhagic infiltration into the, ii. 937 inflammation of the mucous crypts of the, ii. 938 mortification of the, ii. 938 occlusion of the, ii. 940 oedema of the, ii. 938 polyps of the, ii.-939 pruritus of the, ii. 939 ulceration of the, ii. 937 varicose veins of the, ii. 940 warty excrescences within the, ii. 938 Walls of the abdomen, abscess of, ii. 711 tumors of, ii. 714 Wardrop's operation for aneurism, i. 748 Warm applications in the treatment of stran- gulated hernia, ii. 609 Warmth, as a local antiphlogistic, i. 108 Warts, i. 622 treatment of, i. 623 £f the larynx, ii. 439 Wart-like excrescence of the larynx, ii. 439 of the prepuce, ii. 874 . of the tongue, ii. 552 within the vulva, ii. 938 Wasting palsy, i. 682 Wax, accumulations of in auditory tube, ii. 383 curette for removal of, ii. 384 Webbed fingers, ii. 991 Weiss's lithotrite, ii. 778 White swelling, ii. 32 Whitlow, ii. 995 treatment of, ii. 996 Windpipe. See Air-passages. Wounds, i. 298 adhesive plaster in, i. 299 amputation in, i. 340, 536 ' arrow, i. 321 arterial, i. 6S9 articular, ii. 19 amputation in, i. 539 bandages in, i. 305 caoutchouc in, i. 300 collodion in, i. 300 contused, i. 315 treatment of, i. 317 dissection, i. 362 dressing of, i. 299 gunshot, i. 323 treatment of, i. 333 healing of, i. 306 incised, i. 310 treatment of, i. 311 insect, treatment of, i. 348 isinglass plaster in, i. 300 lacerated, i. 313 amputation in, i. 315 treatment of, i. 314 maggots in, i. 345 mode of dressing, i. 299 of arteries, i. 689 of the abdominal organs, ii. 689 of the abdominal walls, ii. 709 of the antrum of Highmore, ii. 499 of the anus, ii. 649 of the arteries of hand, i. 792 of the bladder, ii. 722 of the brain and its membranes, ii. 233 of the chest, ii. 481 Wounds of the chest— collapse of lungs from, ii. 482 external, ii. 481 fistulous, ii. 486 hemorrhage from, ii. 487 internal, ii. 482 treatment of, ii. 485 of the cornea, ii. 297 of the diaphragm, ii. 497 of the emternal ear, ii. 374 of the face, ii 269 of the fauces, ii. 563 of the gall-bladder, ii. 706 of the groin, ii. 1035 of the gums, ii. 533 of the heart, ii. 494 of the intestines, ii. 691 of the iris, ii. 308 of the lids, ii. 361 of the lips, ii. 536 of the liver, ii. 704 of the lungs, ii. 481 of the membrane of the tympanum, ii. 390 of the muscular walls of the abdomen, ii. 709 of the muscles, i. 642 of the nates, ii. 1032 of the neck, ii. 466 causing paralysis of superior extre- mity, ii. 468 of the nerves, i. 665 treatment of, i. 665 of the oesophagus, ii. 579 of the palate, ii. 563 of the penis, ii. 870 of the pericardium, ii. 494 of the pharynx, ii. 579 of the plantar arteries, i.- 801 of the rectum, ii. 649 in the lateral operation of lithotomy, ii. 793 of the scalp, ii. 193 of the sclerotica, ii. 305 of the scrotum, ii. 860 of the spermatic cord, ii. 865 of the spinal cord, ii. 248 of the spleen, ii. 706 of the stomach, ii. 689 of the tendons, i. 647 of the testicle, ii. 844 of the tongue, ii. 547 of the upper jaw, ii. 499 of the windpipe, ii. 431 poisoned, i. 346 by dissection, i. 362 treatment of, i. 366 by glanders, i. 359 treatment of, i. 362 by insects, i. 346 by malignant pustule, i. 367 treatment of, i. 369 by rabid animals, i. 352 by serpents, i. 348 punctured, i. 318 treatment of, i. 320 rest and position in, i. 305 secondary effects of, i. 343 serpent, Bibron's antidote in, i. 352 treatment of, i. 351 subcutaneous, healing of, i. 310 sutures in, i. 301 tooth, i. 322 treatment of, i. 323 1134 INDEX. Wounds of the tooth— union of, i. 306 venous, i. 830 treatment of, i. 830 Wrist, amputation of, ii. 1072 dislocations of, ii. 135 excision of, ii. 1045 tuberculosis of, ii. 58 Wryneck, ii. 469 Wutzer's operation for the radical cure of re- ducible hernia, ii. 597 Xanthic calculus, ii. 768 Xeroma, ii. 295 Zinc, chloride of, as an escharotic, i. 500 THE END. NLM03�*R�40